D. TREATMENT AND RESULTS OF SHELL-SHOCK. (continued 3)

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.

“Rapid reëducation follows at once. He is given no time to think, but urged to move the arm more and more strongly, to grip the physician’s hand, to flex and extend the elbow, etc., and the pressure is not relaxed until the whole arm has returned to its normal vigor. If recovery is stationary, faradization is repeated with stronger and stronger currents. If it seems as though he might relapse on leaving the hospital, he is told that this is very unlikely, but that if it should occur, he should report sick at once and come back for treatment with a current far stronger than that already used.”

Adrian and Yealland claim that they have applied their combination of suggestion and reëducation in more than 250 cases (including 82 cases of mutism, 34 of deafness, 18 of aphonia, 37 brachial or crural monoplegia, 46 paraplegia, 16 hemiplegia, and 18 of non-organic gait disturbance), and that although a majority of the cases have been of several months’ standing, treatment has been almost immediately successful in at least 95 per cent of the cases.

Exposure in the retreat from Mons: Persistent hysterical sciatica. Treatment by faradism and verbal suggestion.

Case 565. (Harris, 1915.)

A soldier developed pains about the hips and down the right thigh after getting wet through in the retreat from Mons, August, 1914. He was treated for a period of nine months in various convalescent homes and military hospitals, incidentally receiving forty baths at Droitwich. He hobbled on a stick, leaning upon the left leg and dragging the right stiffly. The thigh was tender and hyperesthetic.

The proper treatment of cases of hysteria, according to Harris, is strong faradism, applied by a small electrode or wire brush to the moistened skin. The stimulus is made powerful enough to force the patient to admit that he feels. The theory is that the powerful stimulation “breaks down the psychical auto-inhibition which produces the hysterical anesthesia.”

Faradism is only the first phase of the treatment. Verbal suggestion follows. Building on the basis of the feeling produced by the faradism or on the basis of the ocular evidence of motion in the hitherto paralyzed muscles, the patient is informed that the electricity will now be more and more strongly felt and that he will be cured in a few minutes.

The two elements in the therapy, then, are: encouraging verbal suggestion and the suggestion afforded by the paraphernalia of a complex looking, noisy machine. The knowledge on the part of the patient that a powerful and mysterious stimulus, namely, electricity, is being employed is a third element of suggestion.

Persistent hysterical sciatica, such as that of the present case, may require prolonged treatment. In this instance, the man was completely cured in five minutes, so that he was made able to run across the room. He said he would now be able to go back to the front, and wondered why he could not have been cured before.

Prognosis of intensive reëducation in reflex (physiopathic) disorder—complete recovery (except for the hysterical fraction of the disease) not expected.

Case 566. (Vincent, 1916.)

A young soldier was superficially wounded in the left knee, in August, 1914. A year later, he showed amyotrophy of the left calf, which measured 2.5 cm. less than the right, a weak slow Achilles reflex on the left side, cyanosis and hypothermia of the left foot, weakness and limitation of movements in the left foot, with slight contracture in flexion of leg upon thigh.

Thenceforward and for eight months, this soldier was submitted at the Tours Centre to intensive reëducation. For two hours every day upon prescription he walked, ran, and hopped upon the left leg. In September, 1916, after twelve month’s training, there was a certain improvement in his disorder. The leg was now completely extended upon the thigh, and the amplitude in the movement of the foot was almost normal; but the amyotrophy, vasomotor disorder and certain electrical disturbances remained quite unchanged. The man himself recognized that his status was greatly improved, but he could not walk more than four or five kilometers without great fatigue.

In view of the inferior results of reëducation in some of these cases, should any attempt at all be made to reëducate? Vincent thinks that that should be; but that it should be borne in mind that sometimes no results may be obtained. If the reflex disorder (in the Babinski sense) is minimal and the chief difficulty is hysterical, then sometimes the man may go back to service after reëducation; but in intense examples of reflex (physiopathic) disorder, invaliding has often proved necessary.

