Part 61

But the next morning he was again stone deaf in the left ear. Blistering and electricity failed to produce benefit. He was, however, puzzled about himself.

After a fortnight he was again given ether and a little chloroform was added. The yes-no test was again positive. He was allowed to recover gradually from the chloroform, but he had now lost recollection of what had happened. The left ear remained deaf. Ether was again given. He was asked to close his right ear with his finger. While answering questions addressed to his left ear, he was suddenly awakened and immediately said that his hearing had come back. This return proved permanent. He returned to his dépôt. In the conversations under ether there was no stuttering. He had been totally deaf in the left ear for five months.

Blow in neck by rifle butt: aphasia, right hemiplegia and hemianesthesia, and especially (here MEDICAL suggestion) trismus: Recovery by anesthetic and suggestion.

=Case 554.= (ARINSTEIN, September, 1915.)

A Russian soldier was struck in the head and neck by a rifle butt, and developed paralysis of right arm and leg with loss of speech. After the excitement experienced by the patient when exhibited to the students by the late Prof. M. N. Szukowsky in the neurological clinic of the Military Medical Academy, trismus developed.

The patient spent a year in various hospitals, the most diverse methods of treatment by drug therapy, electricity, and suggestion yielding no results. The patient had to be fed chiefly by nose and rectum, though small quantities of fluids were fed through the mouth through an opening formed by the falling out of one tooth in the upper jaw. The patient became greatly emaciated and weak and was, October 29, 1915, brought into the nervous wards of the hospital.

He showed flaccid paralysis of left arm and leg, together with anesthesia, analgesia and thermanesthesia over the whole left side of the head, extreme general atrophy of muscles, somewhat more marked on the palsied side. The temperature of the paralyzed half of the body was not lowered. No knee or Achilles reflex obtained upon either the affected or the healthy side (general exhaustion?). Abdominal and testicular reflexes lively. The pupils responded well to light. Corneal reflexes lively. The neck was held awry to the left, and the head was inclined somewhat downwards and leftwards; hearing on left side impaired. The jaws could not be opened even with the greatest effort. Wassermann reaction negative.

Patient thought himself incurable. Purves Stewart’s case, in which chloroform and oxide of nitrogen were used, was the basis of Arinstein’s treatment. It was suggested to the patient that he submit to narcosis with the proviso that he would not be operated upon. His consent was secured; with the coöperation of others, the chloroform was administered November 6. The stage of excitability was not well marked. 8 gr. of chloroform was used altogether, by the drop system. Nevertheless, even with the weak initial excitability, the patient became capable of some movements with paralyzed hand and foot. On opening mouth, the patient yawned yet uttered no sound. Between the jaws was put a rubber insertion and upon awakening the patient was let see with his own eyes that his jaws were open and that therefore food might be introduced through the mouth. Upon repetition of the narcosis, 5 gr. of chloroform was used altogether, and the stage of excitability was this time better marked. To strengthen movements in the paralyzed extremities, the device of pricking the patient with a pin on the unaffected half of the body, with the unaffected hand and leg held horizontal by assistants, was adopted. The patient then made reflex defensive movements in the paralyzed extremities, especially the hand. At this point the narcosis was suspended, and the irritation with the pin was continued until consciousness returned. At this moment, the patient’s attention was called to the disappearance of the paralysis and his restored ability to move the paralyzed extremities.

From that time on, the patient’s condition underwent a sharp transition. Artificial feeding became unnecessary. The patient ate by mouth; the mouth was opened by the leverage of a small stick held by the patient between his teeth. Speech returned gradually. In reading aloud the patient aided the movements of his lips with his hands. At the time of report the patient spoke well, ate normally, had gained in weight, and with some effort could sit down and even stand and walk. All this was attained in a relatively short time after a whole year of paralysis.

The author felt that the success attained in this case gave him the right to use the same method where the cause was not a contusion.

