Part 55

Favorable effects of lumbar puncture.

=Case 488.= (RAVAUT, August, 1915.)

An accountant, 20, in the 135th infantry sustained shock from mine explosion near his trench, March 6. He was kept two days at the relief station. March 8, at the ambulance, he did not appear to understand questions and had a fixed stare. He complained of a violent headache and kept pressing his head between his hands. He kept looking about him anxiously, and the slightest noise made him jump. He would mutter a few incomprehensible words, and in reply to a question would give only the last phrase which he happened to have been saying. Lumbar puncture showed a very slight excess of albumin. Next day, he answered his name. March 12, he could speak in monosyllables, and he began to understand what was said. After the lumbar puncture, the headache disappeared and did not set in again. March 13, he began to be able to write and say short phrases. March 16, expression was good though hesitant, and the patient wrote a letter to his parents, telling about his shock. Lumbar puncture showed that the albumin was now normal. From the rear, April 5, the patient sent Ravaut a postcard in perfect form, telling how he was ready to go back to the front.

_Re_ lumbar puncture, Imboden quotes Podmanizky as having used lumbar puncture as a method of suggestion for the cure of abasia. See also cases 560 and 561, in which Claude cured two cases of dysbasia by the device of stovaine anesthesia of the spinal cord. Pastine also has a case in which a slight improvement was produced on removal of cerebrospinal fluid, and a sudden and complete cure was brought about by the second puncture, a very painful tap. Pastine’s case is thought by him (1916) to be in part at least organic.

Bullet wound of forearm: Hysterical clenching of fist. Recovery by fatiguing the flexors.

=Case 489.= (REEVE, September, 1917.)

A soldier, 28, was thrice wounded between August 18, 1914, and July 14, 1916. The third time, a bullet passed through the fleshy part of the forearm, whereupon the hand became clenched and remained so after the wound was surgically healed. As a case of war neurosis, the man was treated by electricity, massage, passive movements, and fixation in a straight splint during a period of nine months, without result. He was admitted to Maghull Military Hospital, April 18, 1917.

Two days after admission a treatment was given whose principle consists in producing a condition of fatigue in the muscles responsible for contracture. This fatigue is produced by continuous passive movements in a direction opposed to the normal action of the muscles in question. Many hours of forcible movement are sometimes necessary in the case of the more powerful muscles before the limp, toneless fatigue condition is brought about. Relays of men are told off for this purpose. Patients are got to assist in the work, particularly such as have been cured by the treatment. Also, the patient is himself told about the nature of spasms and the relief which the method will bring. This patient was told that after the flexor muscles were fatigued they would no longer be able to pull the fingers into the clenched position, whereupon the antagonistic muscles on the back of the forearm would begin to work.

The fingers were forcibly opened without interruption for six hours, in each case as soon as the fingers closed into the palm. In a few hours they began to return more slowly, and at the end of the six hours remained extended. The extended position was still found the following morning. The extensor muscles were feeble in action, but improved day by day. The spasm did not return. The patient was discharged July 2, 1917, about two and a half months after admission to Maghull. The hand was now strong and useful.

Bullet through shoulder girdle: Hysterical adduction of arm. Treatment by induced fatigue.

=Case 490.= (REEVE, September, 1917.)

A man, 29, was in hospital more than two years before the Reeve fatigue treatment was applied to a functional contracture. This man had a bullet pass through the right scapula and out the pectoralis major, June 4, 1915, was (according to patient’s story) operated two months later, then further operated for drainage of septic wounds, and from August, 1915, had his arm fixed to the side, going into spasm at any attempt to move it passively. The elbow was extended and at first the fingers were tightly flexed and wrist extended. The finger flexion and wrist flexion cleared in March, 1917, and recurred in May. Electrical massage in June, 1917, yielded free movement, but the spasm returned.

