Part 57

Early in the war, a lad, 19, was blown up by a shell. He was sent home paralyzed from waist down, and was seen by Capt. Buzzard after he had spent ten months in various hospitals, “carefully nursed, on the water bed, constantly using a bed urinal, smoking innumerable cigarettes, and eating countless chocolates.” He could not move his legs. They were wasted and flaccid. The knee-jerks could be got with difficulty. Plantar reflexes flexor. Complete anesthesia from umbilicus downwards, but preservation of abdominal reflexes. The navel did not shift downwards when the patient attempted to sit up. The incontinence was not real; urine was passed into the urinal at appropriate intervals.

Buzzard directed treatment “not to his spinal cord but to his mind; isolation; the stoppage of tobacco and all visits; the assurance that he would rapidly get well, together with some suggestive faradization of his legs.” This brought about a cure in a very short period. The atrophied legs eventually grew strong enough to walk.

_Re_ cigarettes in Shell-shock, Mott decries the over-liberal gifts of cigarettes that induced cigarette habits in both officers and men. Of course, the cigarettes are still more detrimental to cases of soldier’s heart than to other cases of neurosis. Mott remarks how over-frequent are the social tea-parties, joy rides and drives given by well-meaning ladies for the “poor dears,” actually perpetuating neuroses.

_Re_ atrophy, Babinski and Froment again bring up the question whether muscular atrophy can be brought about by a hysterical motor disorder. In point of fact, Charcot and Babinski were the first to describe the true hysterical amyotrophy, but this hysterical amyotrophy is exceptional in hysterical paralysis, and is slight when it occurs.

Shell-shock blindness, mutism, deafness: Blindness spontaneously vanished, 24 hours. Mutism, 2-3 months. Deafness cured by “small operation.”

=Case 514.= (HURST, September, 1917.)

A lance corporal, 26, became blind, deaf and dumb, though without losing consciousness, when blown up by a shell, August 29, 1916. His sight returned next day. On reaching England he talked in his sleep. Encouragement, electricity, etherization failed to effect improvement. One night in November he woke up and asked the sister for a drink; thereafter he talked normally.

Seven months after the shell explosion he was transferred to the neurological section at Netley, March 21, 1917. Deaf to air and bone conduction, a loud noise behind him caused a slight tremor of hands, with blinking and dilatation of pupils; but further stimuli of the same sort failed to produce such reactions. Normal nystagmus and giddiness on functional tests of vestibular nerve and canals. The internal ear was then probably free from organic changes. Since shell-shock mutism is always hysterical, it was probable that the deafness was hysterical. Under hypnosis (staring at lines for fifteen seconds) he showed no change. During natural sleep, also, a shout of “Fire” and metallic noises failed to wake the patient or to produce contraction of eyelids. Electric suggestion (despite the patient’s belief in electricity) and reëducation failed.

April 16, he was told that a small operation would have to be done April 20. To this he readily consented. Two small incisions were made behind the ear under light ether and suture was inserted. A loud noise was made during the “operation”; he heard this noise and jumped from the table. To his intense delight normal hearing returned in a few minutes. Next day hearing was tested and found normal to air and bone conduction. He was discharged to duty three weeks later and on his way to France, June 29, demonstrated his normal hearing to the physicians.

Deafness: cure by stimulating vestibular apparatus.

=Case 515.= (O’MALLEY, May, 1916.)

A private, 20 years of age, lost speech and hearing after the battle of Neuve Chapelle. Eight days later he came under the care of the laryngologist in a very excited state, pointing to lips and ears and carrying a note with information concerning his deafmutism.

Dr. O’Malley wrote on a piece of paper that he would restore the patient’s speech and hearing. Dr. O’Malley then used the mirror until the point of retching, and wrote, “You can speak now; count up to ten loudly.” He did.