Re values of intensive reëducation, Vincent’s technique and results have logical resemblances to those of Yealland and of Kaufmann. Vincent established in the 9th district neurological center a method of intensive reëducation which is particularly suited to old hysterical cases. He divides the treatment into three stages: First, the stage called by the poilu by the picturesque name of torpillage; secondly, the stage of fixation; thirdly, the stage of training. According to Roussy and Lhermitte, there are few cases at the front suitable for the treatment of Clovis Vincent, which is especially devised for the old cases. See under Case 574 for further details of Vincent’s treatment.

Re prognosis of the physiopathic disorder, there has been some controversy in France. See discussion under Case 530. Re suitable treatment for physiopathic disorders, Babinski and Froment suggested the application of heat. The warm bath test is also of value in diagnosis. Babinski and Froment claim progressive improvements with hot baths, hot air douches, and light baths—but counsel great prudence. The improvement is never rapid.

Wound of calf; operations: hysterical contracture with “physiopathic” features. “Brutally conquered” by reëducation.

Case 567. (Ferrand, March, 1917.)

A French infantryman, class of 1912, was wounded, May 12, 1915, in the upper third of the right calf. His posterior tibial artery had to be ligated. In a few weeks the wound was healed, but he began to walk badly, presenting a contracture of the calf with retraction of the tendo Achillis.

Toward the last of 1915 a surgeon under the impression that the disease was organic cut the tendo Achillis but the soldier could not walk any better. As he could not take the position of equinism, he semiflexed his knee and walked upon a crutch.

Another surgeon was now found to perform a tenotomy on the flexors of the leg and put the patient in a plaster cast to correct the flexion and immobilize in extension. This second operation was in July, 1916. The patient now walked without a crutch.

He was then sent to a neurological center, Dec. 8, 1916, walking on two canes, right leg in forced extension on thigh, in permanent and absolute contracture. All movements except leg flexion could be executed, though slowly and weakly; but positive movements were impossible, except flexion of the knees. There was no sensory disorder. Reflexes were normal save that the leg reflexes were a little stronger on the affected side, and the patellar reflex on that side was nullified by the contracture. Electrical reactions proved normal. There were marked trophic disturbances of the right foot and of the lower third of the lower leg. There was a certain amount of edema, cyanosis, coldness and thickening of skin; marked muscular over-excitability of the distal extremity of the leg. In short, Ferrand was here dealing with a case of Babinski’s group of the so-called physiopathic cases. The man was somewhat feeble-minded, and anxious and a trembling suppliant for cure.

He was put, December 15, in a reëducation room and by means of fatigue, induced by violent physical exercises, was (Ferrand states) “brutally conquered.” The contracture after a half hour of physical movement of flexion and extension of the leg ceased. The patient was shown how he could himself both flex and extend the limb himself; he was then caused to do this spontaneously. These active movements were aided and at times provoked by somewhat painful galvanic discharges. The patient then walked slowly, and flexed both knees to the maximum. He was cured after a treatment of 2½ hours. There were, of course, some (surgical) intra-articular adhesions in the knee and it was necessary for the patient to break these adhesions. An X-ray had shown the bone to be intact. A slight hydrarthrosis developed the next day, but a few days later he was able to walk as well as anyone. For five weeks he followed a training platoon in the reëducation work and was evacuated, January 23, 1917, to his station, though he had entered the neurological center with the idea that he was to be invalided with a pension.

He had a few relics of physiomotor disorder when he left, including the abnormal delicacy of skin and muscular over-excitability above mentioned. On the basis of this and similar cases Ferrand believes that, although the physiopathic group of Babinski exists, it does not signify a separate clinical syndrome and the occurrence of physiopathic symptoms does not contraindicate psychotherapy.

Re this controversy, see remarks under Case 530.

Shell-shock: Paraparesis. Cure by electricity.

Case 568. (Turrell, January, 1915.)

Turrell, in a paper on electrotherapy at a base hospital, narrates a case of spinal concussion which rapidly yielded to the persuasive influence of Bergonié’s machine for electrically provoked exercises. Turrell grants that such a rapid cure would probably be attributed to suggestion, but thinks that the term demonstration might be preferred on account of the vigor and amplitude of the muscular contractions excited.