Ten months’ field service; severe FEBRILE DISEASE: Afterward hysterical TRIPLEGIA, MUTISM, “JUMPING-JACK” reactions to stimulation of feet. Cure by anesthesia, verbal suggestion, faradism to palate.

=Case 555.= (ARINSTEIN, September, 1915.)

A Russian private, 30, brought to a field reserve hospital, June 20, 1915, was in a grave condition diagnosed typhoid. By the end of June the general condition had improved and the temperature had fallen.

July 9, worse; happening to be in the company of a sanitary in a privy, he was observed suddenly to fall unconscious, with both feet and left arm paralyzed. Soon afterward he lost the power of speech. From September 30 to October 19, he lay in field hospital; but was then transferred to the nerve hospital with diagnosis: convulsive paralysis and aphasia. At entrance, complete paralysis of both legs and left hand; loss of speech and aphonia (speech understood). Upon touching a foot, strong convulsions developed with legs rapidly drawn apart and drawn together much in the manner of dancing toys. The mouth was twisted to the left. Though he silently opened his mouth and made rapid movements with the lower jaw, he could not utter a single sound, either vowel or consonant. Left hypalgesia. Hypesthesia of skin of hand and mucosa of tongue. Knee-jerks absent because of the strain of the muscles of the legs. Wassermann negative.

The history showed that the speech of the patient had been incorrect and indistinct from childhood. Moreover, in 1908, in chopping wood in the forest he had fallen under a sleigh and hurt his left hand, which had not since fully recovered. He had volunteered for the war.

The psychogenic character of the disease seemed clear. Suggestion was followed by ether narcosis, during which, on pricks of the healthy side with a pin, the patient made defensive movements with the paralyzed hands, and also moved both legs. Speech was not regained either during or immediately after the narcosis, although the patient gave forth indefinite sounds. Speech was restored on the same day, September 7, with verbal suggestion and faradic brush applied to palate. The patient at once began to speak clearly and distinctly, read his prayer book, and described distinctly and in detail how he went to war. From that moment the convulsive movements in the feet disappeared, the region of anesthesia on the left side narrowed, speech was permanently reëstablished, and the patient began to move with his feet and finally began to walk after six months of paralysis. Before that time no medical treatment had had the slightest effect. The effort to stop mechanically the jerks even temporarily by means of plaster casts had been unsuccessful. In sleep the twitches ceased, but upon reawakening, even before full consciousness returned, the jerkings would resume. It is curious to note that upon falling asleep under the anesthetic the patient would issue always one and same kind of yells--“_Help, there goes the German! They are shooting! Russians, do not yield!_”

_Re_ chloroform anesthesia, Milligan remarks that the treatment should be carried out in a quiet, single room, with the chloroform slowly administered and the suggestions made by the anesthetist during the optimal phase for suggestion,--just before the stage of involuntary struggling.

Shell-shock; unconsciousness: Mutism and musical alexia. Cure by anesthesia.

=Case 556.= (PROCTOR, October, 1915.)

A private, 23, was admitted to the Duchess of Connaught’s Hospital at Taplow from Gallipoli, September 10, 1915. A shell had exploded behind this man. He had been picked up, unconscious, and remained so about a day. He recovered without the power of speech. Cerebration was slow at first but improved steadily.

The man had been a professional musician. Curiously enough, though his ability to read ordinary print was as good as ever, his reading of music was lost with the speech.

September 20, he was etherized, but being of a phlegmatic type, he was not readily excited and took the anesthesia very quietly. After perseverance, however, he was induced to talk. The ability to read music returned with the voice. He was discharged, October 4, 1915.

_Re_ the use of anesthetics for curing deafmutism, Colin Russel rather disapproves of this method on the ground that no attempt is made to get at the genuine pathogenesis of the case and that accordingly there may be a tendency to recurrence.

_Re_ the peculiar musical alexia, see discussion under Cases 353 and 450 of confusion and amnesia. The most highly selective amnesias have been found in confusional cases. However, Case 556 had been a professional musician and the effect may have been a highly specialized suggestion. See also Case 369 of Feiling for differentiated musical disorder. Mott has used the retained knowledge of tones as an avenue of approach in certain mute cases.

