Part 64

The patient was transferred back to the reserve hospital on January 2, 1915, whereupon the stammering became worse, sleep restless, and arms and legs subject to spasmodic pains and twitching. On January 25, he was removed to the Jena Hospital. He remarked that at the convalescent home he became very much excited at the Christmas celebration and had to cry, whereupon his speech became more and more difficult; he could not find the beginnings of words and had to stammer. Upon admission he also complained of sharp pains in the soles of the feet and in the finger-tips.

Neurologically, there was marked dermatographia, the deep reflexes were increased, abdominal reflexes were absent; there were points of pain on pressure in both supra-orbital regions, and there was a general hypalgesia with the exception of the head, the lower legs, the feet, the scrotum, the penis and the anal region. Pin-pricks were recognized on the right side only, when the patient was tested bilaterally. They could be recognized on both sides when the patient was examined on one side at a time. There was a static tremor on both sides (?). He could move his arms, but in dorsal decubitus he could move his legs only jerkily and uncertainly. His gait was waddling with dragging of toes.

There was a marked photophobia. The palatal and swallowing reflexes were in excess; speech was hesitant and stammering. The first letters of words, especially initial consonants, could be pronounced with difficulty, explosively with cheeks blown up, after several attempts. The consonant would be repeated several times before the vowel could be added. The patient’s name was Singer, and he would pronounce it: _S … S … S … Si … n … n … ger_; the last syllable (_ger_) being brought out with a strong accentuation. The whole process took five seconds. The word _Flanelllatten_ took 14 seconds. It seems that the patient had already suffered (in 1907) from nasal catarrh and disturbance of hearing from stoppage of the Eustachian tubes. Another attack in 1908 had been accompanied by an irritating cough, and there seems to have been catarrh on the right in 1913, as well as cerumen on the left side.

Treatment: The patient was isolated; in the next few days there was improvement in the headache. The patient complained of muscular twitchings, which would occur suddenly in different parts of the body. On February 1 there was a subjective feeling of happiness since all pains had disappeared.

The patient was given regular exercises in speaking and there was gradual improvement in speech. Body-weight increased, regular walks were taken, and the patient occupied himself with garden work.

By June, 1915, he had still further remarkably improved, working now all day long, partly in the garden, partly in the hospital office. Disturbance of speech was not noticed except for hesitation before the last syllables of long words during comparatively long conversations. All trace of difficulty in walking had disappeared. In this patient no hereditary taint could be proved. He appears to have been of normal development, serving in the army from 1901 to 1903. In his life as a traveling salesman, there was frequently catarrh of the throat, and in 1912 there was a marked swelling of the vocal cords with extreme hoarseness and inability to speak, which condition was cured after local treatment.

_Re_ hysterical speech and voice disorders, Binswanger has found them amongst the most obstinate conditions, often persisting when all other hysterical phenomena have dropped away. He states that apparently the cure of some of these cases must be postponed until the end of the war.

_Re_ general results of the therapeutic treatment of the war hysterias, Binswanger states that he has been able to send some cases back to the front that have successfully stayed there. He has had failures, however, even amongst men who have had no _mauvaise volonté_ and have themselves desired to be sent back to the front.

Gordon Wilson observed 250 cases of Shell-shock at the Ypres salient and on the Somme. Fifty of these cases complained of deafness, and 17 of the 50 were found to have actual nerve deafness. Wilson treated “fixed idea” cases by hypnotism, and sometimes by cold water run into the ear. He, in general, divides the cases in to (_a_) cases of nerve deafness, (_b_) fixed idea cases, and (_c_) malingerers.

Marage states that frequent exposure to the noise of shells for long periods may produce a permanent deafness, as has long been known in naval gun-makers and boiler-makers in peace times. He advocates obturators, a good form being plasticine wrapped in gauze moulded to the shape of the internal meatus. Celluloid plugs, sometimes used, have been known to be set afire by the flash of a shell. Cerumen sometimes protects against deafness, but Mott speaks of the driving of the wax into the tympanum as a dangerous effect in certain shock cases.