This soldier was driving an ammunition wagon at the front, when a shell exploded under the wagon, killing one horse and severely wounding the other. The patient himself was blown into the air, fell, dragged himself to a trench where he lay all night, and found himself in the morning unable to walk or stand. He recalls that pins were stuck into his legs by the examining medical officer and that they produced no sensation. When he was finally brought to the Third Southern Medical Hospital, he was unable to draw up or move his legs, or to stand up (yet neurologically normal).

After a few days’ rest in bed, he found himself able to walk a few steps with assistance, and was then transferred to the Radcliffe Infirmary for electrical treatment. This treatment consisted in electrically provoked exercises to the back (positive) and seat and thighs (negative). He was able to walk back to his ward, leaning on a wheelchair. Next day he walked to the electrical department with sticks, and after the exercises were repeated, he was found able to walk without assistance. On the third day, the Morton wave current was applied to the back, to clear up any persistent stiffness. The patient was then discharged on sick furlough.

Re the Morton wave and similar applications of electricity, Zeehandelaar speaks of a high frequency hall fitted up at Berlin. Touching the walls of the hall with the finger elicited a powerful spark. The scheme appeared to be on a commercial basis, and it was proposed to start similar institutions for poor metabolism and neuroses in other cities.

A year’s field service, gunshot; typhoid fever: Astasia-abasia: Lourdes-like cure: Residual amnesia.

Case 569. (Voss, November, 1916.)

A soldier in service from the outbreak of war, shot in September, 1915, afterward suffering from fainting spells, was treated in several hospitals. He developed a typhoid fever at Lindau, which was at first taken for hysterical fever. Eventually he came to the observation of Voss, unable to stand and falling hysteria-wise if compelled to walk.

Thorough examination was made. It was emphatically explained to him that there could be no reason why he should not stand or walk.

A miracle occurred. From the second day of his hospital stay he not only walked about but began to polish doors and windows with inexhaustible strength.

But when he was about to be told that he must now be looked upon as well, the miracle was not so manifest. It now transpired that he had serious gaps of memory and disorders in recognition, a sphincter disorder and ever since his typhoid incontinence with fluid feces.

In short, waking suggestion had caused a very prominent symptom to disappear, but the total personality remained sick. According to Voss, the procedures of Kaufmann are dubious just because they cannot stand the test of time. Yet so far as the cure of this man’s astasia-abasia was concerned, it was not at all unlike the cures wrought at Lourdes.

Re miracles of this sort, see cases of Colin Russel (503 and 504) as well as those of Veale (511 and 512). Voss’ arguments run parallel with the contentions of various persons that the miracle cures (such as those by anesthesia, electric suggestion, and hypnosis), do not get sufficiently to the bottom of the affections in question. Buzzard, in the preface to Yealland’s book on the Hysterical Disorders of Warfare, remarks that the question of the ultimate prognosis in cases thus suddenly cured must be left unanswered.

Dysbasia after a fall: “Kaufmann” cure in six weeks.

Case 570. (Schultze, August, 1916.)

Severe dysbasia, due to monoplegia of the right leg of sudden origin (a fall), was variously treated 64 weeks without effect.

July 15, 1916, the patient walked in on a stick, and fell down on trying to walk without. August 1, 1916, at 9 o’clock, he was rapidly examined: Anesthesia to pain and temperature; inability to lift right foot; the right knee could be lifted about a hand-breadth above the body if the foot was supported.

At 9:10, a small electrode was applied: sensibility became normal at once. Second application: leg raised much better. The man was told that he was better and that his hand could be put under the heel. Third application: Leg raised 8 cm. The patient showed pleasure at the advance. Fourth application (slightly increased strength): Patient able to stand and to lift knee with flexion at 135° while standing. Walking exercises under direction. At 9:30, five minutes recess was given for fatigue, whereupon the exercises were taken up again and transition made from stationary running to walking without aid as well as a variety of other associated acts (grasping handkerchief instead of physician’s hand, and the like). The patient became exhausted after 8 or 9 minutes running about, and another pause was given.

