Part 56

An officer and his servant were blown up by a shell. The servant ran to fetch a stretcher for the officer, to whom he was much attached, but on his return the officer made a few convulsive movements and died. Immediately after, the servant had a fit. During the next two months he had eleven more. Hurst made a diagnosis of hysterical fits resulting from emotion, explained his idea of their origin and nature to the servant, and the convulsions then ceased completely.

_Re_ hysterical convulsions, see remarks under Case 443.

Course of a case with crises of trembling.

=Case 502.= (ROUSSY, April, 1915.)

A soldier in the artillery, who had been in the lines from August as a kitchenman, looking after the food of the first line trenches, with which his shelter was connected by communication trenches, 800 meters away, was on January 17, 1915, with three other men placed in the shelter kitchen of the trenches but a short distance away from the French artillery. The firing passed over the heads of these men but they could feel the windage, which obliged them to lie down each time. The evening of that day, several hours after firing had ceased, the kitchenman had a shivering spell, with trembling that lasted all night; after which these crises came on every day. He had finally to be evacuated to the rear.

According to Roussy, such patients always have neuropathic taint and a history of previous crises. Such a patient ought to be handled with rather severe discipline. In this way, according to Roussy, the reappearance of a severe attack of convulsions can be prevented. But these patients cannot go back to the front.

_Re_ tremors, see Cases 224 and 225.

Two cases of lameness cured by persuasion: Russel.

=Case 503.= (RUSSEL, August, 1917.)

A man on crutches, paralyzed completely in the right leg, partially in the left, developed paralysis in the right arm from the use of the crutch. There were marked vasomotor changes in the right leg and arm together with anesthesia to pinprick. Assured that he could move the legs perfectly he said that he had tried and failed. After a persuasive talk in private he began to use the arm, and to walk perfectly. It seems that in the trenches he had a sharp pain in the right knee, after which he did not use the leg and it gradually became more and more useless. It had been paralyzed for three months. The reason he did not use this leg was not on his own account, but on account of his mother at home. He seemed really grateful for the cure.

=Case 504.= (RUSSEL, August, 1917.)

A sergeant in hospital for a year for shell-shock still had a marked shaking of the right leg whenever he raised it from the ground. He walked in leaning on a silver headed cane. The functional nature of his shaking was explained to him by Russel, whereupon he walked out normally saying he could do without his cane. Russel suggested that crutches and sticks thus given up were often donated to the shrine. The sergeant whose cane must have cost at least three pounds beat a hasty retreat carrying the cane in front of him.

_Re_ Russel’s general point of view concerning malingerers and psychogenic cases, see under Case 458.

Hard patrol work: Delirium; head tremor augmented by excitement: Virtual recovery on bandaging neck, isolation, open air, to-and-fro transfers to mental and nervous wards.

=Case 505.= (BINSWANGER, July, 1915.)

A metal moulder in civil life, 29, in military service 1907 to 1909 (no hereditary taint, moderately good scholar), became unconscious for a half hour after taking a cold drink following a somewhat long practice march, at some time during his first year of military service.

He was in several skirmishes in Belgium and Northern France early in the war, being once surrounded in patrol work (November 11) by Turcoes and Zouaves. There was a lively exchange of shots, in the course of which five of the eight men on patrol fell. The three survivors hid themselves for three days in a quarry, and on the fourth were found by the advancing troops, and immediately went into battle.

But during a pause while on the point of taking coffee, the man suddenly fell sick, tried to carry on, but lost consciousness and apparently remained unconscious for about three-quarters of an hour. It seems that he raved and shouted and tried to bite his fingers, being held with great difficulty by several comrades. He was removed to a dressing-station three km. distant.

At the dressing-station, his head began to shake, although he was unaware of this until his attention was called to it by his comrades. He said that he felt restless and that his head ached almost continually. He was carried to the reserve hospital, and from thence, December 9, 1914, to the nerve hospital at Jena, where he was unaware of the shaking of his head (which had now lasted for three weeks), and said that he felt a thick fog in his head (to say nothing of headaches), and was only free and clear in his head while standing in the open air.

His sleep was restless and poor; there were war dreams almost every night. In the process of getting to sleep, his arms and legs frequently twitched. He would soon tire and feel weak. Also since his dangerous experience, he had noticed a change in his speech: always fluent before, it was now hard for him to speak because one had to exert one’s head so much in speaking.

This head tremor was in fact the most marked symptom of his illness. It would increase on every active motion of the head, but ceased almost entirely when attention was diverted. The head would then be held bent to the right.