BURIAL by shell explosion: DEAFMUTISM. Treatment: phonetic reëducation.

=Case 580.= (LIÉBAULT, 1916.)

A machine gunner, 26, was buried at Rheims, January 5, 1915, by the explosion of a large shell bursting over the dugout. He was unconscious three days and deafmute on coming to, without amnesia but with a feeling of constriction in the throat.

After fifteen days in the ambulance he was sent for four months to the Maritime Hospital at Brest, and treated by hypnotism. Seven or eight sittings had no other result than to fatigue him. There were then three months of convalescence. Returned to Vannes, September 20, 1915, he was put into the auxiliaries. As he could not work much he was sent, December, 1915, to the Hôtel-Dieu at Nantes. Here electric vibratory massage was given, which secured a few hoarse sounds.

Phonetic reëducation was then undertaken at Prés-à-goutrière, May 10, and his respiratory capacity increased from 170 the first week to 250 and 300 the following weeks. His blowing strength was raised from 15 to 20 to 25 at the same time. In a few weeks he was much improved and June 27 passed on to his auditory reëducation. The respiratory capacity in this man was insufficient. He could not speak, but his respiratory movements were good and he learned again to speak in a voice as good as ever.

According to Liébault, it is a general principle that, if the respiratory capacity is increased, the voice will clear or become better; but, if the respiratory capacity remains stationary, the voice will not improve. It is the same with normal persons. A subject with a very subnormal respiratory capacity cannot speak loudly, but, if his respiratory capacity approaches normal, he can speak normally. According to Liébault, all cases of this sort have had some respiratory anomaly and each case must be systematically examined with the aid of anthropometric tables, including weight, height and chest capacity. The vocal disorder is proportionate to the degree of functioning of the phonating apparatus taken as a whole. It is not merely that the larynx should be examined, but the motor side of the apparatus, the respiratory muscles, the resonating apparatus, the lips, the mouth, the nasal fossæ and the pharynx.

_Re_ curability of different types of war deafmute, Roussy and Boisseau maintain that the type (_a_) that comes gesticulating, pointing to the ears, and desirous of writing, is the type that responds most rapidly to psychotherapy. There are two other types less responsive: (_b_) is an apathetic type, with impassive and stupid facies, lies immobile in bed, or sits in a chair in mental confusion; type (_c_) shows a facies of terror, looks haggard and anxious, confused, disoriented, and possibly delirious.

_Re_ general treatment of deaf cases, Zange suggests that emotion should not be aroused by intense auditory impressions, that he should not be reminded of his shock, and should be kept as cheerful as possible. Zange states that he found the static electric current of service, and got good results in hysterical deafness of sudden development by applying a strong faradic current.

A year’s service; leave: Hysterical aphonia developed at home. Respiratory gymnastics.

=Case 581.= (GAREL, April, 1916.)

A soldier, 35, went on leave August, 1915. Arriving at his farm, he had a violent feeling of moral perturbation and suddenly lost his voice. When he returned from leave he seemed stupid, spoke very few words and seemed to look about in a vague and undecided way. He was several months in this state and sent January, 1916, to Saint-Luc.

The vocal cords were there found of a normal color and without paralysis. “It was, therefore,” remarks Garel, “a nervous aphonia susceptible of instantaneous cure.” The patient was made to make a sound in the lowest tone possible. While he was making this attempt, sharp pressure was exerted upon the lower part of the sternum, to provoke expiratory reinforcement. The sound emitted was loud, to the great astonishment of the patient, who, thus aided by suggestion, shortly began to talk aloud.

In this particular patient a temporary return of voice was readily obtained, but not maintained. Special exercises had to be instituted, whereupon the patient immediately fell back into a complete aphonia. He was then made to scan words, syllable by syllable, executing with his arms classical movements of respiratory gymnastics, or sometimes with the utterance of every syllable the epigastrium was manually compressed or the shoulders suddenly lowered. The patient could now read a book in a jerky manner, and after a few lines he could read without his shoulders being pressed.

