Chapter XVII: Section D: Shell-Shock Treatment and Results (13)

This man had been rather enjoying it and was in the best of spirits until the shells began to burst. The platoon was retiring over open ground. He was kneeling on both knees, trying to creep under wire entanglements, when two or three shells burst near by. Three more shells burst behind and one in front. The escape was described by an eye-witness as a miracle. He managed to get back under the entanglements and into the trench, and shortly, as the fire slackened, rejoined his company.

His sight had become blurred immediately after the shell burst. Opening his eyes hurt him, and the eyes burned when closed. The right eye “caught it” more than the left. At the same time, he was seized with shivering, and cold sweat broke out, especially about the loins. He thought the shell behind caused the greater shock, like a punch on the head without pain. The shell that burst in front had cut his haversack away, bruised his side, and burned his little finger. This shell he thought caused his blindness.

He was led to the dressing station by two comrades, opening his eyes to see where he was going but finding everything blurred except immediately after opening his eyes. There was no diplopia. Objects seemed to dissolve. He was weeping and worrying about becoming blind. The horse ambulance took him to a hospital and thence to another hospital, and thence he went by motor ambulance at night to the starting point, where he arrived five days after he had entered the field. He could remember nothing about the ambulance trips. There was a slight deafness which soon passed off. In hospital he shivered almost incessantly in bed, and he kept thinking about his experience and the shell bursting. The shivering ceased November 3. No micturition from the afternoon of October 30 until the afternoon of November 2. No movements of bowels from October 30 to November 5.

It seems that this soldier had been for two months in the Aisne district, sleeping badly on account of lumbar pains and toothache. There had been albuminuria, and the patient said he had failed to pass a medical examination. The fields of vision were found to be distinctly contracted. There was difficulty in taste and smell, which the patient said he had lost since the shell-burst.

Hypnosis was tried but the patient “insisted on resisting.” The suggestions were offered during the concentration period. November 13 taste and smell began to return and the fields of vision were less contracted. He was transferred to England for further treatment, and by November 27 had become much improved and not so “nervy.” February 1 he had begun to attend hospital as an out-patient.

SHELL WINDAGE (NO EXPLOSION): Multiple affection of cranial nerves.

=Case 273.= (PACHANTONI, April, 1917.)

August 22, 1914, a French officer was leading his company to an attack and carried on, though wounded in the side by a bullet. Suddenly he felt as if he had received a terrible blow with a hammer on the left cheek and eye and as if his arm had been torn off. He fell to his knees without losing consciousness. _There had been no explosion_, and none of his soldiers had been hit. He felt of his arm and carried his hand to his head to make sure of the wounds. There were none, but he was bleeding from the nose and the mouth. His left eye was closed and his left cheek drawn “by an invisible hand.” His tongue had swollen until it had to be pushed out of his mouth. He was breathing hard. He fell upon his side without losing consciousness and he was carried by his men to shelter in a trench. Placed on his back he felt that he could not lift his head as “it had become too heavy.” His voice was lost. He could neither cough nor spit. In order to get air he had to remove bloody saliva from his mouth with his finger. The left side of the head was swollen. On opening his eyes he could no longer see with the left eye. His cheek was covered with ecchymoses but without wound. A few hours later he was made prisoner by the Germans. For two months he had an increase of temperature every evening and for three months he lost his voice. Six months later there was still visual impairment. He was anesthetic in the left cheek, unable to chew, paralyzed in the left facialis region. There was alteration of taste, with atrophy of the left side of the tongue deviating to the paralyzed side, and nasal regurgitation. There was continual drooling and convulsive coughing. In dorsal decubitus the head could be lifted with difficulty. There was a kind of paresis of the esophagus, as he felt the bolus stop at the level of the third ribs so that with each mouthful he had to swallow a little water. Apparently he had a paralytic state of the following nerves: optic, oculomotor, trigeminal, glossopharyngeal, pneumogastric, spinal accessory and hypoglossal. There was evidence of a slight old tuberculosis at apices. The man was slightly pale. There was an atrophy of the optic nerve and some retinal swelling. No pupillary reactions to light on the left side; but the accommodation reflex and sensory reaction were preserved. Divergent strabismus of the left eye. The taste on the left side and on the anterior part of the tongue was slightly diminished. Diminution of galvanic and faradic excitability on the left side of the face. No reaction of degeneration. Bitter, salt and sweet tastes altered. Left-sided atrophy of the tongue. No reaction of degeneration in the tongue and thyroid muscles although there was a marked diminution in faradic excitability.