The man was admitted to Maghull, June 12, 1917, that is, a little over two years after his injury. The arm sprang back to the side like a clasp knife on being released. The wrist and fingers were moved freely. Three days after admission the elbow was forcibly flexed for some hours, whereupon the spasm disappeared. Next day the arm was forcibly abducted and reabducted: for four or five hours the arm could be voluntarily abducted. Two assistants were necessary, such was the force of the adductor contraction. At the end of a week the patient was found able to lift his hand to the back of his head. There was no longer spasm.

_Re_ abrupt treatments, amongst which Reeve’s treatment by induced fatigue may be counted, Babinski and Froment consider that abrupt treatment is far superior to slower psychotherapy combined with isolation, whether or not we are dealing with a recent or an old disease. So far as psychotherapy goes, Babinski wants to obtain a definite improvement, if not a cure, on the first application of treatment. According to Babinski, the patient’s faith in his physician’s power to cure him is most active at this first meeting, whose emotionality favors the cure.

Burial and bruises of back: Hysterical cross-legs. Treatment by induced fatigue of contractured muscles.

=Case 491.= (REEVE, September, 1917.)

A man, 32, was buried by a shell and bruised about the back, August 2, 1916. He was bedfast until February, 1917. Every attempt to move the legs brought on tremors. He was then allowed up; but the attempt to walk caused one foot to knock the other, and his ankles became bruised, necessitating cotton wool pads for feet.

He was admitted to Maghull, June 12, with one leg crossed over the other and the thigh adductors spastic, especially on the right.

The fatigue treatment was carried out in dorsal decubitus, each leg being pulled by a man, and the separation repeated when necessary. Four hours a day for three days of this work finally reduced the spasm so that the patient was able to walk with assistance. On the sixth day he walked a mile without assistance. The spasm has not returned.

_Re_ leg contractures, Bérard got successful results by continuous extension combined with injections of 1 per cent novocain into the sciatic nerve trunk and the contractured muscles. According to Babinski and Froment, there ought to be an almost certain cure of any genuine hysterical state. They quote the observations of Souques, Meige, Albert Charpentier, Clovis Vincent, Roussy, and Léri as proving this claim.

The Reeve method, so far as it is psychotherapeutic, bears a resemblance to Clovis Vincent’s first stage of what the poilu calls _torpillage_, namely, the stage of crisis and of intensive reëducation. But Clovis Vincent uses in his direct and forcible reëducation the galvanic current.

Bullet wound of neck: Hysterical torticollis. Treatment by induced fatigue.

=Case 492.= (REEVE, September, 1917.)

A soldier, 20, had a bullet pass through the back of the neck, July 10, 1916, and returned to his dépôt surgically well October 1. A fortnight later a Zeppelin raid turned his troop out in the middle of the night, and on the morrow the man’s neck was twisted around and inclined upon the left shoulder.

Treatment followed in various hospitals, with fixation in the corrected position by plaster of Paris but without result. The patient was admitted to Maghull, April 18, 1917, with spasm of left trapezius and right sternomastoid muscles. Under hypnosis the deformity could be easily corrected. Unfortunately, it returned.

The fatigue treatment described by Reeve was started a week after admission to Maghull. The neck was forcibly straightened and restraightened upon return to its twist. In a few hours the contracting muscles had become fatigued; the neck was straight.

The next day the deformity returned slightly. The fatigue treatment was repeated. The patient was discharged well, July 2.

Burial by shell explosion: Abasia, tremors. Claw foot persistent two years cured by induced fatigue.

=Case 493.= (REEVE, September, 1917.)

A man, 24, buried by a shell, February, 1915, had had a functional “claw foot” for more than two years, cured by the Reeve fatigue treatment in less than a week. According to Reeve, claw foot is perhaps the most common of the war contractures, particularly intractable, and often seen out of hospital with an “inside splint.”

After his burial this man could not walk, had tremors, was in bed for four months and on getting up showed strongly inverted foot. Three months’ splint treatment, strong faradic currents, massage, passive movements, special boots with leather wedges to tilt the foot over, were methods of treatment tried, but unsuccessful. At Maghull from November 18, 1916, he was treated by exercises, passive movements, suggestive and reëducative measures, and after a few months got about without sticks.