Another plan was to have the man read or talk while walking. As soon as he was stopped and accosted, however, he lost his voice again. Up to the time of report it was impossible to secure a definite return of voice, as the patient was not willing to associate words with peculiar movements. It might make him ridiculous. Accordingly, the nurses were requested not to fulfil requests unless they were made aloud. Recovery was to be hoped for from this measure.

Wounded: Recurrent stammering: Reëducation.

=Case 582.= (MACMAHON, August, 1917.)

A young English officer, previously cured of stammering while a boy, fell to stammering again after being twice wounded. The impediment was of the laryngeal type. When spoken to he was often quite speechless. In Shell-shock stammering, the chief difficulty according to MacMahon is in the production of voice consonants and vowel sounds. In mild cases the trouble is best left alone.

This officer was anxious to pass into the regular army from the reserve to which he was attached. The stammering prevented this. He was treated nine months and improved rapidly. He passed through the trying ordeal of the medical board successfully and went to his regiment.

In severe cases the patient is taught how to fill his lungs properly. He is taught to acquire an inferior lateral costal expansion in inspiration. During expiration the abdominal muscles are trained to contract slowly and strongly, pressing the diaphragm upwards and drawing the lower ribs downwards and inwards. This steady breathing produces a sensation of repose in the stammerer. He is not to raise the upper chest and not to tense the throat, tongue or jaws.

The main vowel sounds are now taught. The main vowel sounds are oo, oh, au, ah, a and ee. They combine in six ways, oh and oo in the word wound, ah and ee make the long i, au and ee in boy, oh and oo in road, a and ee in rain and fair, ee and oo in new and you. There are also words in which no main vowel or compound sounds appear, which may be placed either on the open ah position or the closed ee position. Such words as long, abbot, among, which are on the position of ah and such words as it, sister, minister which are in the position of ee. The voice consonants are b, d, g, j, l, m, n, r, v, w, y, z, w being oo sound and y the ee sound. The breathed consonants are c, f, h, k, p, q, s, t.

The treatment of stammering intensified by Shell-shock is more difficult than that of Shell-shock stammering de novo.

Wound of face: Speech disorder. Recovery by reëducation in two months.

=Case 583.= (MACMAHON, August, 1917.)

An officer was wounded under his left eye, October 7, 1916. His speech was affected only five days later in a casualty clearing station. Observed by MacMahon, November 5, he was found to speak with great difficulty and became exhausted after a few words. He was tensing all the muscles in attempting to speak. Breathing advice was given and counsel how to relax in the abnormal efforts.

November 12, the officer, who was at Number One London General Hospital, began to speak with more freedom. “I am getting a bit better. I feel I must keep quiet, and it comes after a bit. I think far quicker than I speak.” He said that the breathing exercises had helped him most.

November 15, he still spoke in a rather staccato way; but the words did not check as they had. In a week further there had been so much improvement that he was discharged with a prognosis of complete recovery.

January, 1917, he had recovered.

Shell wound and burial: Camptocormia (psychoelectric treatment successful in one séance) and lameness (long reëducative treatment successful).

=Case 584.= (ROUSSY and LHERMITTE, 1917.)

At a Neuropsychiatric Center, September 2, 1916, arrived a chasseur, 29, showing lameness of a pseudocoxalgic type on the left side, combined with an anterior camptocormia. The whole situation had lasted a year. The chasseur had been wounded by shell explosion on the left side and was buried on July 29, 1915. He lost consciousness and had respiratory trouble and mutism. His arched walk and lameness began August 20, 1915.

He had a number of terms in hospital and six months at the dépôt. He was sent back to the front, June 20, 1916, being proposed for auxiliary work. There was some mental weakness. After one séance of electric treatment, the improper attitude of the trunk was corrected. The lameness, however, persisted and required long daily reëducation.

The patient was discharged cured, October 20, 1916, without lameness or camptocormia. There were a few persistent lumbar pains.