During emotional excitement, the shaking spasm would spread over the entire upper part of the body, but would remain more severe upon the right than upon the left side. The forearms would fall into a lively shaking movement of pronation and supination. The hands and fingers would be attacked by a less marked tremor. After calm had set in, a fine tremor of the right hand would remain plainly noticeable. The musculature of facial expression would frequently fall into spasmodic movement, the left corner of the mouth twitching, the lips set for whistling, or the upper lip making movements as if snuffing spasmodically.

Physically the man was of medium height, strongly built, with adherent lobules, and a somewhat pointed skull. The teeth were defective and irregularly placed. Both deep and skin reflexes were increased. Marked dermatographia and mechanical excitability of the muscles: periosteal reflexes strongly developed; numerous pressure points in the head. The right temple and back of the head were painful on percussion. The patient showed no disturbance in touch and pain sensibility. Outstretched tongue showed marked fibrillary twitching; speech was difficult, being slow, awkward, stumbling, and sometimes hesitating (suggesting the speech of general paresis). At other times, the speech was of a peculiar sighing, tremulous nature, reminding one of the speech of children complaining or asking for pity. Rest was secured by injections of salt solution. A few days later, the treatment was continued by a bandage about the neck. After this the tremor grew slighter and would even remain absent for some hours. The patient was told to rest in bed and not to speak much; being “seriously ill,” he was kept alone. He was often irritated, querulous, and subject to outbursts of profanity. He took food well and slept well, receiving sodium bicarbonate.

The bandage was changed after five days. The tremor was very marked. The patient was furious because visitors were refused to him. He was especially angry with his nearest relatives and his betrothed, and wrote defiant letters to all of them. He became one of the most troublesome patients in the psychiatric division of the hospital. He complained sometimes of anxiety and feelings of unrest. He received treatment by pantopon. He continued to be a very disagreeable patient, feeling himself opposed and not properly considered. He thought himself seriously ill, behaved much like a spoiled child, and was of the opinion that he would not get well in the hospital because they were grieving him so. His appetite became bad; he complained of pains in the loins and of rheumatism in the legs. A cord was found hidden in the bed. The patient expressed suicidal thoughts at various times.

At the beginning of January there was marked improvement. The headshaking ceased almost entirely; the patient walked in the garden some hours daily. However, in the middle of January, on refusal of furlough, the head-shaking began again markedly. At his request a bandage was placed on the head again for a few days. He seemed emotionally very tender; his head would shake at the sight of a dead rabbit.

He was transferred to the nerve division of the psychiatric clinic at the end of January. He had recently begun to complain of flickering before the eyes. The ophthalmologists established an existence of a choroiditis disseminata. The eye examination had a markedly depressing effect upon the patient, and the shaking spasm of the head appeared again. Upon being told that he would have to be sent back to the psychiatric section of the clinic, the shaking immediately disappeared (24 hours after it had begun).

Thereafter slow improvement followed. He stayed in the open a great deal and walked. March 2, he showed a vehement outburst of anger, quarreling and using violence with a comrade. He was brought back to the psychiatric section, and in transit had a severe hysterical attack with unconsciousness, crying fits, and stepping movements of the extremities. He was promptly taken to a section for those seriously ill. The next day, upon his assurance that he could control himself, he was put in a more quiet division. He began to take part in gymnastic exercises, worked as a coachman, and then as an experiment was sent to a gentleman’s estate for recreation. At last accounts he was feeling well except that he occasionally had headaches during work. He could not work so hard as before on account of the rapid onset of fatigue, especially when working in the sun. The head-shaking recurred but seldom and lasted for a few hours only when the patient became angry or when there was much noise about.

Rationalization of war memories: Returned to duty.

=Case 506.= (RIVERS, February, 1918.)

A young English officer was wounded just as he was extricating himself from burial in a mass of earth. He became nervous and sleepless and lost his appetite. After the wound had healed, he was sent home on leave, which had to be extended as he got worse. An out-patient in London for a time, he was finally sent to a convalescent home, still troubled with insomnia, battle dreams and concern about his recovery. He made light of his condition and was on the point of being returned to duty by the medical board, when his sleeplessness led to his being sent to Craighlochart War Hospital.

He could not sleep without a light in the room, else every sound attracted his attention. He tried hard all day long to banish all unpleasant and disturbing thoughts, but at night it took him a long time to get to sleep and then came vivid dreams of warfare. He did not, himself, feel that he could ever forget the war scenes.

Rivers, in general believing that the attempt to banish such experiences absolutely from the mind is poor psychotherapy, narrated his views to the patient. Rivers advised him no longer to try to banish the memories, but to try to transform them into tolerable, if not pleasant, companions. The war experiences and anxieties were talked over. That night the man had the best night he had had for five months, and during the following week the sleeplessness was no longer so painful and distressing. If unpleasant thoughts came, they had to do rather with home life than with the war. General health improved; insomnia diminished. He was at last able to return to duty.