The claw foot continued. Toward the end of June, 1917, the feet were forcibly flexed and everted for eight hours. The deformity disappeared, but returned slightly next day. Further fatigue treatment for eight hours caused the spasm to cease permanently. He was discharged quite normal, July 20, 1917. Reeve remarks that this fatigue method might be applicable to certain hysterical contractures in civil practice.

Skull trauma over right eye: Delirium, febrile? post-traumatic? exhaustive? Operation: Epileptiform excitement. Later, explosive diathesis: Operation: Euphoria. Seizures and slight mental change.

=Case 494.= (BINSWANGER, October, 1917.)

A soldier (brother choreic, sister infantile palsy) had had measles at 13 and in his fever climbed out of bed upon a couch, fell from the couch and was found by his mother lying on the floor. He was of moderate intellectual grade, of an emotional, passionate Saxon nature and had now and then been intoxicated.

In September, 1914, he was wounded over the right eye. He did not lose consciousness but concluded that he could not get back to his own lines on account of the enemy fire. Using a knapsack to cover his head, he lay down for twenty-four hours, until rescued by a passing body of the sanitary corps who were about to leave him for dead when he called loudly to them.

He was very weak in hospital and, towards the evening of the day after receiving his injury, he must have fallen into some sort of psychotic state lasting ten days. For this he remained quite amnestic, although he was told by comrades that he had hallucinations and had scolded and yelled, hearing voices. Apparently there were situation-deliria--the call to go over the top. Temperature, which had run to 38.8, after ten days sank to normal, and consciousness cleared up.

Was this a case of protracted febrile delirium? Or of psychosis due to _commotio cerebri_, that is, an effect of heightened intracranial pressure? Or was it exhaustion-delirium following loss of blood, sleep and food?

But this was not the end. The wound suppurated, and in May, 1915, eight months after the injury, operation was performed to relieve this abscess. Temperature immediately rose to from 38.4 to 38.6, the fever lasting three days, and a second psychotic phase with complete amnesia entered. He went into this phase immediately after recovering from the operative narcosis, looking wildly about and cursing the sister. The patient was violently excited and was put in a straight jacket on the second day. This phase may be regarded as one of epileptiform excitement with delirium. The operation may have played a part in the psychosis.

There were no further psychotic phenomena which could be attributed in any way to _commotio_. There were, however, attacks of cortical origin and emotional seizures. The patient became emotionally excitable and lost all inhibitions against expression of emotion, such as crying. Once he actually tried to suppress his emotion with a noose about his throat. He became seclusive and withdrew within himself--a victim of Kaplan’s explosive diathesis, or of Bonhoeffer’s emotional hyperesthetic defect condition.

A second operation was performed in September, 1916, to loosen the brain scar, and a large splinter of bone was removed. During the operation, under local anesthesia, there was a severe cortical seizure with complete disappearance of the reflexes. Ether was then administered. Later, in the same day, there were several minor cortical attacks.

After this operation the man’s emotional status changed; he was no longer irritable or exclusive, but became slightly euphoric and contented. He received during the next two weeks four tablets of Sedobrol and for a long time thereafter two tablets daily. There were never any phenomena of bromidism or any suggestive effects of the bromides.

The first attack after the second operation came in November, 1916, and was followed by slight dysarthria. Repeated attacks followed which were attributed to contractions in the scar. Accordingly, a third operation was performed and an attempt was made to bridge over a defect in the right frontal bone. The man’s emotional status remained good after the operation, but further attacks appeared six weeks later and there were spells of dizziness. Occasionally, in process of thinking, he said something stuck in between his thoughts. Sometimes thinking broke off sharply as if he had cut through a wire with an electrical current in it. There was a slight reduction in attention and a slightly increased fatiguability.