The author records this case of multiple lesions of cranial nerves as due to shell windage. Thirty-one months after the onset of the paralysis the cranial nerves, although manifestly regenerated, had not regained conductivity. The officer was examined by Pachantoni at Louèche-les-Bains in Switzerland.

_Re_ windage, see remarks under Case 201.

Wound of thigh: Claudication, vasomotor disorder, hypothermia, but no exaggeration of tendon reflexes. Under CHLOROFORM, ELECTIVE EXAGGERATION OF REFLEXES, _i.e._, in this case, hyperreflexia of affected thigh, including patellar clonus, after other reflexes (including conjunctival) had become extinct. The case described led to the new formula of THE PHYSIOPATHIC SYNDROME (BABINSKI).

=Case 274.= (BABINSKI AND FROMENT, 1917.)

Babinski examined in August, 1915, at the Pitié, a soldier who had been wounded in the upper and outer part of the thigh. He showed a most marked claudication with outward rotation of the foot. There was a muscular atrophy of the thigh but no appreciable disorder of the electrical reactions. There was a slight limitation in the movements of the hip, namely, the movements of flexion and internal rotation of the thigh upon the pelvis; yet this limitation of movements did not seem to be in proportion to the rest of the motor disorder. The X-ray showed no joint lesion. The right knee-jerk was a bit stronger than the left, though this was controversial. Achilles reflexes were normal and equal; epileptoid trepidation of the foot, and clonus of the patella absent; the limb showed marked and permanent vasomotor disorders and local hypothermia; both phenomena were of a sharp and definite nature.

On the basis of the intensity of these vasomotor disorders, Babinski felt that, in accordance with his general ideas, he was not dealing with hysteria, and that he was in fact dealing with the so-called physiopathic syndrome. Lacking for this syndrome was the exaggeration of the tendon reflexes of the affected limb. Might it not be that the improper attitude and muscular stiffness of the limb were based simply on retractions of tendons? The patient was chloroformed. This procedure was the more warrantable as a number of physicians had thought of the patient as an exaggerator or even as a simulator. Under chloroform there was in fact a slight tendon retraction; yet on the whole it was clear that the attitude and stiffness of the limb were largely dependent upon a contracture. When during narcosis all the other tendon reflexes and skin reflexes had become extinct, there was still to be observed on the affected side a hyperreflexia, and even a clonus of the patella; and the clonus lasted an hour after recovery from the anesthetic. This curious phenomenon of elective exaggeration of tendon reflexes in narcosis, Babinski has observed to be not infrequent. It is a valuable diagnostic sign for a sure proof of excess tendon reflexes in cases where doubt prevails under ordinary circumstances. Sometimes the contracture will yield, but only in the deepest sleep, outlasting even the conjunctival reflex and the reactions to pricking of the normal extremities. Moreover, the contracture would return from 20 to 25 minutes before any manifestation of consciousness. If an endeavor was made to reduce the contracture under full anesthesia and in complete unconsciousness, a spasmodic movement was provoked which exaggerated the abnormal attitude of the limb. Sometimes even the leg would be thrown into flexor contracture.

The case above described was the one which led Babinski to his new formula of the PHYSIOPATHIC SYNDROME. This he describes in general terms as follows:

These disorders consist in post-traumatic contractures, paralyses or paretic states, but are not attended by any of the signs of the so-called organic diseases, either of lesions of the central nervous system, or of the peripheral nervous system, or of the great arterial systems. In fact, these disorders somewhat resemble hysterical manifestations. The underlying lesions appear to be sometimes extremely small; in fact, so minimal as to be out of proportion with the functional disorders that they produce. These disorders do not correspond with any known anatomical regions, but they are singularly tenacious, and, unlike truly hysterical (pithiatic) phenomena, they are completely resistant to suggestion. Yet it is not merely in resistance to suggestive therapy that these reflex disorders differ from hysteria; for besides the contracture and the paralysis or paresis found in the different segments of the extremity concerned, the complete Babinski syndrome includes also muscular atrophy, exaggeration of tendon reflexes, alterations of skin reflexes (even amounting to areflexia), hypotonia, mechanical over-excitability of the muscles with retardation of the muscular contraction; quantitative changes in electrical excitability of muscles (excess or diminution without R. D.), mechanical over-excitability, and occasionally electrical over-excitability of the nerves, disturbances in objective and subjective sensibilities (anesthesia and pains), heat regulation disorders (especially hyperthermia), and disorder of the vasomotors (cyanosis, skin redness, oscillometric lowering at the periphery of the extremity in the presence of low temperature), secretory disorders, and various trophic disorders of the bony system, the skin, and the nails.

