Part 51

F. K., a 23-year old soldier, in civil life a turner, of Polish descent, and of a somewhat nervous and easily excitable disposition, early in August went from Strassburg into the Vosges and Lorraine. On the 26th a number of shells exploded near him. The troop was excited and took refuge in a cellar. K.’s best friend was torn to pieces by a shell. When his body was removed, K. felt sick and lost consciousness. He arrived at the clinic in Tübingen in a stuporous condition, by hospital train, on August 31, 1914. He walked weakly to his bed, supported by two men, and lay in the bed, apathetic and reacting to questions only with a stare. Things put in his mouth were swallowed. He remained motionless.

Next evening he answered a low _Yes_ to a nurse’s question about eating. A little afterwards he said he supposed he was a prisoner in the enemy’s country. A little later he got properly oriented but still did not know how he had come. September 2, however, he was much clearer and said he had awakened out of a long dream. There was a complete amnesia, however, from the moment when he went to help remove the torn body of his friend up to September 1. Memories became clearer for the period before the shell explosion. The patient became very lively, talking vividly of war experiences, imitating shell hissing with an expression of intense anxiety, getting accustomed to battle scenes, saying that he was now seeing everything again as if real. He remained anxious for some days, complaining of weight on his chest and of feelings of internal restlessness and tension.

Amnesia for the period of August 26 to September 1 remained; all that K. could add to the story of those days was that he had been thrown sidewise for some distance by the air pressure of the shell.

From September 6 onwards, he grew calmer but he was still very labile, given to lively imaginings and emotion. By the middle of September he was well and discharged for garrison duty.

Shell-explosion: Recurrent amnesia.

=Case 450.= (MAIRET AND PIÉRON, July, 1915.)

A man, 33, had suffered shell-shock early in December, 1914. His intervening history is not reported, but he showed on admission to the service of Mairet and Piéron, May 5, 1915, a remarkable amnesia. There was a complete cutaneous anesthesia, anosmia, and ageusia, and he was mute. He lived only in the specious present. His previous life was completely abolished for him. He could dress himself, eat, use a fork and spoon, and a glass. He understood ordinary words; such words as man, woman, day and night, however had no meaning. He was observed for 15 months and presented four phases.

In phase one, there was a measure of success in reëducation, such that he grew able to recognize a few persons, to find his bed, and name objects. He was got to copy writing, to learn the alphabet, and to say a few words. He could not write from dictation, however. Less than two seconds after looking at an _A_, he had forgotten how it looked and could not trace it. This first phase lasted about two months.

The second phase began with fatigue, headaches, and the rather quick effacement of all he had relearned. If an errand was given him to do, he would run to do it before he should forget it; but if the trip required more than 4 or 5 seconds, he had to stop, not knowing what to do with the thing in his hands. He was still able to recognize 4 or 5 persons, but could add no more to his repertoire; and when one of them had been absent for a fortnight, he did not recognize him on his return. He could not remember the time for his meals.

The third phase was ushered in by improvement after vomiting; his speech came back in a feeble voice, November 16, 11 months after the shock. Reëducation could now be undertaken again. He easily relearned a number of things, feeling the greatest astonishment at his new acquirements as to the sun and the moon, the trees and the flowers, and the like. He expressed a curiosity to see his own home, but when he went thither, he could recognize nothing. He wanted to get back home, namely to the hospital where he had lived all his life; where, in fact, he had been born from the psychic point of view.

At this time began the fourth phase, April, 1916--a phase of decline once more, in which a large portion of his acquisitions were again lost and he fell back to his condition in the second phase.