Shell-shock; burial (24 hours?); unconsciousness, 13 days: Deafmutism. Chloroform narcosis cured the deafness (!), not the mutism.

=Case 557.= (GRADENIGO, March, 1917.)

An Italian infantryman was buried under Mt. Zebio after shell explosion. After 24 hours he was found and dug out. He remained unconscious for 13 days and came out absolutely deaf and mute.

At hospital he was markedly depressed and cried very readily on being spoken to. The tympanic membrane had lost its sensitiveness to pain. As for the speech mechanism, the larynx proved negative. All the movements of the soft palate, tongue and vocal cords could be normally performed. The tongue was anesthetic to touch, but the taste function was perfectly preserved. The cheeks and various parts of the face were also anesthetic to touch, and the lobules of the ears could even be pierced with large pins without reaction by the patient.

He tried to pronounce labials, opening and closing the lips rapidly; but the expiratory movement was too weak, and not a single sound was made.

At the patient’s request, he was chloroformed. During a very violent excited phase, he did emit groaning sounds. The narcosis, however, did not put an entire stop to the mutism, since only a few inarticulate sounds could be emitted, and those only after great efforts. Curiously enough, however, the chloroform narcosis had caused the _deafness_ to disappear entirely. Another narcosis upon the patient’s insistent request was given but remained without results, and at the time of report, the patient though cheerful and intelligent-looking, was still mute.

Treatment of two cases.

=Cases 558 and 559.= (SMYLY, April, 1917.)

A soldier was out with a bombing party when a shell burst. He came to in a casualty clearing station, and was sent on to Salonica, deaf, dumb and jumpy. Two months later, an attempt at hypnosis failed; faradism of vocal cords failed.

The patient dreamed one night that if he vomited he could speak. Ipecac produced vomiting without speech. The patient, however, wanted a second dose, and while waiting for it, uttered an exclamation, which he did not himself hear, however. In the meantime, Dr. Smyly had been trying to hypnotize a second soldier, dumb but not deaf. This man’s dug-out had been blown in on him seven months before, whereupon the patient became very shaky, but did not become sick for a week. He was then sent to hospital, and his voice gradually disappeared. He suffered from violent headache and spasmodic movements of the arms and legs. Suggestion seemed powerless, and ether was unexpectedly given to the patient. While going under the ether, he said, “Oh dear, oh dear” several times indistinctly. It seems that another physician had already tried to cure the patient of dumbness by removing teeth without an anesthetic.

While this therapy was proceeding with the dumb man, the deaf-and-dumb man disappeared. It seems that the smell of the gas had caused him to take refuge on an outhouse-roof. The next day he had recovered voice and hearing completely, partly from shock and partly through suggestion.

The etherized patient did not recover voice but lost the spasmodic movements and his insomnia. A week later ether was again administered, and the patient was strapped down; as he was coming to, faradism was applied to the head and face. The patient then quickly recovered his voice and still retains it.

Shell wound: Hysterical dysbasia from contracture. Many methods of treatment fail. Success with “a new measure,” _e.g._ stovaine.

=Case 560.= (CLAUDE, March, 1917.)

A sergeant was struck in the suprapubic region, December 15, 1915, by a shell fragment and got a large hematoma in the perineal region (shell fragment visible on X-ray). The man was treated a year in a center for physiotherapy and was then treated in a neurological center, where a faulty position of the right thigh maintained in extensor rotation and abduction was found. The patient walked on crutches, legs wide apart, balancing with body.

Upon transfer to Bourges, an intraspinal injection of stovaine (after withdrawal of 2-3 cc. fluid, 1 cc. stovaine, 0.07 to the cc., mixed with cerebrospinal fluid) was made. This reduced the contracture and permitted the patient to place his legs parallel. They were then bandaged in the parallel position. The bandages were removed two days later and the limbs did not reassume their faulty position. The man was shortly able to walk with a cane; progress was rapid. This man was very desirous of cure and refused to be invalided, believing he was to be cured, and had received medal and war cross. Simple motor reëducation in competent hands had been without effect. A new kind of measure, such as stovaine, proved successful.

