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.