Dr. O’Malley next used the cold water douche to the right ear to the point of giddiness, then shouting through a speaking-tube (see description below). The patient then found he could hear and the tears streamed down his face. Thereafter he was able to converse freely. Dr. O’Malley writes:

The treatment of functional deafness consists in exciting the vestibular apparatus as follows. Cold or hot water is allowed to flow in a steady stream into and out of the external auditory meatus by means of a tube attached to a receptacle placed about one and a half to two feet above the patient’s head and continued until he becomes very giddy and an active nystagmus is produced. A speaking-tube three feet long is then used by placing the ear-piece in the ear so treated, and the surgeon shouts into the mouth-piece the assertion, “You hear now,” and the answer, “Yes” comes promptly. The tube is now dropped and a conversation held as if no deafness ever existed. So far I have found the treatment of one ear sufficient. The patient is usually very emotional, as the disturbed vestibular function, which in these cases responds easily and markedly, causes him to feel as uncomfortable as a bad sailor on a stormy voyage. This feeling, however, rapidly gives way to one of pleasure at the return of his hearing. Where functional deafness and mutism co-exist it does not appear to be material which is treated first. In two cases of this kind under my care I treated the loss of voice first.

Bullet through mouth; Hysterical mutism. Treatment by operative manipulation.

=Case 516.= (MORESTIN, January, 1915.)

A Colonial infantryman, 32, was wounded December 17, 1914, at the Boisselle, being struck by a bullet which entered on the right side in the upper part of the neck and came out behind the left side of the mouth, having traversed the tongue, broken two teeth, and caused a good deal of hemorrhage by mouth. The patient felt his tongue swell, and from this time on he could not pronounce a word. He was sent to the ambulance, then to Mien, then to Saint Germain, and finally to Morestin’s surgical service. With wounds by this time healed, the patient found it hard to open his mouth. There was no trace of fracture of the lower jaw. The tongue could be only incompletely examined. The man swallowed liquids easily but could take no solid food. He tried hard to speak, made pantomime movements, grew emotional and lachrymose.

On the whole, however, it seemed that his inability to articulate sound could not be due directly to the lesion. There must be either simulation or hysteria. For four days he was attentively watched, and not once did he pronounce a word. He grew more and more stricken and humiliated by his plight. Rigorous diet did not cause his mutism to cease. Isolation and ennui did not decide him to talk. Accordingly, it was announced, in the man’s hearing, that an operation was to be done to restore speech. January 9, 1915, his face was copiously washed with alcohol and ether. Cocaine was injected to secure anesthesia and resolution of the muscles of mastication. Six c.c. of a 1-100 solution on each side. Shortly the surgeon began to open the jaws, against decreasing resistance. The tongue, which was not spastic, was seized with a tractor and rhythmic movements were executed with it. After a few of these movements, joy was painted on the features of the patient. He said that he wanted to speak and that he was about to speak. He shook the surgeon’s hands effusively and said, “_Merci_.” Although the first words came hard, little by little speech became free and a perfectly sincere elation at having recovered speech set in.

This man was neuropathic, having always been a rather strange, irritable and restless person, and given to nervous crises in anger, in which he lost consciousness entirely.

_Re_ pseudo operations as forms of disguised persuasion, almost countless methods have been used. See Cases 514, 515, 518, 519, especially 521, 560, 561. Sham injections under ethyl chloride have been made (Goldstein). See also under Case 484, _re_ continuous bath, and under Case 488, _re_ lumbar puncture. Very close to these methods are the methods of _torpillage_ of Vincent and the methods employed by Yealland in England and Kaufmann in Germany. See under Cases 574, 563, and 564, and 570.

Léri quotes Babinski as saying, “We cannot fight hysteria in trench warfare; manoeuvres are necessary.”

_Re_ treatment of mutism, Chavigny remarks that the principle of treatment for mutism is quite different from the principles of treatment of paralysis. The reëducation of mutism is psychic. Chavigny claims probably absolute success in the treatment of mutism through faradism to the larynx region simultaneously with a signal given to the patient to make an effort to pronounce the letter A. Garel modifies the treatment (in case the faradic apparatus is not at hand), by a vigorous and sudden blow to the patient’s epigastrium simultaneously with the patient’s endeavor to imitate the movement of the doctor’s lips.