See discussion under Case 353 and under Case 367. _Re_ confusional mental states, Roussy and Lhermitte, after distinguishing stuporous confusion from simple confusion, go on to differentiate what they call obtusion (see also discussion under Case 353). These authors say that Régis, in common with most psychiatrists, fails to distinguish the slow thinking and amnesia of true mental confusion from the temporal and the spatial disorientation that characterize the so-called obtusion. Of course, in all attacks of confusion, both attention and memory are affected, but there are special types in which attention defects and memory defects stand out in relief. The first of these types is the aprosexic type with birdlike movements, described by Chavigny (see for an example, Case 446). This aprosexia may be combined with mutism, deafness, or convulsions. The form of confusional disease in which amnesia is the out-standing feature is due to toxic or infectious disease, or is a Korsakow phenomenon, _i.e._, in the psychiatry of peace times; but the war has brought out amnestic confusion in other states than the toxic, infectious, and alcoholic states (Régis, Chavigny, Dumas, Roussy and Lhermitte). The amnesia may be incomplete, a sort of dysmnesia, or twilight memory, but as a rule, the amnesia is lacunar. The toxic and infectious amnestic confusions have a loss of memory for events following the onset, but these war cases of amnestic confusion have the loss of memory running back far into the patient’s past, slipping from the mind his name, his parentage, age, and vocation. Instead of being like the toxic confusional amnesia, an anterograde amnesia of fixation, the Shell-shock amnesia is apt to be antero-retrograde. These antero-retrograde amnesias, whether due to emotion or to strong physical shock, may sometimes leave in sharp relief the recollection of the shock or event itself which initiated the amnesia. Meanwhile the patient does not forget automatic actions of dressing, reading, writing, and the like. The amnesia may be very selective, imitating aphasia, word blindness, letter blindness, agraphia, and the like. All this is part of the hallucinatory form of mental confusion which Régis describes as oniric delirium (see for oniric delirium, discussion under Case 333).

Lépine distinguishes amongst the confusions, five forms as follows: Simple confusion, hallucinatory confusion, acute delirium, stuporous confusion (under which Lépine also considers the battle hypnosis of Milian, see Case 365, and Roussy’s narcolepsy), and amnestic confusion. All these phenomena from the clinical point of view are connected with an acute and fleeting insufficiency of the most delicate or, as it were, psychic portions of the cerebral cortex, the delirium, so to speak, being activity of the unconscious, whereas a confusion is due to a clouding of the centre O of Grasset’s polygon.

Soldier’s heart, both neurotic and organic.

=Case 451.= (MACCURDY, July, 1917.)

A territorial, 19, who had enlisted in January 1914, reached France in September, 1916. He was of neurotic make-up (night terrors, fear of dark, giddiness in high places, fear of tunnels, enuresis until 10 years, worry about seminal emissions), and had always had a tendency to short wind. Enlisting at 16, he found it hard carrying his pack at first but soon grew stronger. The trench life was distasteful. He began to wish that he might be killed, or at all events removed from the trenches. Pains developed under the heart, with shortness of breath, palpitation, dizziness, and faint feelings. The man connected these heart symptoms with what he called his weakness of gall bladder (namely, enuresis). He was several times sent off duty for heart treatment. After three months in and out of hospital, he got trench foot, was sent to England, and transferred to a special heart hospital. Here the pulse test was positive, in that the rate did not diminish as it normally does after two minutes’ rest. After graduated exercises for several months, the pulse test had become negative and the heart had gradually improved from the organic standpoint. The patient, however, insisted that his heart trouble was as bad as ever, and was probably consciously hoping that his symptoms might persist.

_Re_ soldier’s heart, Abrahams classifies cases that come to the military surgeon for heart symptoms as (_a_) functional fatigue cases; (_b_) nicotine and drug cases; (_c_) organic heart disease and Graves’ disease; (_d_) the true soldier’s heart, occurring in men with a neurasthenic soil that lose control of the vasomotors and inhibitors of the heart.

Soldiers heart, neurotic.

=Case 452.= (MACCURDY, July, 1917.)