Despite the permutations and combinations of these symptoms, according to Babinski they amount to a new group of disorders and represent a nosological species: a species of disease phenomena that lies midway between the organic affections and hysterical disorders. Babinski proposes the term _physiopathic_ for these phenomena, a term which excludes the connotation of hysteria and all forms of psychopathia, on the one hand, and seems, on the other, to express the fact of their correspondence to a physical material perturbation in the nervous system of a novel sort.

Bullet wound of ankle: Contracture effect of chloroform.

=Case 275.= (BABINSKI AND FROMENT, 1917.)

A man was wounded, September 1, 1914, by a bullet in the left ankle. Contracture of the foot and of the four outer toes in extension followed, with a flaccid paralysis of the great toe. The left knee-jerk was a little stronger than the right; the left Achilles jerk also appeared weaker but observation was difficult on account of contracture of the foot.

Chloroformed, October 22, 1915: There was no sharply defined asymmetry of the tendon reflexes. The left Achilles reflex appeared a little weaker. In the phase of muscular resolution, the contracture disappeared entirely, but it reappeared a little after the return of the tendon reflexes. The reappearance of the _contracture preceded_ the reappearance of _consciousness_ from twenty to twenty-five minutes.

Post-typhoidal reflex or physiopathic disorder of right leg. Elective exaggeration under chloroform.

=Case 276.= (BABINSKI AND FROMENT, 1917.)

A typhoid patient, October 20, 1914, showed phlebitis and abscess of the right buttock with contracture of pelvic trochanteric muscles. He was sent to the Pitié on medicolegal grounds.

September 22 there was found a slight laxity of the patella tendon, as well marked on the left side as on the right. The right side was more cyanotic, due to the inactivity of the limb. There was no edema. Tendon and skin reflexes were normal. The lack of power was diagnosticated as purely functional, and the report was rendered that the soldier could begin to walk as soon as he desired. The two knee-jerks were noted to be stronger and polykinetic, and the right knee-jerk appeared a little stronger.

The patient was chloroformed, October 25, 1915. Almost immediately, the knee-jerks, Achilles jerks, plantar, and cremasteric reflexes disappeared. During the first period of anesthesia, there was no accentuation of the reflexes, but at the beginning of recovery the anticipated reappearance of the _right_ knee-jerk was observed. This knee-jerk was already sharply defined at a moment when the left knee-jerk was still abolished. In a later phase of recovery, the right knee-jerk was very markedly exaggerated and a patellar clonus was demonstrable on the right side. Even percussion of the _left_ patellar tendon brought about a contraction of the _right_ adductors. There was a true clonic and tonic spasm of these muscles. On the other hand, percussion of the right patellar tendon was able to provoke no contraction of either right or left adductors. Nor was there at any time any ankle clonus.

Hysterical lameness (bullet wound of calf) cured, but the associated “reflex” disorder (in the sense of Babinski and Froment) NOT cured.

=Case 277.= (VINCENT, April, 1916.)

A corporal was wounded by a bullet in the calf, September 8, 1914. At the end of July, 1915, his lameness continued and he disliked to lean on his left leg which bent under him. There was a slight atrophy of the left calf. The lower leg could not be extended upon the thigh if the foot was in dorsal flexion, and the dorsal flexion of the foot was itself limited. There were no reflex, vasomotor or electrical disorders. The man was given the usual treatment by Vincent and soon learned to carry his body on either foot, and, being well disposed, speedily abandoned his lameness, acquiring such skill in movements that he became monitor over the other soldiers, watching over them in his capacity as corporal.

For about a year he thus served as monitor, and when fully dressed did not seem abnormal or look as if he were walking lame. However, after walking, say 6 kilometers, rapidly, he dragged his leg; nor was extension of the lower leg upon the thigh absolutely complete in habitual walking, though he was able to extend perfectly if requested. Dorsal flexion of the foot was also still somewhat limited, and the measurements of the two lower extremities at both calf and thigh showed a persistent slight atrophy on the left side. He was then sent into the auxiliary service and did good work as draughtsman. In the winter the left foot got cold rather easily.