Rationalization of war memories.

=Case 507.= (RIVERS, February, 1918.)

An English officer was buried by shell explosion and developed severe headache, vomiting and disorder of micturition, yet remained on duty for more than two months. Collapse came when he went out to seek a fellow officer and found the body blown to pieces, with head and limbs severed from the trunk. This vision haunted him in dreams. Sometimes the officer appeared as on the battlefield; again as leprous. The officer would come nearer and nearer in the dream, until the patient woke pouring with sweat and in utmost terror. Accordingly, he was afraid to go to sleep, and spent all day thinking painfully about the night to come. Advice to keep all thoughts of war out of mind merely brought the memories in sleep upon him with redoubled force and horror.

Rivers’ therapy was to draw attention to the fact that the terrible mangling proved conclusively that the officer had been killed outright and without pain. The officer said he would now no longer attempt to banish the thoughts and memories of his friend, but would concentrate on the pain and suffering his friend had been spared. No dreams at all came for several nights, but one night in his dream he went out into No-Man’s-Land and saw the mangled body, but without horror. He knelt down, as he had in the original experience, and woke as he was taking off the Sam Browne belt to send to the relatives. A few nights later came another dream in which he talked with his friend. There was but one more dream in which horror occurred.

Rationalization of war memories: Eventually unfitted for military service.

=Case 508.= (RIVERS, February, 1918.)

A young English officer, after doing well for a period, was rendered unconscious by shell explosion. The first thing he remembered was being led by his servant towards his base, thoroughly broken down. He had headaches, sleeplessness, war dreams and spells of terrible depression appearing with absolute suddenness, unlike ordinary “blues.” For ten days in hospital no such attack appeared, but one evening he came to Rivers pale and anxious. A few minutes before, he had been writing a letter in his usual mood, when this causeless depression came on. In the afternoon he had walked about on some neighboring hills. The letter dealt with no depressing matter. In ten minutes the depression vanished. Nine days later another came as he was standing idly looking out of a window. The attack lasted for several hours, as no physician was present to meet the issue. If he had had a revolver he would have shot himself.

Rivers was inclined to interpret these gusts of depression as due to a forgotten but active experience. As there was no definite tendency to dissociation, Rivers hesitated to plunge in with the hypnotic method, nothing short of which, however, served to recall the incident. The man was gravely apprehensive about fitness for further service, and was repressing his fear, as he thought it either was cowardice or would be called cowardice. The patient, by his discussions with Rivers, had already become familiar with the idea that the gusts of depression might be due to a submerged experience. Perhaps, however, there had been no experience, and the patient was advised that possibly the thing repressed was the idea about fitness for service. Accordingly, the patient agreed to face the situation. One transient attack of morbid depression occurred, after an operation. Then the man fell into a state of anxiety neurosis such that he was passed by a medical board as unfit for military service.

Rationalization of war memories: Commission relinquished.

=Case 509.= (RIVERS, February, 1918.)

An oldish English officer lost consciousness while looking at the havoc wrought by shell explosion. Probably there was a second shell that sent him off. He was eventually admitted to an English hospital with paresis and anesthesia of legs, severe headache, sleeplessness and terrifying dreams. Hypnotic drugs and advice neither to read nor to talk about the war were the measures adopted and after two months in hospital he was given three months leave. He buried himself in the heart of the country, away from relatives, with aspirin and bromides. He began to sleep better and had less headache. When the president of the medical board asked a question about trenches at the end of his period of leave, however, he broke down and wept. He again repaired to the country for two months’ leave, for the chosen treatment by isolation and repression.

An order was then given that all officers must be either in hospital or on duty. He was sent to an inland watering place and treated by baths, electricity and massage, whereupon he rapidly became worse, especially as to sleep. He was transferred to Craiglochart in an emaciated state, with an expression of anxiety and dread, paresis of legs, sleeplessness and war dreams.

He was now advised to give up repressing, to read and talk a little about the war, and to accustom himself to thinking about war experiences. He did this but half-heartedly, as he thought the ideal treatment was what he had so long followed. Nevertheless, he got distinctly better and the content of the war dreams was altered to home scenes. He was still loath to acknowledge his improvement and thought that he would have recovered if he had not been taken from his retreat and sent to hospital. As it was obvious that he would be of no further use in the army, he was allowed to relinquish his commission.

Rationalization of war memories, without redeeming feature as nucleus.

=Case 510.= (RIVERS, February, 1918.)