Hard service; shell explosion with loss of teeth: Vomiting. Cure by restoration of self-confidence.

=Case 495.= (MCDOWELL, January, 1917.)

A married reservist was called up at the outbreak of the war and went through Mons, the Marne, and the Aisne and was finally blown up by a shell at Ypres. Early in November, 1914, he lost his speech but got it back in time to get home for Christmas. A number of teeth had been lost in the injury. Vomiting began first in England. While on leave at home he vomited at every meal. Asked whether it was his food or his thoughts, he said, “You are quite correct, Sir, you know I have always been with thinking.”

Under medical care, June, 1915, he was found suffering from hesitating speech, general tremulousness and emotionality. He worried a great deal on account of money matters at home. He lay awake thinking. A child became ill and died, and all the while he got worse, “thinking all the time.”

It was explained to him that the vomiting was a matter of emotions. The lost teeth were replaced by false ones. As he began to get control of his emotions, he vomited less and increased in weight. Finally he was boarded for discharge and was sick again on the day of the meeting. A fortnight later when sent to sign discharge papers he vomited once more.

According to McDowell, the vagus may possibly be incriminated as a cause of these gastric disturbances. Practically, the vomiting is a result of emotional stress. The cure is to produce insight on the part of the patient, the removal of worry and the restoration of self-confidence.

Michell Clarke cured such cases with milk diet.

Roussy and Lhermitte find hysterical vomiting to be relatively common and as a rule without difficulty in diagnosis; but they remark that there is often some underlying organic condition to be sought for and treated after the neuropathic element has vanished. They remark, also, that there is no tendency to spontaneous cure of the disease. They advocate a strict dietetic régime and psychotherapy.

Cure of self-accusatory (“started retreat from Mons”) and other delusions by “autognosis.”

=Case 496.= (BROWN, January, 1916.)

Capt. William Brown, in the discussion at the Section of Psychiatry of the Royal Society of Medicine, January 25, 1916, speaks of a method of treatment which he calls _autognosis_--a method of giving the patient self-knowledge, by revealing to the patient through his own confessions the cause of mental change leading to his symptoms. One of Brown’s examples is that of a sergeant in the firing-line during the retreat from Mons. He was admitted to Maghull with the delusion that people thought he had given the signal for the retreat from Mons on a silver whistle, a shooting prize of his. German officers used silver whistles that made a note like his own. In fact, he had other like delusions, such as that people thought him responsible for an Edinburgh railroad accident in connection with his troop-train. A German spy might have heard this.

In the process of procuring autognosis, Capt. Brown found that at the age of 12 this man had been falsely accused of stealing pork pies from a shop, and had been brought before a magistrate. In point of fact, he proved an alibi, but he was greatly worried by the charge. According to Capt. Brown, this incident of the insistence of the false accusation was the beginning of his tendency to delusions. In two months’ time there was a remarkable improvement.

_Re_ psychoanalysis, autognosis and various modifications, Forsyth remarks that when the acute stage is passed, the Shell-shock case becomes an everyday neurosis in which war experiences are merely the latest phases in the patient’s life, and that psychoanalysis may then become necessary. Eder regards the “mechanisms” of what he terms “war shock” as the Freudian mechanisms of hysteria, and has commended psychoanalysis for a few cases, preferring hypnotism for acute cases. Adrian and Yealland decry psychoanalysis on the score of time limitations.

Deafmutism in three men shell-shocked at one time.

=Cases 497, 498, 499.= (ROUSSY, April, 1915.)