This case is instanced by Vincent to support the contentions of Babinski and Froment that the truly “physiopathic” or “reflex” disorders do not completely clear up in the recovery from the associated hysterical disorders. That limb, which is the seat of physiopathic disorder, is not in a state of meiopragia.

Foot trauma: Pains and dysbasia, hysterical; slight atrophy of calf, physiopathic. Differential disappearance of hysterical symptoms; increase of physiopathic symptoms.

=Case 278.= (VINCENT, April, 1917.)

Clovis Vincent examined a man who had been wounded in the foot but without injury to the bones. He was first examined in July, 1915, when he complained of foot pains and was walking with crutches. The left calf was smaller than the right (4 cm.). The tendon reflexes were normal. There was no abnormality of electrical reaction. There was no proportionality between the trouble with walking and the organic status. A large part of the trouble appeared to be hysterical. In fact, upon treatment, the man was soon able to abandon the crutches and to walk, though lamely. He was put into the auxiliary military service.

However, the pains grew more marked and the lameness increased. Incapable of working, the patient was sent to the neurological center at Montpellier, whence he came to the neurological center at Tours in September, 1916. He had never been confined to bed, and had never ceased his daily walking, aided by a cane. The walking disorder was very pronounced. The patient said he was still suffering much. The difference between the two calves was now 8 cm. and the thigh was atrophied, though the atrophy had been absent in July, 1915. There was hyperexcitability of leg muscles. The right foot was colder than the left. The hysterical phenomena, so pronounced in July, 1915, were now absent, yet the reflex phenomena were sufficient to invalid the man.

Shell-shock paraplegia may AFTER TWENTY MONTHS develop vasomotor and secretory disorders: The whole to vanish on treatment.

=Case 279.= (ROUSSY, April, 1917.)

A foot chasseur, 22, a farmer in civil life, sustained shell-shock _à distance_, June 2, 1915. He had no wound, but lost consciousness. He was evacuated for “contusion of back” to a hospital June 4 to 12; for “contusion of back and _commotio cerebri_” to Portarlier, to July 21; for “internal contusions and _commotio cerebri_” to Besançon, where he was in three hospitals up to May 31, 1916, and the diagnosis “hysteria, old _commotio cerebri_ and trepidant astasia-abasia” was rendered and psychotherapy tried. The man was then evacuated to Saint Ferréol and the diagnosis “hysterical paraplegia” rendered. He finally reached Veil-Picard in February, 1917, still victim of paraplegia.

Up to this point there had been no signs suggestive of organic lesion of the spinal cord or any hysteroörganic intimation whatever. But in February, 1917, besides the motor disorder there was a hypothermia of several degrees, with cyanosis and hyperidrosis of both feet, with a marked diminution (and absence on one side) of the plantar cutaneous reflexes. The man was also victim of “hysterical pregnancy.” The cyanosis, hypothermia and hyperidrosis lasted six weeks.

March 23 the man was given treatment and for the first time in 21 months was able to stand and walk. The foot now turned from blue to red, and instead of cold became warm, even hot. In about a week the hyperthermia diminished, and, with the other troubles, disappeared. There remained only a slight swelling of the foot and ankle joints, due to the painful exercises given the patient.

It would seem, then, that a hysterical paraplegia of long duration may finally associate itself with marked vasomotor and secretory disorders and that these may be altered with extreme rapidity on the very day in which the hysterical phenomena are removed, and quite disappear in a fortnight.

Tetanus clinically cured: Phenomena in part reproduced UNDER CHLOROFORM ANESTHESIA five weeks afterward.

=Case 280.= (MONIER-VINARD, July, 1917.)

An infantryman, wounded at Notre Dame de Lorette, May 9, 1915, by a shell fragment in the right popliteal space, was given a preventive injection of 5 c.c. of antitetanic serum, evacuated to a hospital, May 12, and developed signs of tetanus August 1, with trismus and pains and spasms in the right leg.

The disease progressed with dysphagia, stiffness and paroxysmal hypertonia of the legs, especially of the right leg, fixed orthotonus of the trunk, neck hyperextended, arms stiff but able to move. Antitetanic serum was given daily. At the end of eight days there was a marked improvement and the whole course ran to approximate recovery in 25 days from the onset of tetanic symptoms, at which time the man was able to get up and walk on a crutch. The external popliteal nerve had been sectioned, and the foot was in a marked equinovarus.