_Re_ “new measures” for hysteria, see items under Case 516. See also remarks upon cures by lumbar puncture under Case 488.

Burial: Hysterical dysbasia. Treatment by stovaine anesthesia.

=Case 561.= (CLAUDE, March, 1917.)

A chasseur, buried June 24, 1916, had a number of general symptoms, apparently got well and was given seven days’ leave at home. On the way he felt abdominal pain which he thought due to the jolting of the car. Suddenly he felt his legs trembling on extension. He left the train and went into a hospital where a diagnosis of radicular and spinal lesions was made. Two months later he was sent to Claude who found that he could walk only with knees flexed. If he was requested to stand up and extend his legs on the thigh, a trembling set in suggestive of an epileptoid trepidation. Even in the horizontal position the same clonic trepidation occurred which only stopped if the patient flexed his legs on the thighs.

However, no sign of organic lesion could be found. There was an analgesia limited to the ankles. Psycho-physiotherapeutic treatment was unavailing. January 28, 1917, the stovaine injection method was tried. After anesthesia had set in, it was found possible still to produce the spastic state by extending the legs; but a half hour after injection the spastic state could no longer be produced. The patient was shown that the trepidation was abolished. During the period of return of sensibility, the legs were constantly moved and the patient constantly told to make movements himself. He was convinced of his power. There was no longer any clonus. The patient remained all day in bed without epileptiform movements. Next day he complained merely of weakness in the legs and was got to walk without having convulsive tremors. During the next few days he began to walk with a cane, later without support, and there were no more contractions except transiently in the left leg if the patient walked a little too long. He left the hospital cured.

Shell-shock deafmutism: Psychic treatment.

=Case 562.= (BELLIN and VERNET, January, 1917.)

A soldier in a colonial regiment was sent, August 14, 1916, to an evacuation post with a diagnosis “deafness following shell-shock, unfit for service.” The patient asked that he be spoken to very loud because he could not hear, and he himself spoke in whispers. He kept watching his interlocutors’ lips and moved his own as if to pronounce the words.

A shell had burst nearby fourteen months before in June, 1915. After being in several hospitals, he was sent to an oto-rhino-laryngological service where he had his hearing reëducated and was taught lip reading. It was soon perceived that he could hear without lip reading and he was assured that he could be cured at once, but naturally he was not convinced. He produced a carefully filed paper stating “atrophic ozenous rhinitis, deafness from labyrinthine shock following shell explosion, hearing diminished 60 per cent right, 30 per cent left.”

However, energetic psychotherapy was started and in the absence of electricity, subcutaneous injections of ether were given. Such patients had always been cured, and a drug injected under the skin, not dangerous but extremely painful would cure him! This treatment was carried out in a dugout near enough to the lines to be daily “potted.” The patient was left for a space to reflect, and he finally accepted the chance of cure. He was exhorted to stand courageously the pain and to breathe deeply and to repeat a word more and more loudly. Finally he was made to speak normally and eventually to cry out loudly. He now felt much astonished, and in his astonishment forgot his deafness. He said that he had never spoken or heard since the accident, that he had been a deafmute from the first month of his illness, and that for the last three months he had been able to speak only in a whispered voice.

He should have been watched a few days to confirm the cure. This was impossible in the crowded dugout and no risk could be run of his escaping. Kept over night he was found next day unable to hear and talking in the same voice as before.

He was now found to be either an exaggerator or a simulator. He was given a half hour to exercise his voice in and told that he must succeed unless he was a simulator. At the end of half an hour it was found that he had skipped. He was sent back by the division surgeon with orders to send him to the otological service for inquiry. The otological service found an atrophic ozenous rhinitis, a normal larynx, perfect audition. He was given a psychic X-raying and a few electric sparks were also drawn from his neck. He then began to talk in a loud voice and to hear normally. August 30, he was sent out completely cured and rejoined his regiment.