There were three Zouaves in a first-line trench north of Arras, January 14, 1915, who were blown up by a bomb thrown from the enemy trench some hundreds of meters away, by a mortar, a _crapouillaud_. This projectile burst with a great noise, louder than that of a bomb, and made a very strong windage. A dozen men were blown under the trench wall, just after entering the trench; two were killed; and the others, most of whom had been buried to the neck, were pulled out and carried, trembling, to the nearest relief post. Two of the three Zouaves were bleeding at nose and ears, and all three were absolutely deaf and mute. Evacuated to an ambulance, and thence to Paris, they arrived at Val-de-Grâce, January 17, that is to say, three days after the shell burst. They communicated with the attendants by signs; one got hold of paper and wrote several hours in the day rapid notes about the accident. However, hysteria or pure simulation was suspected in these three Zouaves, and they were placed in small separate rooms. They were informed through the physician’s remarks to his staff that these were cases of nothing but simple nervous shock such as we had often observed, and the claim was made that they would be completely well either on the morrow or the day after.

On the morrow, two of them partially recovered hearing and got back their voices. They became loquacious and began to tell about the battle. The day after, the third patient began to speak. Two of them showed traces of auricular hemorrhage, and in fact, actual ear lesions were found in all three. One had a suppurative right middle ear, with perforation; another had both drums perforated and a suppurative middle ear, also on both sides. The third, who recovered his speech after the others, had perforation of the left tympanum with a little suppuration of the right ear tympanum and a slight tear of the right tympanum. In April, 1915, the hearing was cured.

These men had been under fire several months, and had taken part in the battle of the Marne. It was not a question of their first baptism of fire, and in fact, each of them had been previously wounded. According to Roussy, the story is, that the shell-burst produces by displacement of air tympanic perforation, and at the same time a violent nerve shock with loss of consciousness for a few minutes. The men come to, but the ear lesion, probably exaggerated by the nervous status of its bearer, creates a complete bilateral deafness. This deafness produces an absolute hysterical mutism.

_Re_ case groups of war neurosis, several writers speak of dangers of contagion, but also emphasize the values of contact of patients with one another in the securing of therapeutic results. What Mott has termed the _atmosphere of cure_ was no doubt present in the three instances of Roussy just cited. The cure of one may act heterosuggestively to produce the cure of a second, and so on. Functional deafmutes are somewhat refractory as a rule. H. Campbell states that there is some danger attached to allowing large numbers of functional cases to consort together too closely. He suggests making use of small wards and screens, and a process of sorting out patients so that they shall not affect one another injuriously. Steiner especially stresses the value of individual rooms in preventing psychic infection, of which, he says, the danger is large in open dormitories. The psychic contagion is as a rule that of hysterical seizures and tremors; but complaints about faulty hospital arrangements are also readily spread. Steiner advocates never questioning a nervous patient concerning his troubles in the presence of other soldiers. To reach 60 to 70 patients, Steiner had one examining and treatment room. Roussy’s institution at Salins in 1917 had a service limited to traumatic hysteria, from which, in three months’ time, 200 subjects had been discharged cured (see Boschi).

Dysentery: Milk diet persisted in: Vomiting, incontinence, inability to walk. Cure by persuasion.

=Case 500.= (MCDOWELL, December, 1916.)

A soldier, 25, a low menial when war broke out, developed “dysentery and gastritis” at the Dardanelles, although even before the dysentery his nerves had gone bad. He had diarrhoea and vomiting, was sick every day, found himself unable to walk, and found himself always wet with urine dribbling day and night. Arriving in England and treated in a hospital, he still had vomiting. He had lived on milk and custard and been kept in bed.

Capt. McDowell convinced the patient that his legs were not as weak as he supposed. He was encouraged to walk, put upon light diet and then upon ordinary diet. He became an active worker in the ward, later going for five-mile route marches. Two months later he went back to duty in good health, weighing seven pounds more than before. This man was weakminded and, when his dysentery was cured, did not dare to start eating ordinary food. He was a victim of hospital régime. Individual attention would have obviated much of the subsequent state.

_Re_ vomiting, see remarks under another case of McDowell (Case 495).

_Re_ incontinence, see Case 384, of Guillain and Barré.

Officer dies in convulsions: Servant develops hysterical convulsions, which vanish on being explained as such.

=Case 501.= (HURST, March, 1917.)