Shell-shock: Impairment of vision (even commanded men to fire on kindred troops!) Improvement by verbal suggestion, faradization, injections.

=Case 517.= (MILLS, October, 1915.)

A sergeant-major, 29, in private life a bookkeeper, said that shrapnel struck the ground in front of him and burst as it struck. Unconscious for a moment, the sergeant-major thereafter saw everything imperfectly, led his men in the wrong direction, and even commanded them to fire in the direction of his own troops.

Seven days afterwards the eyes looked normal, fundi were normal, vision was reduced to the perception of hand movements; with a plus 10 sphere the right eye could count fingers at 5 c.m. and with a plus 8 sphere the left eye could count fingers at 3 c.m. There was a right frontal analgesia.

Treatment: Sweating; rest in bed for several weeks; assurance of complete recovery. There was a slow but constant improvement, aided by faradization and injections of strychnine sulphate into the temporal region, but the prospect of a return to the front retarded the improvement.

_Re_ injections into the temple, see also Case 521 of Bruce. _Re_ cure of blindness, Grasset has a case of a blind deafmute who was cured by a nurse. She put a pencil in his hand and guided the pencil while she wrote a question. The patient replied in very good MSS. In blind deafmutes sight is described as returning first, hearing next, and speech last.

For other cases of blindness, see especially under Section C, Cases 433 to 438, with discussions thereunder.

_Re_ retardation of improvement by the prospect of further military service, Lewandowski has insisted upon the strong factor of the wish in all such functional conditions. Lewandowski wants all functional cases, however, to be sent to duty in the rear or to be discharged as unfit.

Aphonia: manipulation in larynx.

=Case 518.= (O’MALLEY, May, 1916.)

A corporal, 28, had a bullet pass through his neck from a point in the middle line at the upper border of the thyroid cartilage to a point behind the right sternomastoid muscle, two inches below the point of entry. The corporal lost his voice at the time of injury, spat up a teaspoonful of blood, and thereafter was able to whisper only. The laryngoscopic examination betrayed no intralaryngeal lesion. Treatment as described below enabled the patient to speak. O’Malley describes his technique as follows:

The patient is placed in the common position for the examination of the larynx, the tip of the tongue being seized in a piece of linen by the left hand fingers and the laryngeal mirror introduced with the right hand. The patient is then requested to say “e” or cough, and if the cords do not approximate, they can be made to do so by using moderate friction on the fauces and pharynx with the mirror to excite secretion. The latter begins to drop into the larynx, and acting as a foreign body, a protective reflex is at once excited which adducts the cords to prevent the secretion from entering the trachea. At the same time an involuntary cough is produced to expel the mucus, and if the friction and flow of secretion are maintained and the patient is urged to cough vigorously, voluntary coughing and a tendency to retching with forced laryngeal notes will rapidly follow. It is usually best to persist until retching occurs, as the cords are then forced together to protect the larynx and trachea from the possible entrance of regurgitated stomach contents. Involuntary laryngeal sounds are thus produced and the patient is conscious of laryngeal effort. Some of these cases are at the moment very shallow breathers, which can be demonstrated by X-ray screening, but the act of retching causes a wide excursion of the diaphragm with a more pronounced expiratory blast, to be rapidly followed by deeper inspirations. This method of treatment is best carried out just before a meal, as the stomach is then practically empty and the unpleasant effects of the sudden regurgitation of food are avoided. When the explosive sounds accompanying retching have occurred two or three times the mirror is withdrawn, the tongue released, and the patient is requested to swallow, take a deep breath, and cough, and then urged to count up to ten, directing his voice to a certain point on the ceiling. This method has given me uniformly good results, and was rapidly effective in all cases coming under treatment soon after the onset of the neurosis.

