Part 63

Struck by shell fragment; run over by shell; paresis and regionary sense disorder. Treatment by reëducation.

=Case 575.= (BINSWANGER, July, 1915.)

A German subaltern officer, 27, was wounded September 25, 1914, in a battle in France. He gave the following account:

“We had been firing without interruption four days, and then were sent back. While going back from cover we were under shell fire. Three or four horses fell. I got a glancing blow from a shell fragment in the back of the head, and fell down. I was not quite unconscious. I tried several times to get up, but I could not, for I had very bad pains in the head and a confused feeling in it, too. I remember also that a wheel ran over my foot, and that I got a sharp blow in the chest. Then I was unconscious for about an hour. When I awoke, there were two comrades busy over me and they pulled me back of the firing-line. Then I got to a field hospital.”

The man arrived at the nerve hospital (Jena), October 8, 1914, with insomnia, respiratory disturbance, sudden perspiration, feelings of cold in the right foot, and poor appetite. He had had nausea for a few days. Lungs and heart proved normal. X-ray of the right foot showed normal relations. The man was a small, powerfully-built man, well nourished, with lively reflexes, especially the knee reflexes, of which the right was greater than the left; slight patellar clonus, right; left plantar reflex greater than right; segmental disorder of touch and pain sense in the right foot and lower leg, a zone of analgesia lying above the zone of total anesthesia. Gait was lame on account of inability to move the right ankle joint. In walking, the right foot was trailed.

Treatment was suggestive and supported by active gymnastic exercises, breathing exercises, exercises in moving the right leg, massage, faradism and local hydrotherapy. The gait gradually improved, the cold feeling disappeared from the right leg, disturbances of pain and touch sense disappeared. The patient was released on the 2d of February, 1915, capable of garrison duty.

With respect to this man, who was married, he was from a healthy family and had healthy children. He is said, however, to have suffered from convulsions for a long time in early life, but thereafter had never been sick in any way. He was a good student and had been a post-office official since 1908. After two years’ military service, he became, in 1910, _Unteroffizier-Aspirant_. Later he was advanced to his subaltern position in the reserve.

This case seems to be a characteristic example of segmental disorder of sensations of both touch and pain, combined with a paresis in the same region. Mechanical and mental factors seem to have been present, and the case belongs in what Binswanger calls the “hysterosomatic” group.

_Re_ Binswanger’s so-called hysterosomatic group, he defines the cases as having emotional, mechanical, and toxic (gas) factors. On the whole, they are best classified as a kind of psychoneurosis. Binswanger finds all physical and drug treatment without result except as supportives. He has used hydrotherapy and electrotherapy with the perfectly clear conception that the procedures were of suggestive value only. In fact, Binswanger had before defined such procedures as _Realsuggestionen_ or material suggestions. Common verbal suggestion, says Binswanger, will work sometimes only when aided by these material suggestions. See also under Case 576.

Post-traumatic (ANTEBELLUM) seizures with unconsciousness: Further seizures, astasia-abasia, anesthesias, following no special period of stress in field service. Recovery by reëducation.

=Case 576.= (BINSWANGER, July, 1915.)

O. F., 26, healthy, of a healthy family, in military service, 1908-1910, a miner in October, 1912, had fallen into a shaft from a considerable height, and is said to have been unconscious for three days and two nights and to have had some sort of attack a short time after waking. Later he had another attack, beginning with violent headaches, running from the back to the fore part of the head, then dizziness, then a fall with unconsciousness. The whole attack lasted about four minutes and was followed by feelings of extreme fatigue.

It seems that in the spring of 1913 these attacks had begun to repeat themselves two or three times a week. In the spring of 1914 there had again been two attacks at an interval of two weeks. They had occurred on the way to work and had been introduced by the same symptoms as before. They lasted about half an hour.

He was in the war in France from August 6, 1914. While he was cooking, one day, in the middle of September, he had an attack and this without special occasion. The next attack occurred a little while afterwards, at the time of an assault. He said that he fell down and lost his senses. When he came to his senses again, he found he could not move his legs.

He was taken to a reserve hospital in Germany, and while there had several attacks with unconsciousness and spasmodic convulsions--the last on December 7, 1914. He was transferred to the Jena Hospital on the 11th.

The Jena examination had the benefit of an inquiry concerning the case. It seems that he had left the field hospital in the enemy’s country, in a half-conscious condition, and rode away therefrom aimlessly. It was only in Germany that he, on his own story, found his bearings again. However, upon admission the disturbance in walking was very noticeable, since the patient came hobbling through the garden of the clinic with the upper part of his body bent forward, and with the support of two canes. The legs were moved with difficulty; he seemed to take short, tripping steps, with the toes dragging on the ground. His inability to walk he explained through the violent pains which he would feel in the joints of the legs and an extraordinary weakness in his legs.