An Australian gunner, 35, of a neurotic make-up (night terrors; horror of blood; fear of thunderstorms, high places, tunnels, horses; shy with both sexes), benefited by military training physically, but remained as neurotic as ever. On the way to his first service in Egypt, he feared shipwreck, and in Egypt was troubled by the weather and occasional palpitations and sinking feelings. He was transferred to the French front, May, 1916. He was terrified and depressed under shell fire, and horrified by blood. Peculiar sinking sensations or feelings that the soul was leaving the body came to him as he was going off to sleep; from which he woke at times with sudden starts. Later he had nightmares of things, mainly shells, falling on him. He worried, wanted death, and thought of suicide. In May, 1917, he was blown off his feet by a shell. Thereafter he began to feel that shells were being especially aimed at him, and four days later got a pain in the side, and began to tremble and breathe with difficulty, as if his throat were swelled up and he were going to choke. He ascribed this to gas. The bombardier finally sent him back to a hospital, where he grew weaker and screamed aloud on being awakened by his dreams. After six weeks in a special heart hospital, all the symptoms cleared up except the choking feelings and fear of instant death. Organically the man appeared normal. An initial pulse of 96 ran up to 168 after exercise, and down to 84 after two minutes’ rest.

_Re_ soldier’s heart, Abrahams speaks of sundry hypotheses that he regards as erroneous. Soldier’s heart has been thought to be (_a_) athlete’s heart; others regard it as (_b_) a toxemic condition, possibly of bacterial origin; (_c_) hyperthyroidism (a larval form of Graves’ disease has been incriminated); (_d_) excessive cigarette smoking; and (_e_) deficiency of buffer salts in the blood, have been proposed by other authors.

Gallavardin has especially studied the tachycardial cases revealed by the war, cases in which auscultation is frequently unable to detect aught. These tachycardiacs are often hypertensive. Sedentary service should be found for them.

_Re_ pulse 168 after exercise, Gallavardin found 8 per cent of 500 non-organic and non-tuberculous cases to run up from 150 to 175 (125 to 150 in 27 per cent; 100 to 125 in 37 per cent; 75 to 100 in 26 per cent; 50 to 75 in 2 per cent).

_Re_ cardiac neuroses, Brasch points out that cardiac neuroses in the male in war time have found a strange new association with hyperesthesia of the skin. The patients showed dermatographia and hyperreflexia. The hyperesthetic zones of Head and Mackenzie were found by Brasch in all cases of organic cardiac disease, but also in two cases of cardiac neurosis in hysterics.

Moore calls attention to somewhat similar phenomena in the somatic group of nervous and depressed cases found in the war. These patients are fatigued, exhausted, sleepless, tremulous, vascular, and cardiac cases, with dermatographia, areas of paresthesia, and pains in the neighborhood of wound scars.

War Strain; Shell-shock: Hysteria (question of malingering).

=Case 453.= (MYERS, March, 1916.)

A sergeant, 32, with 11 years’ service and eight months’ service in France, was admitted to a base hospital for inquiry as to possible malingering. It seems that he had taught in an army school for seven years before the war. He found heavy marches in France too much for him and fainted in the retreat from Mons and during the fighting on the Aisne, where he had reported sick for dysentery. The field ambulance where he was treated was near the shell fire, and a shell knocked him into a ditch. The ambulance had to move to a cave. Thereafter the patient suffered from tremor when spoken to or when watched. After discharge, he was employed as a dispatch rider on a motor cycle, but after three months lost his nerve for this work and took charge of fatigue parties. He found the work too much for him. He had been a total abstainer. Finally the malingering charge was brought up.

The patient was nervous, delicate-looking, with widely dilated pupils, prominent eyeballs, tremor of right arm, and pulse of 102. The tremor was markedly lessened when he was alone, and was somewhat under control. He felt that his memory was defective, and tests demonstrated the defect.

In hospital patient slept better, the pupils grew smaller, the pulse rate diminished. There was a reduction in sensibility to pain over the right side of the head and body and over the right limbs. A prick of the right arm or leg was described as a finger touch. There was also almost complete hemi-anosmia and complete hemi-ageusia on the right side. Visual acuity was diminished on the right, and there was general limitation of right field; left-sided vision and field normal.

After a month in hospital at home and two months’ leave, the patient was discharged no longer physically fit for service. He is now weak physically and mentally, subject to severe headaches, and tremulous, especially in the right arm, when tired.