Chloroform was administered for the purpose of straightening the foot, September 2, that is, about five weeks after the apparent end of the tetanus. The first stage of the anesthesia lasted about two minutes, but at this point the trunk and leg muscles passed into a state of diffuse contracture. In fact, a _tetanic syndrome_ took place _in the midst of the anesthesia_. At a time when the corneal reflex was completely abolished, it was still impossible, with the exertion of the greatest strength, to flex the segments of the lower extremities. Moreover, the trunk was stiffly extended and the jaws were in trismus. Tonic and clonic contractions were produced by the efforts made to straighten the foot, and these contractions passed from the right side to the left. The chloroform was now increased and a transient resolution of the muscles was obtained, lasting hardly more than a half minute. As all efforts to reduce the pedal deformity failed, anesthesia was stopped. The contractures and paroxysms lasted a few minutes. The knee-jerks were extremely exaggerated and there was a bilateral ankle clonus. After a brief phase of excitement, the patient emerged from anesthesia, began to talk with his comrades, and ate his usual meal without inconvenience. The chloroform anesthesia had lasted twenty minutes, and 60 grams had been administered.

It was now determined to section the tendo Achilles and the tibialis posticus. September 8 the man was chloroformed again and the same phenomena were exactly reproduced. Sixty grams of chloroform was again administered. The tendon resections permitted placing the foot in the proper attitude. Next day the patient was examined neurologically. The skin reflexes were found normal. The Achilles and knee-jerks were somewhat exaggerated, but equal on the two sides. There was no ankle clonus. Sensations proved normal. There was a mechanical hyperexcitability of the muscles of the anterior aspect of the thighs and of the calf.

In another case chloroformed 17 months after recovery from tetanus no such phenomena appeared. It would seem that the impregnation with tetanic virus or toxin must last in the nervous system a good deal longer than the apparent disease clinically lasts, but that this belated and concealed intoxication eventually passes.

The phenomena are perhaps _analogous to_ those of _Babinski and Froment’s_ so-called post-traumatic physiopathic or _reflex phenomena_. It was following the special work of Babinski and Froment upon the use of chloroform anesthesia in detecting physiopathic conditions that Monier-Vinard made his observations in cases of tetanus.

Shell-shock from falling of shell at a distance: Hysterical hemiplegia, terminating in brachial monoplegia. Case to show that the reflex or physiopathic disorders of Babinski and Froment may occur without mechanical injury in the region involved.

=Case 281.= (FERRAND, June, 1917.)

A soldier of the class of 1917 who never went to the front, while in training at Belfort, felt violent emotion on the occasion of the falling of a big shell in the town of Belfort. The explosion was a good distance from him. He lost consciousness a few moments, February 23, 1917, and almost at once found himself unable to move his left side. He was hemiplegic three months, but his leg shortly regained power. December 23 he entered a neurological center with his arm flaccid and a paralysis affecting the shoulder also. There was an almost complete anesthesia of the arm terminating in segmentary fashion about the shoulder, and the whole of the left side was slightly hypesthetic, although there was no disorder of motion except in the arm. The tendon reflexes of the left arm were exaggerated, and there was even contracture upon percussion of the muscles themselves. Percussion of the thenar and hypothenar eminences produced movements of the hand. There were several vasomotor disorders. Percussion led to large vasomotor plaques, and rubbing of the skin produced a reddening which passed away slowly. The hand was red and cold. Slight electrical hyperexcitability of flexors with feeble galvanic current; excitation of the extensors not associated with any contractions of the antagonist muscles. Threshold lower for flexors on the affected side in the forearm. Half centimeter atrophy of the biceps. The forearm and hand were possibly slightly increased in volume from a blue edema of the dorsal surfaces. The man was very timid, complained little, and accepted all treatment, which, however, was not very effective. This is presented by Ferrand as a case with physiopathic disorder in the sense of Babinski and Froment, though it does not present any sign of organic lesion whatever.

Shell fire: Delayed shell-shock symptoms, sub-lethal, appearing in England.

=Case 282.= (MCWALTER, April, 1916.)

A soldier was picked up insensible in the public street and brought to hospital by ambulance, unconscious, breathing stertorously, pupils dilated, lips parched, unresponsive to stimuli, but without signs of injury or alcoholism.