An English officer was flung by shell explosion so that his face struck the ruptured and distended abdomen of a dead German. The officer did not immediately lose consciousness and got distinct impressions of taste and smell and an idea of their source. After a period of unconsciousness he came to, vomiting and much shaken. He carried on several days, still troubled by vomiting and haunted by taste and smell images. Several months later he was observed by Rivers suffering from horrible dreams, in which the battle experience was faithfully reproduced. He got no relief except when he went into the country, far from every suggestion of war. Rivers’ psychotherapeutic plan of finding a redeeming feature in the experience, upon which the patient might concentrate, failed because there was no redeeming feature. Accordingly, it was thought best that the man should leave the army and seek the conditions that had given him slight relief.

_Re_ psychoanalysis and its modifications, see remarks under Case 496, under which several favorable opinions were mentioned. Boschi in his report on French conditions gives no reference concerning psychoanalysis or hypnosis. Bruce has found blended with the war dreams many episodes quite alien to the war, and considers that the patient’s ante-bellum history is of importance, since ante-bellum emotions may be revivified by the war. Craig states that he has not been impressed favorably by the results of psychoanalytic treatment. Arinstein from Russian experience gives preference to Dubois’ psychotherapy over hypnosis and psychoanalysis. Nonne states that the data of the war prove that hysteria is neither a degenerative disease according to classical theory, nor a disease based upon Freudian principles.

Post rheumatic “paraplegia” (or abulia?) cured by removal of crutches, after question of discharge “unfit” had been raised.

=Case 511.= (VEALE, November, 1917.)

A soldier, 23, had fever with swelling of several joints and temperature in 1915, and was furloughed to England. He complained of pains in the limbs and shortness of breath, and was put in hospital. As he did not improve, he was sent to a special hospital for baths and electricity. There he remained from August, 1915, to March, 1916, with D’Arsonval baths, cataphoresis, electric treatment and massage.

He was now sent to the second Northern General Hospital to see whether he should be discharged permanently unfit. Here he shuffled along on two crutches, very tremulous, and sweating, and suffering from palpitation on exertion. He wanted to take poison if he could not be cured.

The crutches were taken away. He was asked to walk up and down. He had to be supported at first and fell several times. The exercises were continued. Massage and drugging were stopped. The next day he was able to stand alone. In twenty-four hours he walked by himself. The other patients in the ward encouraged him on account of the genuine exertions he was making to get well. April 7, he returned to duty, smart and well set up.

Babinski and Froment always give the suspected subject the benefit of the doubt, never uttering the word simulation in the presence of the soldier, and proceed to psychotherapy; for psychotherapy will act to cure simulation or exaggeration just as it acts to cure hysteria. They say that in their experience, all these disorders of doubtful nature--that is, that lie diagnostically between hysteria, exaggeration, and simulation--are as a rule cured by resort to psychotherapy provided that the due amount of energy, tact, and perseverance is employed. See also remarks under Case 453. Veale’s case (511) never showed _mauvaise volonté_, and nothing more than aboulia.

“Trench foot,” “neuritis,” a year of astasia-abasia or at least of complaint of inability to stand or walk. Treatment by a “cruel though justifiable” process.

=Case 512.= (VEALE, November, 1917.)

A regular army man, 38, well built and muscular, in Flanders the first winter, returned to England in January, 1915, with “trench foot.” “Neuritis” then developed, with loss of power to walk. Baths, electricity, massage, sympathetic wheeling about in a chair by women, all failed.

January 11, 1916, he still complained of inability to walk or stand. The reflexes were exaggerated. He was able to get into a wheel chair from bed by jerks, associated with palpitation, tremors, flushing and sweating.

He was told that he had now recovered from the neuritis. Crutches, sticks and wheelchair were removed. He flopped about and then lay on the bed exhausted. In a few days he began to shuffle about and was put on the stationary bicycle. January 29, he left the hospital well, remarking that though the treatment at first seemed cruel, it was fully justified.

_Re_ genuine polyneuritis, Mann gives German experience regarding neuritis as somewhat frequent and affecting a special form which he terms polyneuritis neurasthenica. He states that the commonest instances of mononeuritis developing in the war are the sciatic and trigeminal. The neuritis often outlasts the other symptoms. The treatment was rest, tepid baths, and electricity. Naturally, alcohol and syphilis must be excluded in the diagnosis.

Nonne also described non-alcoholic, non-syphilitic, and non-infectious polyneuritis in neurasthenics, which he, however, finds most common in the ulnar, median, radial, anterior crural and posterior tibial nerves.

_Re_ “spa” treatment, Turner thinks there may be easily too much massage, electricity, bathing. He prefers segregation in special hospitals to “spa” measures in general hospitals, prefers occupation to rest, and calls attention to the stimulating value of the gratuity to be paid on leaving the hospital.

Shell-shock paraplegia: Treatment by bed, cigarettes and chocolates altered to isolation, no tobacco, no visitors, faradization. Recovery.

=Case 513.= (BUZZARD, December, 1916.)