_Re_ malingering, Sicard denies the existence of unconscious malingerers (presumably regarding this phrase as a figure of speech in relation to hysteria), and divides malingering into a creative and an acquired form. The _simulateur de création_ assumes attitudes and symptoms to attract attention or pity; the _simulateurs de fixation_ having been sick in the beginning, perpetuate their disease, in brief, crystallize their neuroses. The _fixateur_ may be very realistic in all this, seeing that he has known from his own experience what a real disease is. The formula runs: The _simulateur de création_ improvises; the _simulateur de fixation_ repeats.

According to Mott, malingering in the form of an assumed Shell-shock is not uncommon amongst soldiers, and is rather hard to distinguish from a neurosis developing on the basis of an _idée fixe_.

Ballet’s definition of simulation is “a subjective or objective disorder which the patient invents with the idea of voluntarily and consciously misleading the observer.” Closely related to simulation is exaggeration or prolongation, conscious or intentional, of a real disorder. Babinski states that cases of genuine simulation are very rare, and that the subject under suspicion should be given the benefit of the doubt. Especially the word _simulation_, or similar words, should not be uttered in the presence of the patient. Practically speaking, psychotherapy applied as in cases of hysteria may often cure the simulator and the exaggerator.

The officer who could not kick.

=Case 454.= (MILLS, January, 1917.)

An officer had had a bullet in the right calf, of which nothing was evident months later but small scars of entrance and exit. Nevertheless he complained of pain, especially after walking, and of inability to dorsiflex the foot beyond a certain point. No wasting could be found and no impairment of sensation. The muscles were faradically normal. Mills thought the symptoms were exaggerated and so remarked to the officer.

Under anesthesia, however, the dorsiflexion also proved to be impossible, and after exerting considerable force, Dr. Dunhill was able to rupture a massive fibrous band of adhesions that had prevented extension. The officer made a good recovery.

Dr. Mills confessed his error to the officer who had naturally resented the suggestion of malingering. The officer forgave him.

_Re_ malingering, Moore states that no diagnosis of malingering should be made without the most careful examination and consideration of the individual as such, on account of the fact that the erroneous diagnosis dejects the patient and postpones recovery. It is particularly unwise to term the trouble “imaginary,” or to talk about “suggestion” or use similar terms in the presence of the patient.

Craig has found very few cases of actual malingering and states that tremors and paroxysms are often mistaken therefor. Bispham remarks that few malingerers are found among the patients of a doctor who is known to be a thorough examiner.

_Re_ orthopedic cases like Case 454, Gleboff remarks upon the simulation of joint affections and upon methods of surprising the malingerers into sudden movements made in obedience to request in the course of medical examination.

Doubtful accounts by patient concerning arm palsy: Incorrect diagnosis of simulation.

=Case 455.= (VOSS, November, 1916.)

A volunteer, 18, just before the war had a fall in which apparently he injured his skull. In December, 1914, he hurt his left forearm. About this injury he sometimes said he fell in a storming attack in a trench and broke his arm, and again he said his arm had been smashed by stones from a falling house. From that time forward there was paralysis of the left forearm with flexor contracture. May, 1915, slight hypesthesia could be demonstrated on the ulnar side of the arm, suggesting ulnaris injury. There were, however, no considerable electrical changes.

Six months later the man was sent up with a suspicion of simulation. In the meantime the contracture had resolved and there was a typical hysterical paralysis with all signs of neurosis. Six months later he was well enough to be examined for military service.

Here was a case in which the incorrect data offered by the patient himself as to the origin of his paralysis gave rise to the suspicion of simulation, whereas, as a matter of fact, the man was clearly hysterical.

_Re_ incorrect data supplied by the patient to his own disadvantage, Lumsden remarks on the great difficulty of diagnosis in cases where hysteria and malingering have been combined, and Morselli states that, if the doctor has really made up his mind that the man is shamming, he should send him back to the fighting line at once.

Forearm wound: Hysterical edema?

=Case 456.= (LEBAR, July, 1915.)