The pulse grew slower, the respirations more sighing, the heart-beat more diffused and labored; but towards evening, about eight hours after admission, he began to move the eyelids and lips, and muttered a response to the request for his name. After ten more hours, respiration grew better, and Croton oil led to a movement of the bowels. Natural sleep intervened, and 18 hours after the onset of unconsciousness, the man woke up, and in the course of a few days became fairly well though still dazed and confused.

This soldier had never received any definite injury in his war service, but McWalter attributes his break-down to the effects of the constant shocks from the bursting of shells, and the scattering of shrapnel.

McWalter generalizes that a soldier, in the course of some civil occupation _after_ the war, might develop symptoms, even fatal symptoms, and still the death in the case would be a direct consequence of the war.

Shell-shock symptoms, some initial, with recovery--others late and gradual, with deterioration.

=Case 283.= (SMYLY, April, 1917.)

A soldier became blind, deaf and dumb, as well as paralyzed, as a result of shell explosion. When he arrived at the hospital, he was able to see but had visual hallucinations. In a few days he recovered his hearing. There was a fine tremor of the hands, controllable by suggestion. There was an almost complete amnesia, but the patient remained able to read and write.

The pain persisted several months. The patient was physically well and seemed perfectly intelligent despite his aphasia and amnesia. One night, he sprang out of bed, shouting, “The guns are coming over us!” and from that time forward was able to speak. Amnesia, however, supervened for the months in the Dublin Hospital, and the patient believed that he was still in France. He also became unable to read or write, and was unable to recognize any letters except those he had been taught to speak during his period of dumbness. Still later he got a flaccid paralysis of the legs. From seeming perfectly intelligent, he began to seem markedly deteriorated. Hypnosis with waking suggestions had no power upon him. After a time, intelligence reappeared, but there had not been any recovery of locomotion at the time of report.

Wounds, gas, burial: Collapse on home leave.

=Case 284.= (E. SMITH, June, 1916.)

A non-commissioned officer went through the first eleven months of the war in France and Flanders and was subjected to every kind of strain therein. He was wounded twice, gassed twice, and buried under a house, in each instance being treated in the field ambulance and returning to the trenches. Some time thereafter he was granted five days’ leave.

On reaching home, while waiting for a train, the officer suddenly collapsed and became unconscious. For months thereafter, he was the subject of a severe neurasthenia; “the whole of his trouble seemed to be due to the dread, lest on his return to the front, the added responsibilities which would fall upon his shoulders might be too much for him.” He thought his intelligence had been numbed by his experience. He thought his memory was unreliable, and that he could understand neither complex orders nor even the newspapers.

As to the reason for his maintenance of composure at the front, this may be laid to the excitement, the officer’s sense of responsibility, and the example he felt he should set his men. This kind of case “demands a great deal of patient and sympathetic attention before the real cause is elicited, and then months of daily reëducation to build up anew the man’s confidence in himself.”

Bullet wound of neck: Late sympathetic nerve effect.

=Case 285.= (TUBBY, January, 1915.)

A Belgian was wounded, October 21, 1914, at Dixmude. The bullet wound was just below the right mastoid process. He was admitted to the London General Hospital, October 29. He said that the bullet had passed into the tonsil, lodging there, but that on the third day, while vomiting, he brought up the tonsil with the bullet in it. There was in fact a large ragged wound at the site of the right tonsil. He could swallow fluids only, but articulated clearly. There was a question of injury to the following nerves: facial, glossopharyngeal, vagus, hypoglossal, spinal accessory, and sympathetic. None of these nerves, however, appeared actually to have been injured. The difficulty in swallowing was due probably to the faucial wound, and it is hard to see how the pharynx could have been involved on account of the perfect articulation. November 3 the right sympathetic nerve was slightly affected; the right pupil was smaller than the left although it reacted to light. November 12 the patient left the hospital and nothing further is known of his history. Thus there was a late effect upon the sympathetic nerve thirteen days after the wound.

_Re_ peripheral nerve disorders, see remarks under Case 252 (Tubby).

Fall from horse under shell fire: Crural monoplegia, hysterical. Reminiscence? Autosuggestion?

=Case 286.= (FORSYTH, December, 1915.)

A patient of Forsyth had been exercising a high-spirited horse. Artillery fire close by made the horse leap sidewise, and the rider fell, his back striking the ground. He seemed to be curiously shaken out of proportion to the gravity of the fall. In a day or so, he lost the use of one leg.