_Re_ methods for curing aphonia, Muck has a method called the “ball” method. A ball is put into the larynx to cause a temporary suffocation, which produces a reflex that starts the adductors. He would apply the method as soon as the man was well over the shock that produced aphonia. Muck states that he has applied the ball method, not only to cases of aphonia, but to cases of mutism and deafness, with success.

Tilly mentions a case in which the patient refused to open his mouth, so the device was adopted of passing an electrode through the left nostril so that it finally reached the larynx. A spasm was produced, which was carried to the point of considerable cyanosis, but the aphonia was relieved and for the first time in three months the man spoke. Incidentally he began to hear also.

_Re_ treatment of aphonia, Schultz has used the electric current externally over the larynx, all the while carrying on a laryngoscopy. Schultz remarks upon the fatigue that may come during the first few sittings. Roussy and Lhermitte remark that, although aphonia sometimes exists from the outset of shock, it is often a phase in recovery from mutism.

Liébault notes that, not only cases of true nervous aphonia but cases of laryngitis, apparently of infectious origin, and cases of true voice strain, may also turn up for treatment. Some men have been improperly discharged from the army for aphonia actually due to voice strain.

Hysterical aphonia in a mechanician (war time contributory?). Cure by suggestive manipulation of larynx.

=Case 519.= (VLASTO, January, 1917.)

A mechanician was refitting an engine valve, when steam was suddenly put on and the drains were opened out. Some of the steam entered the throat of the mechanician, who rushed up, gasping, unable to speak. Oedema of the larynx was thought of; but there was no complaint except the inability to speak.

A month later he was discharged to the hospital ship at Plassy, where he got faradic treatment, the effect of which was to cause him pain without recovery of voice. The man could whisper well enough and cough fairly loudly. The vocal cords of the larynx appeared normal on laryngoscopic examination, but adduction of the cords was not be properly effected. He was now given rest and constant assurances that he would get well.

Ten days later, another laryngoscopic examination was made, with mild mechanical stimulation of the air passage. The patient remarked that he had never been so near being able to speak since his dumbness came on. The patient was now informed that his muscle of talking was going to be replaced and that the success of the operation depended upon his help, so that he was to shout out as soon as he became conscious of the physician’s working inside his throat. The patient was given ether lightly, into the second stage. When consciousness was about to return, the laryngeal mirror was placed lightly on the larynx. The patient was commanded and encouraged to count out loud and shout. Speech returned permanently.

It is to be noted that there was no specific war effect underlying the phenomena, unless we regard the fact of its being war time as contributory to the shock produced by an incident in every day engine room duties.

Gradual onset of mutism and amnesia without special occasion. Faradism. Dream.

=Case 520.= (SMYLY, April, 1917.)

A soldier was slightly wounded in the arm and returned to the trenches. Later he found himself in hospital at Boulogne, unable to speak and unable to remember what had happened to him from the time he was in the trenches. It appears that his voice and memory had gradually disappeared, according to what was told him by his comrades.

A month afterward, in a London hospital, the patient was roused suddenly from sleep, and then proved able to speak, although there was great difficulty in getting each word out. Two months later, he went to bed, feeling indisposed, in the night had a kind of fit, and remained unconscious until the following night; the next morning, his voice was again lost. The aphonia persisted for a fortnight, and the patient could hear only loud shouting when close to his ear. He was anxious to get well and requested electricity from the physician, Dr. Smyly, having heard probably of another case cured thereby. Dr. Smyly applied faradic current to the larynx externally, instructing the patient to blow at the same time. At first the patient spoke so low that he could not hear himself speak, but on suggestion succeeded in speaking up loudly enough. He was shortly able to speak and hearing improved. The climax arrived with a bad dream one night, from which the patient awoke in a fright and found himself able to hear and speak perfectly.

_Re_ nocturnal spontaneous cures, see observations by Mott under Case 473. Note also in this case the presence of what Mott has termed “the atmosphere of cure.”