The large brush electrode with stronger current was now given to the back and to the back of the right leg. Practice in slow walking, lifting knee, and holding hip joint firm. The patient became tired, but remained very willing. Exercises in pulling on stockings, in climbing stairs—the whole concluded at 10 o’clock, whereupon it was found that the patient could walk alone for a distance of 50 meters. The patient was a very suggestible one. It was striking that the patient in the time between 9:35 and 9:40 minutes could walk better on the right (that is, the previously affected leg) than upon the left. Rest in bed and phenacetine were ordered, with the suggestion that in the morning he would walk much better. He became irritated after the treatment but grew quieter in the afternoon.

On August 3, he was found able to walk well, better when not observed than when observed. August 5, he complained that his leg was worse and used a cane, without permission. He was roundly scolded by the physician and threatened with being sent to bed if he did not practice earnestly. August 7, he was better, and confessed that he could not walk as well on command as he could alone; the exercises were nothing but a fraud and he could go out and beat everything up (alles zerschlagen) if he did not have to carry out such exercises.

August 15, he was much better, quiet, and satisfied. The lameness was practically gone. August 30, there was no sign of lameness, even when he was observed. According to Schultze, the Kaufmann method is not merely an Erb tradition, and rather special measures need to be taken in executing it.

Re Kaufmann’s cure, Imboden sums up this “highly logical and brutal method” as a method in which powerful electric shocks and loud military orders to perform certain exercises secure results. Imboden suggests that relapses may follow, sometimes on the slightest provocation. Mann states that Kaufmann’s method of suggestion and electric shock forms very good treatment; yet Mann states there have been two deaths under this treatment: in both instances there was an enlarged thymus at autopsy. A better technique, especially the use of the faradic current alone, might have avoided these deaths. Mann himself prefers to Kaufmann’s Ueberrumpelung milder methods, such as rest. Kaufmann keeps up the sitting until the man is cured, even if it takes two hours of electricity and staccato commands. For similar persistance, see the treatment by induced fatigue of Reeve (Cases 489-493).

Wound of shoulder: Heterosuggestion of BRACHIAL paresis. Electrical suggestion of muscular power. Recovery in five days.

Case 571. (Hewat, March, 1917.)

A reënlisted soldier arrived at the Royal Victoria Hospital, as a case of ulnar paralysis. He had been wounded in France six months before by a bullet which passed through the fleshy part of the shoulder, above the middle third of the clavicle. Power in the right arm gradually diminished; yet two months after the wound he seemed fit enough to be sent to Egypt. The paresis developed, and in a month’s time he was invalided home. He had been unable to use a rifle for months.

The healed bullet wounds were found about the region of the brachial plexus. The patient was sure the bullet had damaged the nerves in that region. The right arm and hand were limp and over-inclined to blueness, and the muscles were flabby. Active movements of all sorts could be carried out with the arm but not against resistance. There was a definite anesthesia and analgesia throughout, and responses to touch and pain stimuli were irregular.

By way of treatment, the patient had the muscles of the paretic arm stimulated electrically, and at the same time he was told that no nerve of the neck had been injured. He was greatly surprised to see his palsied arm move vigorously.

A milk isolation treatment in bed behind screens was adopted, whereat the patient was angry, looking upon the Weir-Mitchell treatment as punishment.

On the next day, another electrical application secured complete power in the arm and abolished sensory disturbance. Three days later the man went back to full duty. According to Fergus Hewat, someone doubtless had suggested to this patient that he had received a nerve injury. He had become obsessed thereby and developed a typical functional paralysis. This was a “cortical misinterpretation,” which disappeared upon forcible demonstration of the error.

Exposure; intestinal disorder in weakminded neuropath: Camptocormia and hysterical paraplegia: Cure by psycho-electric treatment.

Case 572. (Roussy and Lhermitte, 1917.)