Physically, the man was a tall, strongly built and well-nourished subject. Neurologically, the knee-jerks were somewhat decreased and weaker on the right side than on the left; the Achilles reflexes were lively. The plantar reflex was not obtainable on the left side; decreased on the right. The abdominal reflexes were absent on both sides.

Most remarkable was the general diminution in sensitiveness of the skin to touch and pain, involving the whole body, up to the neck, where the sensory impairment abruptly ceased in a sharp line. The anesthesia was not everywhere complete. In a few places pencil strokes were successfully localized and recognized. Deep pin-pricks were everywhere recognized as itching. When the trunk was everywhere examined on both sides symmetrically, a strong pressure with a pin-head was felt as a strong pressure on the right side, but was felt not at all on the left side. Anesthesia and analgesia were total in the legs. Deep folds of skin could be punctured by needles without reaction.

The legs could be moved freely upon urgent request with the patient in dorsal decubitus. Still these movements were slow and difficult, as explained by the patient, on account of violent pains in the joints. If put on his feet, he would begin to sway greatly and permit himself to slide down to the ground, stating that he was quite incapable of standing or walking without aid. With two canes, however, he could move freely about in the ward and in the garden, and even with considerable speed, in a peculiar, dragging, shuffling way; in the execution he gave no sign of pain, contentedly smoking a cigar or a pipe.

While his status was being taken on admission, he became suddenly dull and irresponsive, with a staring look. He could not state his age or his birthplace. However, he became clear shortly, upon urging, and explained the spell by saying that the blood had risen to his head. A few days later, he was transferred to the psychiatric division. He was given strict rest in bed, smoking was forbidden, prolonged baths were used, and the legs were massaged. He felt very comfortable in the prolonged baths and could then move his legs without pain.

A few days later he was taken out of bed several times a day, the canes being removed immediately, and he was led about the day-room with the light support of two nurses. Being promised a cigar as a reward, he proved able to walk through the day-room supported by but one nurse. A week later the pains in walking exercises had disappeared. He had become able to walk alone, supporting himself lightly along the wall with one hand. Walking was still uncertain and slow.

December 20, the patient could stand free without support, swaying slightly; improvement became rapid. He could shortly stand and walk without support though his walk was still awkward and on a wide base with knees pressed in and body bent forward, soles were kept applied to the ground. December 22, the patient could walk in the garden without aid.

December 23, there was a spell of great weariness and complaint of being sick. The patient lay down on the bed, cried aloud, and had rhythmic twitchings and sudden movements with arms and legs. He scratched the right half of his face with his right hand. This spell lasted about a minute. It was repeated in the same way twice within the half hour.

He had complete amnesia for these attacks. The pupillary reactions were entirely normal in the attacks. He had been in bad spirits that day because a Christmas furlough had been refused. The attacks provoked no bad consequences and his gait improved. He was on furlough from the 30th to January 3; on the 4th he was transferred to the nerve department, but on the 12th of January he was reprimanded for a breach of discipline, whereupon at 9:15 he had an hysterical attack with the same coördinate rhythmic motions as before. This attack lasted about 20 minutes. Two hours before the attack he had complained of weariness and a boiling-hot feeling in the body. Long walks were taken. On February 15 he began to feel very happy. He was informed that the charge against him for leaving his troop had been dropped. He complained of sudden weariness and headache and was markedly depressed, but he had no hysterical attack.

After February 23 he took part regularly in gymnastics, executing the movements with joy and without special weariness. He wanted to be discharged. He was discharged as fit for garrison duty and he has since gone back to field service.

_Re_ gymnastics, Binswanger holds that they have a special value in overcoming inner psychic resistances and weak-willed persons. The _Realsuggestionen_ (see under preceding case, 575), such as hydrotherapy and electrotherapy, serve to concentrate the person’s attention on certain regions. These regional suggestions then smooth the way for the curative suggestion, namely, the constant and monotonously repeated assurance that recovery is advancing. At the next stage, according to Binswanger, gymnastic exercises may be brought in to overcome hopelessness, indifference, or exaggeration of morbid feelings. Binswanger sets methodical tasks for the attention and the will (a so-called _Uebungstherapie_). If these gymnastics lead to manifest improvement, then a proper educational therapy is prescribed, which is no longer a merely exercise therapy, but consists of actions of actual value in hospital routine. The convalescents are gradually led to carry on housework, food service, gardening (the latter under supervision). Hospital clerical work is a suitable occupation. _Re_ supervision over gardening, mentioned by Binswanger, Canadian experience indicates that the idea of supervision may be greatly extended. Particularly is this true in vocational reëducation. Kidner describes the functions of a vocational counsellor, who has to have an expert knowledge of industry and methods of industrial training, as well as an acquaintance with the varying demands for workers, a knowledge of the seasonal variations in employment, and a knowledge of occupational diseases. _Re_ occupational therapy, Todd estimates that from 0.5 to 1 per cent of wounded men in France will require vocational reëducation. Occupational therapy is the proper vestibule to vocational training. He lists the following forms of treatment used in institutions for vocational reëducation:

Active mechanotherapy. Passive mechanotherapy. Galvanic, static, and faradic electricity. Vibration. Hot air baths and blasts. Water baths. Colored light. Massage. Gymnastics.