_Re_ relapses, see Case 476 as well as remarks under Case 474. _Re_ special cases of mutism, Goldstein has insisted upon a greater individualization of treatment for functional mutes than even for other neurotics, and advocates the establishment of schools within the hospitals and aftercare institutions. He thinks the problem very serious.

Shell-shock blindness: Cure by a course of injections in the temple.

=Case 521.= (BRUCE, May, 1916.)

A soldier from Gallipoli was admitted to the Royal Victoria Hospital at Edinburgh, blind. He had been at Gallipoli from May 1, 1915, until August 12, when a shell explosion blew in his trench and buried him. He was dug out nervous and tremulous. Shortly afterwards there was the bright flash of a second shell, and amnesia set in until he found himself in hospital. He could not see at all with the left eye and the sight of the other was poor. He arrived in Scotland, October 9. He was nervous, excitable and now somewhat depressed, complaining of blindness and pain in the left eye, and headache. The left eyelid drooped. The fundus was normal. He had not been given an anesthetic.

It was explained to him that the eye had not been injured; that it had become weak from the explosion; that he would be given a series of injections into the left temple of a strong drug which would restore the sight of the eye.

Gradually increasing quantities of normal saline solution were given every morning. After four days he said that the treatment was doing him good. A week later he said that the eye was much stronger. After the fifteenth injection he could not sleep. The headache was worse, and there was “moving about inside his head.” Early in the morning he went to sleep after a period of restlessness. He awoke at eight o’clock able to see perfectly, and was overjoyed at the result. There was some blurring and four days later he said he was becoming blind again. More normal saline was injected, causing pain. After that there was no relapse, and the man was sent back to his unit.

_Re_ Shell-shock blindness, Ormond and Hurst recommend a light hypnosis; taking the functionally blind man into a dark room and requesting him to make his mind a blank. Some cases are refractory. An anesthetic may be used with suggestion in the semi-conscious stage.

Deafness, cured by suggestion in writing.

=Case 522.= (BUSCAINO and COPPOLA, 1916.)

L. G., 20 years old; fusileer. (Mother of neuropathic constitution. Father died in 50th year of heart disease. One brother had hemiparesis from infantile cerebropathia.) The patient suffered from infantile otitis media bilateralis, which was followed by abundant chronic otorrhea from his fifteenth year. He relates that for a long time he was obliged to wear a very large handkerchief on his shoulders to receive the pus, which came from an ear. No sex disease. Nothing of importance in the physical anamnesis.

Patient entered the army, Jan. 15, 1915. In May, he was sent to the front (Basso Isonzo). Towards the end of July, while he was in the trench, a grenade exploded a short distance from him, causing slight abrasions at the nape of the neck and in the fleshy part of the left calf. He was picked up in an unconscious state, and taken to the hospital at Cervignano, where he was admitted as a deafmute and was given electric treatments. After 18 days or so, first stammering and then pronouncing with difficulty a few words, he finally regained his speech entirely. Deafness continued, however.

Being transported to a special hospital in Florence, he was in a state of psychic excitement for several days, showing also visual hallucinations--saw “many soldiers,” saw “many soldiers all about him.” He was treated with chloral and bromide. The suspicions of several physicians were aroused by the obstinate declaration by the patient that he was incurably deaf.

On being admitted to the clinic on August 22, he showed complete deafness in addition to a slight degree of stupor; he remained impassive to the glance of his questioner without showing signs of worry about his condition, nor did he make any effort to make himself understood by making lip-movements (which is in contrast to another patient affected by organic deafness, who on the contrary made great efforts to understand anything said to him, clearly showing his great grief over his incapacity).

He failed to respond to auditory stimuli either by air or by bone conduction. It was possible from the beginning to exclude suspicion of simulation; during the day, indeed, it was not possible by any of the repeated attempts to awaken surprise in the patient by means of an acoustic stimulus. At night, while the patient slept, it was possible, however, to awaken him by calling his name, or by making a fairly loud sound; the patient would then open his eyes but was quite unable to hear. Neither confusion nor hallucinations were in evidence.