_Re_ treatment of war psychoneuroses, Roussy and Lhermitte recommend rational and persuasive psychotherapy after the manner of Dejerine, Dubois, Babinski, and others. Hypnosis, they say, should definitely be rejected. Mental contagion must be staved off, and Roussy and Lhermitte believe that almost all cases are curable and should be sent back as competents.

They maintain that the medical officer himself plays the leading part. Many patients are “cured” when they find “good masters”; this mastery of the combined confessor and educator is greatly aided by prestige. He must speak with authority, with “iron in the velvet glove”; but with patience and persistence. If a long sitting fails, postpone work on the pretext of resting the patient. The patient must not be early threatened with discipline. Even exaggerators and malingerers must be talked to as if neuropathic.

A careful medical examination, besides correcting false diagnoses and demonstrating hystero-organic associations, will give the patient confidence in his physician.

A new patient is more easily cured than an old one. In general, patients should be treated as soon as possible after the shock. Contractures are habitually more persistent than paralysis; tremors and tic are more pertinacious than deafmutism; ante-bellum psychoneuroses are less easy to treat than cases developed by the war alone.

The neurological centers near the front, with their discipline, inaccessibility to friends, and nearness to the front, present a situation which yields easier and quicker cures than the interior; but after the two-years’ experience which proved this fact, according to Roussy and Lhermitte, many cases still get sent back into the interior for many months,--cases that ought to be cured near the front. Cases having convulsive attacks get confinement in separate rooms; chronic neuropaths are kept in bed on a milk diet.

The general features of the treatment of psychoneuroses commended by Roussy and Lhermitte are summed up in what they call the psychoelectric and reëducative method, divided into four stages: A stage (_a_) of persuasive conversation; (_b_) isolation; (_c_) faradization; and (_d_) physical and psychical reëducation. Roussy and Lhermitte got during six months in one of the army neurological centers, 98 to 99 per cent of recoveries. Clovis Vincent, in a special interior hospital (see for Clovis Vincent’s treatment, a summary under Case 575). _Re_ the first stage of persuasive conversations, Roussy and Lhermitte discuss on the day of admission the general nature of the patient’s condition, and place him in the atmosphere of cure, in contact with recovered patients. The conversation takes place in the physician’s consulting room. The patient is gotten to promise on oath that he will submit to any methods of treatment. Although one may pass from the first stage to the third or electrical stage, forthwith, Roussy and Lhermitte recommend several days of isolation. The patient is placed in a separate room, and kept in bed on a milk diet. This isolation treatment of Weir Mitchell allows reinforcement of the suggestion by talks on the medical rounds, allows the patient, perhaps, to beg for the electrical treatment, which he may have refused at first, and lengthens the period of observation. According to Roussy and Lhermitte, spontaneous recovery not infrequently takes place during this phase of isolation. Lameness of long standing, tremors, and deafmutism disappear.

The third stage is that of faradization, executed by the physician with only such attendants as may be necessary to support the patient. At first, the man lies nude upon the bed, but later may be treated while sitting, standing, walking, or running. Feeble currents are used at first; later stronger ones. The poles are applied to the affected parts, and sometimes to especially sensitive parts of the skin, such as the ears, neck, lips, soles, perineum, and scrotum. Energetic treatment by the rapid method is indicated in the vast majority of cases, especially at the front. If a case is seen early, the rapid energetic treatment almost always cures at once. The success of the method depends upon the production of a crisis, which ought to be produced at the first sitting. Sometimes this sitting has to be continued for hours. Some patients require two or three sittings; some, still more. Instead of faradism, a cold jet of water, or even painful subcutaneous injections of ether, may be used.

The fourth stage is that of physical and psychical reëducation, important in long-standing cases. The various forms of physiotherapy are carried out by special assistants or head nurses, accompanied by psychotherapy, and if necessary by electricity. According to Roussy and Lhermitte, these reëducative methods used alone, without previous faradic treatment, are not successful. Relapse follows premature transference from the front to hospitals in the interior, and too early sick leave.