Central specialized institutions such as those developed in France are necessary, and such centres should be large rather than small, according to Todd, and should contain not less than 200 beds. Todd insists that work is, after all, the most important measure of reëducation; and Turner, speaking of the home for neurasthenics at Golders Green, says that during a period of three months (the number of the patients is limited to 100, and three months is the limit of stay), the vast majority, even of the most obstinate cases, get well through the effects of sympathy and insistance upon work. Near Golders Green is the Maida Vale Hospital for nervous cases, so that in case of need the physicians there may treat the patients. Salmon gives a list of the occupations which are suitable for these cases.

Blown up by shell; wounds, right side, distention and bloody urine: Paresis of right foot and spasticity of hip; later rectal and bladder incontinence.

=Case 577.= (BINSWANGER, July, 1915.)

A Russian from the Ukraine was received at the nerve hospital, Jena, December 12, 1914. Through an interpreter it was established that he was a peasant, had been under shell fire in a skirmish at the beginning of November, and had been hurled (so he said) 1¼ meters into the air without loss of consciousness. There was a wound of the right shoulder and also, he thought, of the legs, from the air pressure. Becoming a German prisoner, he had been treated in various hospitals.

He was a strong man of medium height, with a healthy complexion. There were two healed wounds of the right shoulder, and near the twelfth spinous process a third similar scar. There were a number of ulcers and furuncles over the os sacrum.

Neurologically, the knee-jerks and Achilles jerks could not be obtained, and the plantar reflex, extinct on the left, was weak on the right. Sensitiveness to pain on both sides was lost from the knee downwards but there was hyperalgesia in the thigh. Inaccurate statements in response to tactile tests were made, apparently on account of lack of understanding. In lying down, there was a slight restriction in the movements of the legs, and active movements of the joints of the foot on the right side were impossible. Gait was ataxic-paretic, more markedly so right than left. He could walk only with two canes, and during walking the musculature of the thigh fell into a spastic tension. The tongue deviated to the left. There were severe rheumatic pains in the thighs.

It appears that some weeks before, this Russian soldier had suffered from severe rheumatic pains in both sides and was at that time absolutely unable to walk or stand. At that time, however, there was no question of a crural paraplegia of organic origin, since the man could move his legs well enough when in dorsal decubitus. There were no signs of paralysis of the rectum or bladder at that time.

Treatment at Jena consisted in regular walking exercises with support at the shoulders. The lower legs and feet remained weak and paretic. The decubital ulcers disappeared.

About the middle of December rectal incontinence began, the stool being discharged without the patient’s noticing it while being led to the bath. Later there was incontinence of feces in bed. Pains in the legs were constantly complained of. Nevertheless improvement in walking was maintained. The toes were dragged at every step and the knee-joints were thrown outward in walking. The musculature of the lower legs was weak. Knee-jerks could not be elicited more than before. He constantly complained of pains in the knees and right hip. The rectal disorder did not again occur during January.

Toward the close of January, the patient’s right lower leg and left foot would occasionally feel asleep; both legs felt cold and itched. In a general way, however, the pains had become less marked than they were at first. It seemed that he had no sensations at stool, and consequently had to resort to the closet at a definite time. Moreover, urine was discharged irregularly and involuntarily when he coughed. It appears that a few days after receiving his wounds in battle, there had been pains on micturition as well as blood in the urine, and it appears that he had been catheterized. It is probable that he had suffered from distention, as he described his abdomen, thighs and sex organs as swollen.

In February he began to be able to move alone with two canes through the ward, but he moved his legs from the knee downward very little, and dragged them after the rest of the body. Upon galvanic examination, the peroneal and tibial nerve trunks were found normally excitable. At this time the sensibility situation had changed somewhat, since complete analgesia was present only in the foot, and hypalgesia had developed upon the anterior surfaces of the lower legs. Pin-pricks were described as touches. The posterior surface of the left lower leg was normally sensitive. There was an oblong stripe about 3 cm. long, beginning in the popliteal space and stretching downward on the left side. The right lower leg was entirely insensitive. The posterior surfaces of both thighs as far as the gluteal folds were completely insensible to pain. The Wassermann reaction of the blood was negative. In this condition the patient was transferred to a prison camp hospital.