A French territorial, 45, was observed at the Centre Neurologique, August 28, 1916. He was a victim of hysterical paraplegia with tripod gait. There was a stiffness of the lumbar vertebral column which had lasted six months. This paraplegia had begun spontaneously after cold and an attack of diarrhoea followed by constipation. The camptocormia and disorder of gait had come on gradually in the ambulance. He came on a stretcher. He was found to be able to walk with great difficulty by leaning both hands on a cane. The two legs were tremulous in a pseudospastic gait. The next day, after a single psycho-electric treatment, cure was complete. This patient was mentally somewhat weak and a constitutional neuropath. He was discharged, cured, October 20, 1916.

Brachial monoplegia, hysterical (or feigned?). Found able to descend ladder with arms only.

Case 573. (Claude, July, 1916.)

Claude had a case of a soldier with right-sided brachial monoplegia, which had lasted for 18 months and defied efforts to cure. There was a question of simulation, and Claude handed the case over to Vincent.

The case came on service, June 20, and was seen June 21. He was then treated and found able to descend a ladder applied to a wall with the help of his arms only. On June 24, he was found able to lift a weight of 10 kilos, and could now write with the right hand, although he had been writing only with his left. This man had looked like a simulator to many physicians. He may have been a simulator or an hysteric. In any case, he was cured.

Vicissitudes of treatment of hysterical brachial monoparesis (shell burial).

Case 574. (Vincent, July, 1917.)

A French private was buried in a trench upon the explosion of a large shell, November, 1914. He said he had had a “fracture of the occiput” and had fainted away without regaining consciousness for several hours.

He was evacuated to Dunkirk, then Saint Nasire, and then to Sables-d’Olonne. He showed no paralysis or paresis of limbs. During the first month, he had violent pains in the head, spells and vomiting. There was a slight aphasic disorder. He was treated by cupping upon the head and by applications of ice.

After the visit of the inspector general, he was sent to Nantes to be trephined. Dr. Mathieu regarded an operation as useless. He was treated with bromides and the faradic current by Miraillé, applied to the right arm, which had become paretic.

June, 1915, he started on a three-months convalescent leave in Paris.

From October to December, he had electric treatment at the Grand-Palais.

December, 1915, he went to the Salpêtrière under P. Marie, where he was given electric treatment.

January 1916, he went to Maison-Blanche under Laignel-Lavastine, where he was given electricity 4½ months.

April 4 he went back to his dépôt.

Presented to the invaliding board, May 11, at Decize, he was sent to the neurological center at Bourges. He was there given massage and movements. Upon entrance he had a functional inactivity of the right arm. He should have been cured a long time before by the therapeutics employed. He was then sent to Vincent at the neurological center at Tours for special motor reëducation. Vincent found almost complete functional incapacity of the right arm, without atrophy, with normal reactions, no R. D., and normal arterial pressure. June 26, 1916, the patient was able to write, although slowly. He could sign a letter, and could lift a weight of 10 kilos.

The details of Vincent’s method mentioned under Case 566 are pursued, to use his own words, with methodical ruthlessness. This form of reëducation consists in manoeuvres that make the patients yield despite themselves. The galvanic current is used to force a man to react voluntarily or automatically. See, for example, Claude’s case of a hysterical brachial monoplegic (Case 574) found able to descend a ladder with the use of his arms only. After the physician’s victory is secured, then a sort of consolidation must be obtained by means of the execution of certain movements on the part of the patient for an hour or two. As another factor in the situation set up by Clovis Vincent, is the enthusiasm generated in the moral atmosphere in which the cure takes place. Mott has also insisted upon this atmosphere of cure, which Mott believes is in part responsible for the good results of Adrian and Yealland. Roussy and Boisseau, at Salins, started out with a process similar to that of Vincent, with a preliminary period of isolation. Roussy also uses the faradic current instead of the galvanic (see remarks of Mann concerning deaths with the Kaufmann method in Germany, under Case 570). Vincent’s three stages are given in Chart 19, page 897.

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.

