Marches; battles; slight shell wound of left upper arm: Hysterical anesthesia of the arm and tremors (NO paresis). Causes slight—disease obstinate (partly explained by furloughs among sympathetic friends).
A soldier, 26, without heredity, always well, in long marches and several battles early in the war, August 23 sustained slight shell wounds of thighs and left upper arm. He was unconscious about five minutes. In eight days, the wounds were healed, and all movements were free.
Immediately after the trauma the arms trembled, and at times the legs. Treatment was instituted (baths, drugs, massage, electricity), but without result. After a month’s treatment and a furlough at home, the patient was sent, January 3, 1915, to the Jena Nerve Hospital. He was a powerful man of middle size, with some small movable scars on the left upper arm, remains of the shell injury; two similar scars of the gluteus maximus. The deep reflexes were slightly exaggerated, as were the skin reflexes. The touch and pain sense in the left arm was absent as far as the shoulder in typical segmental fashion. Arm movements were free; there was an occasional tremor in both arms, especially the left. This tremor would pronouncedly increase upon intentional movements and with emotion.
He said that about two weeks before, at home, he had waked up in the night and lain down on the floor beside his bed, feeling giddy in his head. In a week the tremors had diminished, leaving only a very slight tremor of the left hand. The patient went to considerable pains to conceal his tremor, holding his hand in a military position at the seam of the trousers, on the medical visit. Sometimes he would succeed in making the tremor quite disappear. February 5, he was busy about the ward work, going errands and carrying trays. He would intentionally spare his left hand in this work. Upon trying gymnastic exercises, the tremors of the left hand and also of the right reappeared. After a few days these tremors again disappeared, only to come back on the 12th, when there was a constant tremor also when the patient was at rest. He had been affected when observing another patient (8[7]). Accordingly, he was separated from this patient and put in a psychiatric ward. The tremor remained of varying intensity, sometimes being absent for hours together.
Request for furlough at the beginning of March was refused with the statement that it would be granted when cure was complete. The patient was inaccessible to psychotherapeutic influence. He was always of a friendly, modest demeanor, sleeping well, and performing all bodily functions properly. On any exertion the pulse ran to 134. The heart was normal. There were outbreaks of perspiration.
March 26, he renewed his request for leave, desiring his Easter furlough. He was told he might expect it. March 31, the tremor was found to have quite disappeared. Upon his return, April 12, there was a marked tremor of the left arm, especially of the wrist joint, which again disappeared after some days. The middle of June he was released as capable of garrison duty with the recruits.
If there was a mechanical factor in this case, it must have been the shaking-up of the body by the shell explosion. His skin lesions were slight. The main factor was doubtless the emotional shock. The tremor supervened upon a very brief period of unconsciousness. It is hard, according to Binswanger, to explain the localization of the cutaneous anesthesia without the development of a corresponding paresis. May it be, inquires Binswanger, that the wound of the left upper arm at the moment of the setting-in of unconsciousness, or perhaps at the moment of waking from unconsciousness, directed the mind forthwith upon the left arm and in this way produced localized disorder of sensation? If so, why did the wound of the gluteal region not produce corresponding disorders of feeling and sensation of an hysterical nature? The obstinacy of the disease stands in striking disproportion to the slightness of the causative factors at work.
According to Binswanger, this is perhaps due to the long furlough which the patient had. According to Binswanger’s experience, as that of many others, home works badly for these hysterical patients; their friends sympathize with them too much.
Re furloughs, Ballard states that severe Shell-shock cases should get analogous treatment to that of civilian psychoneurotics, namely, a complete removal from the environment in which the illness began. He advocates three months’ leave, after which the man is to be sent to a convalescent home, and thence to a command dépôt. He states that if a relapse then occurs, such a patient will never be a soldier. Ballard would allow the men to walk about with their “pals (not with escorts).” Cimbal remarks that German data show that home furloughs should be avoided in every instance where possible. Fiessinger remarks, on the basis of English experience, that a Shell-shock patient treated by rest, suggestion, and manual occupation may go back to the line “and on a subsequent occasion prove a hero.” (See Case 474 of Gilles.) But Forsyth remarks that it is probably injudicious to send any cases of Shell-shock, with few exceptions, back to the firing line, because their fighting value has been permanently deteriorated, and because, if the fear of return to the trenches is removed, recovery is more rapid. The experience here is not unlike that of industrial accident board cases with rapid recovery after the decree of compensation.