_Re_ bloody urine, see Section B, Case 202. _Re_ rectal incontinence, it might be inquired whether this was possibly functional. Roussy and Lhermitte devote a chapter to visceral disorders. They do not list rectal incontinence amongst the disorders noted in this war, nor have any cases of hysterical anorexia or disorders of sensation in the intestinal tract been seen during the war despite the occurrence of these latter disorders in the civilian group. The main digestive disorder that the war cases show is vomiting (see Cases 495 and 500).

Emotionality: Shell explosion; mutism. Recovery by reëducation.

=Case 578.= (BRIAND and PHILIPPE, September, 1916.)

A plumber, 27, went into the infantry. He was very emotional and was but a short time in the trenches when the explosion of shells threw him into a state of mutism. Deafness, rather curiously, did not manifest itself for several days. He had to go back on horseback, and, as he was a poor horseman, slipped off the horse, giving himself a bad fright. When he got up, he had lost his hearing.

He was sent to several hospitals and finally to Val-de-Grâce, in July, 1915. He recovered hearing in fifteen days, but the mutism persisted several months. According to Briand and Philippe, this is a typical case, except for the duration of the mutism. The first treatment was given this patient August 6. His respiration was examined and tracing was taken. August 15, on the morning visit, he was found able to whistle very distinctly the first bars of “Au Clair de la Lune,” and then began to sing the first verses, articulating distinctly, but stammering a little. He was now left to his own resources, without special exercises, from August 15 to September 26, and completely lost the benefit of his previous exercises. A week of special treatment allowed him to recover speech again, enough to take up every day life. The patient went out well.

The general lines of the examination in this case took up attitude in abdominal respiration and the question of respiratory pauses, especially pauses in abdominal respiration, which, in the above case, were exaggerated. Expiration was deficient and disordered. The normal adaptations that had been established during his childhood learning of speech had failed, and the patient would not have been able by himself to regain proper balance of respiration for speech.

The examination was continued to learn the difficulties of innervation of the muscles of phonation whose proper delicacy had been lost. Such a patient is a kind of bad gymnast, executing an exercise known to be hard by contracting all the muscles of the region, both the antagonist and the agonist muscles. Reëducation must, therefore, endeavor to sweep away the contractions that block sound. Then the patient must be made to perform the contractions necessary in phonation and articulation unconsciously. The methods used for teaching children might here be employed, but more elaborate and designed methods can be used with the adult, _e.g.,_

1. Breathing exercises, especially with the idea of making respiration complete.

2. Blowing exercises.

3. Whistling.

4. Vowel sounding.

Séguin and Rouma, on the other hand, counsel beginning exercises with consonants in stammerers and dyslalics.

_Re_ tests for functional deafness, Ranjard states that on account of the complexity of Shell-shock deafness, exact diagnosis needs to be made. Examination of the hearing by speech alone, or by the watch-tick, yielded poor results; and an accurate mathematical acoumeter (_Sirène à voyelles_, Marage) is recommended. See especially chapter on the functional examination of audition in Bourgeois and Sourdille’s _War Otitis and War Deafness_, a work translated and highly recommended by the English otologist, Dundas Grant.

Three days’ skirmish on East front: Unconsciousness, later delirium, still later (six weeks) stammering, hysterical stigmata: Recovery by isolation and reëducation.

=Case 579.= (BINSWANGER, July, 1915.)

A traveling salesman in civil life, 36, as a non-commissioned officer took part in severe fighting in the East shortly after the outbreak of the war. He was under violent shell fire at one time for five hours at a stretch. In the middle of November, after a skirmish in the woods which had lasted for three days, he was found unconscious. According to his own story, he was awakened from this unconsciousness about a week later in a hospital. He described himself as quite unable to say anything about what had gone on during that week.

The medical report on the case stated that he arrived at the hospital, November 18, in a dormant state of mind. He had appeared markedly excited and kept incessantly talking about military matters, such as the placing of machine guns, the occupation of the edge of the woods by his company, addressing the nurse as “Captain,” and the sister as “Mrs. Captain,” making as it were an official report to them. He showed shyness, and always an extreme excitement. His hands and legs were in constant motion; he complained of headaches and itching finger-tips. Sleep could be achieved only by drugs. This mental state lasted till November 26, when he became oriented. Sleep improved, but he complained of pains in the back of the head.

Upon transfer to a convalescent home, December 5, he was still occasionally excited and sometimes sleepless. On December 30, the patient began to stammer; his speech had before this been somewhat difficult, but the stammering began suddenly; speech was indistinct and slow; syllables failed to follow one another at like intervals. The headache at this time radiated from the middle of the top of the head to the side of the neck. There was a complaint of vibrating pains on the two sides of the vertebral column, and a feeling of weakness and unsteadiness in walking. The patient would sway with eyes closed and turn sidewise. The heart action was tumultuous, the pulse irregular and uneven.