He recalled a rather similar incident: He had taken a hand in a local uprising in a distant quarter of the world. While he was escaping up a mountain track, a rifle-shot from the enemy brought down his horse, which rolled over and threw him violently against a boulder, where the small of the back met the force of the impact. He felt intense pain and lost consciousness. Upon recovery he found he was paralyzed. At the end of several days, in a hiding-place in the rocks, he found himself still unable to move his legs. The friend who had carried him to the hiding-place refused to leave him. He thought of suicide, but then discovered that he could move: at first, the big toes, then the ankles, then the knees, and finally the hips. He was finally able to get into the saddle.

Moreover, years before, he had heard that a man who broke his back was paralyzed in the legs.

_Re_ autosuggestion, Babinski remarks that suggestion may work in hystero-organic cases not precisely as in hysterical cases. Autosuggestion may here replace or accompany the ordinary heterosuggestion. Some temporary disturbance--a slight pain, a trivial injury, or a mere bruise--may start up a complex process of autosuggestion in which it may be difficult to unravel the part played by the patient’s own reflexes, his previous experience and beliefs (in this case, the reminiscences of a similar accident), the solicitude of his friends, and the medical examination itself. Babinski believes that hysterical paraplegia or monoplegia never appears automatically under the influence of emotion; never appears after the manner of sweating, diarrhea, or blushing.

Shell explosion; struck in cave-in: Symptoms in right leg (antebellum experience).

=Case 287.= (MYERS, March, 1916.)

A private, 26 years old, had 11 months’ service and one month’s service in France. He arrived at a base hospital the day after his shock. Concussion had caused the dug-out in which he was standing to collapse. A beam struck him on the left side of the face, and pinned him to the ground on his right side. A piece of iron fell on the left side of his back, and his right leg was pinned by a cross beam on the back of his thigh. He was dazed by the shock; was released and was able to walk, but complained of a pain in the right groin and a giving-way of the right knee. The medical officer arrived about an hour later. A numbness, or state of no feeling, in the right thigh appeared, and increased to the point of total analgesia to the level of the upper margin of the patella save for a narrow strip in the mid-line on the posterior aspect of the leg. The only area of complete anesthesia and algesia was on the outside of the lower half of the leg.

According to the patient, it seems that about three years before, he had been buried four feet deep in a brick yard, beneath a heap of clay. He had felt it most in the right leg, but the thigh had been merely stiff and sore, and not numb. The patient admitted that the present accident immediately reminded him of his previous experience. There were no tremors or sensory disorders in the face, arms, chest, back, or abdomen. There was diminished sensibility to cotton wool of the left buttock (across which a plank had fallen), and there was a degree of hypalgesia of the buttock. The right thigh showed a degree of thermanalgesia and slight loss of vibratory sense. The corneal and conjunctival reflexes were diminished, and the knee-jerk was unobtainable on the right side. Three days later, there was a marked improvement with almost complete return to normal, whereupon the patient was sent to a convalescent camp.

Emotional subject, ALWAYS WEAK IN LEGS; shell explosion; wound of back: PARAPARESIS.

=Case 288.= (DEJERINE, February, 1915.)

A Lieutenant, 25, was wounded at Arras about 10 a.m. October 20, 1914, just as he was leaning on another officer’s shoulder looking at a card in a chateau room. A shell burst in the court yard. A fragment came in the window, struck him in the back and pushed him forward, whereupon he felt pain in the back and a severe dyspnea, due to the gas from the shell. He lost consciousness several times and the dyspnea lasted for about two hours. When he was picked up he could not walk.

He was carried on a stretcher to the ambulance at Avin-le-Compte. During the fortnight there, he was also several times dyspneic. Strength left his legs and he could only get about on crutches. There was now a suppurating wound in the interscapular region where he had been struck by the shell fragment. Evacuated to Paris, he was operated upon on account of a tremendous abscess in the back, and the shell fragment and some bits of cloth were removed. The wound healed; but vague pains in the left thorax remained, especially when the man walked.