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.

A careful examination about the middle of November showed the persistence of a severe paresis of the left arm, and a less marked motor weakness of the right arm. Both legs were paretic, and there were no spontaneous movements of the leg. This paresis of the legs was combined with complete anesthesia and analgesia. Sensory impairment was found only in the right arm and trunk, and there was no evidence of sensory impairment in the left arm. Both motor and sensory disturbances of the arm disappeared rapidly.

However, at the beginning of December, 1914, the complete insensibility of the lower extremities up to the groin still persisted. The anesthesia then began to retreat, so that four days later, the upper limit of anesthesia was somewhat below the groin. There could be found a circumscribed area of anesthetic skin over the os sacrum up as far as the second vertebra of the os sacrum; but the skin around this area, as well as over each tuber ischii, gave normal sensation.

The anesthesia continued to retreat: to the middle of the thigh at the middle of December; to a level 3 cm. above the knee-cap at the end of December; to the upper end of the knee-cap on the right side and the middle of the left knee-cap, January 1. January 11, the anesthesia had retreated to a level 10 cm. below both right and left patella. February 8, sensibility in the legs had entirely returned.

While the anesthesia was pursuing this favorable course, the motor symptoms failed to improve to any marked extent, although active motion of the legs with the patient in dorsal decubitus had gradually returned to a limited degree.

The diagnosis upon arrival at the Jena Nerve Hospital was “rheumatism of the left side of the body and dislocation of the spine.”

The treatment consisted at first of rest in bed and moist dressings of the legs, but the treatment had to depend greatly upon the diagnosis. The patient complained of difficult micturition; yet there were no other positive signs of organic disease, of spine or cord.

Hysteria was the diagnosis preferred to rheumatism, despite the fact that examination at the Jena Hospital failed to show any disorder in pain or tactile sense.

The patient was a rather tall man of slender build, with a slightly accentuated second pulmonic sound, decidedly increased tendon reflexes, weak plantar reflexes, and many points painful on pressure in various parts of the head, over the spine, and in the sciatic regions. The vertebral sensibility to pressure was most acute in the region of the third, fourth, and fifth thoracic vertebrae. There was a marked dermatographia. There was no other sensory disorder and no motor disorder of the arms, though the left hand-grasp was weak. All passive movements could be successfully carried out with the legs. Upon bending at the hip, there were subjective feelings of tension in the posterior parts of the thighs. In active motion there was a marked limitation in leg movements, which appeared to be executed with great difficulty with but small excursion and with considerable trembling. The knee-joint could be flexed only when the sole of the foot had support. The lower leg could not be extended. The excursion in the joints of the feet and toes was slight. Muscular strength was in general decreased. There were no feelings of pain in muscular action but merely feelings of great effort. Gait was slow, shuffling, unsteady, hesitating and only possible with support. Fatigue set in after a few steps. In walking, the legs could hardly be bent at the knee. The soles of the feet dragged on the ground. The patient was unable to stand upright, and when placed upon his feet, anxiously and stiffly clung to some support. Without support, he fell over backwards. When supported he could move his legs at the hip and lift the feet from their base by bending the knee-joints. The patient could not sit in a chair or in bed except with support; otherwise he would fall to the right side. In dorsal decubitus he complained of pain in the loins.

With this hysterical picture, treatment of a psychotherapeutic nature was carried out. The patient was given methodical exercises in walking and standing, during which affirmative suggestions about his new capacity to walk and stand were given with monotonous repetition.

For the first fortnight he walked with the support of two nurses for a half hour every day. He was very industrious and willing to execute this treatment; and later began to exercise with a cane. Two days later, he omitted the cane and found himself able to walk about without support. He was shortly able to stand without swaying, although for some time the walk was upon a rather wide base and somewhat slow and suggestive of spastic paresis.

The general condition of this patient remained good. His appetite and sleep were good. After the middle of March, 1915, there were no more peculiarities in walking, and the patient was able to take somewhat long walks in the city and vicinity. He applied for work in the airship division, for which he already possessed some experience.