_Re_ treatment of deafmutism by other means than pseudo operations and anesthesia, see remarks under Case 556 concerning Colin Russel’s opinion that anesthesia does not get at the true genesis of cases. _Re_ the teaching of lip reading to Shell-shock deafmutes, see discussion under Case 580.

Brachial monoplegia. Cure by electrical suggestion (physician bored-looking, brief, and authoritative).

=Case 563.= (ADRIAN and YEALLAND, June, 1917.)

Adrian and Yealland had occasion to treat an officer with a persistent functional paralysis of the arm, which had successfully withstood hypnotism, psychoanalysis, rest, massage, anesthesia with ether, and painful electrical treatment.

This patient knew something of the functions of the brain and was prepared to discuss his condition exhaustively. He was told, however, that he had come to be cured and that the nature of his cure would be explained to him afterwards. Without further discussion, the motor areas of the cortex were mapped out rapidly. The measurements were repeated aloud to impress and mystify the patient. He was assured that as soon as the shoulder area of the cortex was stimulated faradically, he would be able to raise his shoulder, and that then the rest of his arm would recover. An exceedingly mild faradic current was then applied to the scalp for a few moments and he was then ordered to move his shoulder. He did so at once. In a few minutes, all of the paralysis had vanished and the patient could raise 30 pounds. Adrian and Yealland believe that the success here was largely due to the fact that the patient was not allowed to discuss the case or criticize the treatment beforehand.

It is essential that the patient should be convinced that the physicians understand the case and can cure him. No physical sign should be examined as if it were interesting or obscure. An attitude of “mild boredom bred of perfect familiarity with the patient’s disorder” is cultivated. If the case is exhibited it should be exhibited “as a perfect example” of the type of case that is cured in five minutes by appropriate treatment. “Rapidity and an authoritative manner are the chief factors in the reëducative process.”

_Re_ psychoelectric treatment, see Yealland’s book, published while this compilation was going to press, _Hysterical Disorders of Warfare_, 1918.

Brachial monoplegia following use of sling after bruise or wound. Technique of electrical suggestion and rapid reëducation.

=Case 564.= (ADRIAN AND YEALLAND, June, 1917.)

Adrian and Yealland give the following typical case of paralysis of the arm as a very frequent and very curable form of war neurosis, occurring as a rule after a slight wound or bruise necessitating the use of a sling. The patient, having received a slight wound of the forearm, for months had a useless arm, which he could move but slightly at the shoulder on exerting a superhuman effort. Occasionally he could flex the fingers through a small angle. There was complete anesthesia of the hand and arm of long-glove type. This anesthesia was not complained of, and might not be noticed until suggested to the patient by the physician. It is well to elicit the anesthesia, however, in view of the treatment to be applied. There was no wasting of muscles; the sensory loss was typical of hysterical anesthesia; nor could the whole arm have been involved by an injury that did not affect the upper arm and shoulder.

The patient was told that he was very lucky to have come off with such a slight injury; his arm was to be set right in five minutes by the application of a special form of electricity. He was then made to sit on a large pad electrode connected with an induction coil; the other terminal is connected with a wire brush. The first effect, he was told, would be the return of feeling in the forearm; power would return with the feeling. The wire brush with a fairly strong current was drawn downwards over the forearm from elbow to wrist. He was told that he could now feel as far as the wrist, and a pin was used to convince him that he could thus feel. If he had not felt the pinprick, the current would have been increased in strength until he could feel. The hand was now treated in the same way.

He was now told that, as feeling had returned to the arm, the power of movement would be restored shortly. Adrian and Yealland remark that laymen seem to consider that loss of power and loss of feeling are inseparably connected. The electrode was now used to produce contraction in the muscles. Under these circumstances, the arm will be used hesitatingly, with an appearance of great effort; but the patient is nevertheless convinced that power is returning.