A corporal, 26, formerly a farmer, was struck in the forearm by a shell fragment on the mid-portion of the radial border. The wound was slight (the fragment entering and emerging hardly 2 cm. apart) but bled profusely, according to the patient, who was evacuated next day but one to a hospital in the interior. By this time the right hand was swollen, nor could any movement of hand or fingers be made. Massage, mechanotherapy, passive movements did no good.

The man entered the neurological center of the Eighth Region, July 7, 1915, when there were already a few skin changes with dorsal thinning and palmar thickening. There was cutaneous anesthesia not only of hand and fingers but of the forearm to the elbow, and this anesthesia included heat and cold. Position sense was preserved. There was no evidence of atrophy except for the skin changes. An electrical examination showed normal conditions.

July 13, a sealed bandage was put on, but at the end of five days the hand looked as before. July 19, a new treatment was announced to the patient. With a hot needle a number of pricks were made on the dorsal surface of the hand and a few c.c. of fluid were withdrawn (containing a slight amount of albumin and a few lymphocytes), whereupon a dry bandage was put on. The next day a few finger and thumb flexion movements could be made and sensation had returned. Sensation completely returned July 21. The flexion movements were still incomplete, by reason of the edema and dryness of the skin. However, July 22, flexion was better and the swelling had gone down sixty per cent. Jacquet’s biokinetic treatment (active gymnastics of the hand and fingers) was given for four hours. July 25, the edema had greatly diminished and normal motion had returned.

Examination excluded renal disease. There was no sign indicating phlegmon. Quincke’s disease had other features. Fraudulent application of a bandage might be considered, but the course of the disease under sealed conditions seems to exclude this hypothesis also. May it, therefore, not be a case of hysterical edema?

_Re_ hysterical edema, see remarks under Case 407. In the case above, of Lebar, Babinski calls attention to the fact that the edema and the contracture diminished though they did not entirely disappear after the scarifications. This physical treatment did not act, according to Babinski, wholly as a matter of suggestion, and he fears that some cases of so-called hysterical edema are really cases of physiopathic vasomotor disorder; in fact, three of the cases published (and amongst them, the present case of Lebar), were cases of edema associated with contracture and developing in an injured limb. To prove a case of anything to be hysterical is, of course, according to the Babinski school, to submit it to a therapeutic test and cure it by suggestion.

Shell splinters in head: Suspicion of (_a_) simulation, (_b_) hysteria. Case actually surgical.

=Case 457.= (VOSS, November, 1916.)

A man, injured by shell fragments in the head and sustaining fracture of both arms and a thigh, got well of his wounds, but fell into a nervous state with headache and dizziness. He was given prolonged observation psychiatrically and then sent back to the front as fit for service, but was shortly returned to hospital and sent to Cologne under the suspicion of simulation.

The picture was of unilateral increase of tendon reflexes, accelerated pulse, disorder in the intake of ideas, difficulty in finding words and delayed associations. His gait suggested a psychogenic disorder. X-ray showed two shell fragments in the vault of the skull.

According to Voss, it is a sad fact that victims of skull injuries are frequently charged with simulation or exaggeration. In the above instance, moreover, this charge was undoubtedly inaccurate.

_Re_ simulation, see remarks under Case 453. _Re_ neurological cases, the Neurological Society of Paris sent to the War Ministry a special note pointing out how tardy was the reference of sundry neurological cases to the special neurological service. They pointed out how important it was to send to these special services all cases of bullet and shrapnel lesions.

_Re_ the malingering question, there is a wide divergence of opinion, even amongst experienced workers in the same city. The late Professor Dejerine said he had not seen a single case of malingering. In fact, he thought that malingering amongst soldiers and amongst injured industrial workers had been much exaggerated. Marie, however, working in the examination of many surgical cases, found malingering relatively common. Amongst forty of his cases, he regarded at least nine as malingerers or exaggerators.

“Sciatica,” torticollis, stiff arm: The desire to avoid active service plus functional disease.

=Case 458.= (COLLIE, January, 1916.)