The youth appears to have been of a normal mental and bodily development, though his mother is said to have been nervous and a sister died of convulsions in childhood.

Shell-shock with loss of consciousness: Deafmutism, rhythmic head movements, anesthesia, asymmetrical areflexia. Recovery by suggestion with faradism, massage and reëducation.

Case 588. (Arinstein, September, 1916.)

A Russian private, 30, literate, lost consciousness upon the explosion of a large shell, November 10, 1915. He was brought to hospital, November 14, completely deaf and dumb, and with his head rhythmically swaying sidewise 60 to 70 times per minute. The swaying ceased during sleep. The head was carried inclined to the right; there was complaint of headache. The left leg, the trunk and the hairy part of the head were anesthetic. The knee-jerks were obtained with difficulty, the Achilles jerks were lively; the throat and conjunctival reflexes were absent; the abdominal and cremasteric reflexes were lively. The right plantar reflex was absent; the left normal. The vision of the right eye was impaired, and there was a monocular diplopia of this eye. The drum membranes were pulled in, and the disorder of hearing was explained on the basis of labyrinthine shock.

After a séance of written suggestion with faradism to neck and small palate and vibratory massage to throat, speech returned. November 26, the patient read in a loud voice a written phrase. He did not speak again independently until early in December, when he read aloud written matter. The return of spontaneous speech was gradual. Hearing returned December 5, when he was able to hear in the right ear by means of a tube. In the sitting posture there was less swaying of the head. If the patient lay down, rhythmic movements of the head became stronger and more rapid (120).

Shell explosion; unconsciousness: Amnesia; paralyses. Reëducation.

Case 589. (Batten, January, 1916.)

A corporal in the Belgian army was mobilized when the war broke out, and was in action continuously in the retreat from Liège, in the siege of Antwerp, and finally on the Yser until October 27, 1914, when the explosion of large shells rendered him unconscious. He recovered consciousness only in hospital at Calais. Though he was able to see and hear well, he was dazed and remembered nothing of what had happened. In fact, he did not understand what was said to him.

In a week’s time, his memory and intelligence returned, save for periodic attacks in which he was dazed. From the very beginning he had been quite unable to move his legs, and at first the arms were weak. He had a series of attacks of violent struggling in November and December, 1914, which the corporal himself called fainting attacks, claiming that he did not move his legs in the attacks but only his arms. In fact, he claimed that he could move neither head, body, nor legs, but only the arms. He said, “Sometimes I try hard and set my teeth, but I do not know how to move my head and my legs; I try but they do not move.” Sphincter control was maintained. Although he could see, when he attempted to read, everything went black.

He was finally admitted to the National Hospital for the Paralyzed and Epileptic on July 8, 1915, on the service of Major Walshe. He was thin and wasted. He was firmly convinced, according to the notes of Major Walshe, that he was seriously paralyzed. He said he could not lift his head; when his body was lifted, his head fell back, or rather perhaps was definitely thrown back, lolling about alarmingly. However as he lay in bed he frequently lifted his head unconsciously and placed his hands under it. When asked to lift his head, the sternomastoids were strongly contracted, but at the same time the neck extensors also, so that the head was stiffly and strongly held in an extended position. Despite the patient’s statement that he could not move the trunk muscles, he could turn over readily in bed, and when trying to move the head the trunk was fixed in a strong opisthotonos, and the abdominal walls were rigid. When requested to move his legs, he made no movement whatever, though during head movements the legs were strongly fixed in extension. On passive movements, there was no active muscular resistance. There was an indefinite blunting of all kinds of sensations. Reflexes were normal.

Major Walshe worked hard with the patient, inducing him first to lift his head from the pillow, and finally to move the legs. In three weeks’ time, the corporal could just sit up, and at the end of another month, he was able to stand in the walking machine. At the end of a third month, he was walking upon crutches, and at the end of another, he could walk upon two sticks with his feet wide apart, moving as if glued to the floor. To quote Batten, “The corporal will eventually get well but not, I think, before the end of the war.”