Shell-shock deafmutism. Speech recovered by suggestion and reëducation; hearing by reëducation.

=Case 585.= (LIÉBAULT, October, 1916.)

A corporal, 20, was exposed to the shock of an aerial torpedo, January 18, 1916, at Souchez. The torpedo fell a meter away. There was no loss of consciousness, but the patient was agitated for several hours, not knowing what he was doing. Evacuated to hospital, he remained several days in a stupid state. He was completely deaf and remembered poorly what had happened. He made every effort to speak, but could not. His head felt on fire. He could not open his mouth well and his lower jaw was almost in a state of contracture. He felt that his tongue could not move easily. In this status he remained until February, always trying to talk, but not succeeding.

He then arrived at Hôtel-Dieu. The mouth was now opening better and he was in a better general status, though always feeling fatigued. Vibratory massage was given to the laryngeal region. He was gradually got to emit a few sounds in a low voice. He was sent, April 26, to Prés-à-goutrière. He was now somewhat vocal, but at times would become completely aphonic once more. The voice during the first few weeks of treatment became better, and the respiratory capacity was increased from 450 the first week to 460 and 500 in the next two weeks.

May 12, he suddenly lost his voice again and wanted to commit suicide. However, in three more days he was able to speak normally again and has had no relapse. He was then put under auditory reëducation and at the time of report his hearing had slightly improved.

Liébault remarks that during the time when the patient could not speak his jaw muscles were contracted and his tongue could not mobilize well. He could think words but could not articulate them. It was accordingly important to cultivate the normal functioning of these muscles.

Gassing; tracheitis; crash from airplane; unconsciousness: mutism; stammering. Reëducation; hypnosis.

=Case 586.= (MACCURDY, July, 1917.)

A lieutenant in the Royal Flying Corps, 23, described as “unusually normal,” a successful business man, athletic, socially popular, had been for a year in the Infantry. He was caught suddenly in a gas attack, and, though he recovered after a few days in bed, had a severe tracheitis and laryngitis. The lieutenant had been very proud of his voice and its carrying power. He went to a laryngologist in London, who said that he would never be able to sing again--a matter of some worry.

He soon became an expert airman. In the spring of 1917 he was shot at by antiaircraft guns in a trip over the enemy’s lines. One of the wings was hit and so weakened that in landing the lieutenant crashed to the ground. He was unconscious for three hours and on coming to tried to shout to his servant in the distance, who, on arrival, found the lieutenant quite unable to speak.

According to MacCurdy, there was here a conversion hysteria with regression to the tracheitis that followed the gassing. The mutism MacCurdy regards as a pathological degree of an effort of protection for his voice. In hospital three weeks later he learned to whisper a few words, though with great mental effort. He regained the voiced sounds by coughing and then saying “ah.” Stammering now developed. Not more than one or two words could be said at a breath. Training to say two, three, four and then five letters in one expiration yielded improvement in the stammering. Under mild hypnosis, to the degree merely of distraction, normal speech was re-attained. There was no relapse. Singing was then practiced and in a period of six weeks the singing voice was virtually as good as it ever had been.

Shell-shock: Loss of consciousness, possibly hemorrhage from head: Spontaneous gradual recovery from anesthesias in three months: Recovery from paralysis by reëducation in a few more weeks.

=Case 587.= (BINSWANGER, July, 1915.)

A German youth of 19 volunteered at the outset of the war as a motor cycle rider. About the end of October, he was hurled from his wheel by a shell which struck close beside him and exploded, knocking his back against a pile of beams. He lost consciousness. There may have been hemorrhage.

He came to, two hours later, in the dressing station, hardly able to move his limbs. Such movements as he could make were painful. There was an evident contusion of the back. He had a fainting fit after his bath in the field hospital and then could get to bed only with support. Severe pains in the legs, especially in the knee.

In the reserve hospital, there was a second similar fainting spell, followed by buzzing in the head, feelings of pressure in the chest and an irregular pulse; all of which phenomena disappeared the morning after the fit.