On examination, July 28, 1915, he would in the standing position hold his legs together with the feet resting on their external borders, especially on the left side. The toes were in plantar flexion, and the soles were arched upward more on the left side than on the right. In walking, the legs were always held in extension, the feet twisting outward. If an attempt was made to walk quickly, the man walked more and more upon the external borders of his feet, in such wise that the plantar surface and the heel turned up and became visible from above. He would get tired after five minutes’ walking even if he spread his legs out for a broader base of action. He could lift his legs only about 10 cm. from the bed, but could flex and slowly extend his lower leg on the thigh. He could not adduct or abduct the feet. Movements of extension and flexion of leg on thigh were jerky and abruptly terminated, as also movements of thigh on hip. The patient could not sit, and when leaning forward he could not straighten up against resistance. The reflexes were normal. There was no sensory disorder. The electric reactions were normal. Pupils normal. There was slight hypertension of the spinal fluid and a slight excess of albumin. There were no lymphocytes.

In accordance with Dejerine’s idea that these neuropaths always have antecedents looking in the same direction, it was found that he had always been an emotional person, easily affected, sympathetic with other people’s troubles, given to weeping. As Lieutenant, he had not had the courage to harangue his soldiers. He had often during his life felt his legs weaken during times of emotion and had sometimes been unable to walk, though nothing of the sort had happened during the campaign. He was sure he could get well, and wanted two months’ leave in order to get back to the front. There were no hereditary features in the case. A physician had told him that he had had meningitis. This possibly followed whooping cough. He had had orchitis after mumps at 16. He had not had children, nor had there been miscarriages since marriage at 21.

Wound near heart; delayed medical care; fear of having been shot through heart: Paraparesis (antebellum always “hit in the legs.”)

=Case 289.= (DEJERINE, February, 1915.)

An infantryman, 20, was sent as a Colonel’s bicyclist about 1 p.m. September 30, 1914, with a message to one of the battalions. He was exposed on the way to shell and rifle fire, and was wounded by a bullet which entered 8 cm. below and internal to the left mammillary line and came out in the region of the left hypochondrium. He crawled to some village houses 20 or 25 meters away. Another cyclist came to transfer the order, but could not help him. A friend came to his aid but was struck by a bullet 10 meters off and remained on the ground for an hour while the young cyclist lay behind a tree on the roadside. At 3 o’clock it was possible to take him to a house around which shells were raining. Shortly afterward the house caught fire. The man was evacuated 6 kilometers to an ambulance in the night, and that night six of his wounded comrades died in the same room. The man had lost much blood and began to think that his heart had been hit. He choked, had violent palpitations, and intense thirst. By automobile next day he was taken to the railway station at Maison and was there for a day practically without food.

That evening, 36 hours after the wound, he was evacuated to Juivisez and stayed there one night in the temporary hospital. The hemorrhage had now practically ceased. When he arrived next morning at Vincennes he could hardly move, was unable to walk, had violent palpitation, precordial pain, and two nervous seizures, with outcries and weeping. Several days later he could not walk at all or raise himself in bed. He was operated on May 29; he afterward felt the same leg weakness and was still unable to walk. Early in December, when observed by Dejerine, he was able to stand on crutches with legs flexed, toes on the ground, and heels up. In walking he would scrape the ground with the dorsum of the foot. The wound was now healed. Suppuration had been intense and the scars were extensive. Lying down, the man could move, though slowly, his lower extremities in every way, nor was there any diminution in the strength of his flexors and extensors. The patient in making movements against resistance would let go quickly and jerkily. The plantar reflexes were flexor but weak. There was no other reflex disorder, no evidence of sensory disorder, nor any sign of neuritis or arthritis. Lumbar puncture gave a normal fluid without tension.

There were no hereditary features in the case. The man had been in childhood nervous and irascible, rolling on the ground, crying and weeping when crossed. He had had three attacks of appendicitis--one at 15 years and two at 19 years. After each attack he had felt weakness in the legs. He remembered, too, that after his nervous crises on being crossed, he had always felt this same weakness.

According to Dejerine, these paraplegic neuropaths, like functional gastropaths, cardiopaths, and victims of urinary disorder, have had earlier spells of the same kind, though milder than the attack which brings them to medical notice.

Wounds: Tic on attempts to walk; tremors. Recovery except for frontalis tic (ANTEBELLUM HABIT emphasized).

=Case 290.= (WESTPHAL AND HÜBNER, April, 1915.)

A substitute officer (mother nervous; always slightly excitable, easily fatiguable; had had a habit of wrinkling his forehead) sustained wounds September 8, 1914, in the foot and thigh. The wounds healed well, but in the hospital he slept badly and had battle dreams. When he essayed to walk, he had contractions of face muscles. There was a lively tic involving both face and neck muscles, with the head pulled to one side and backward. This grimacing was but slightly influencible by the will. There was a marked tremor of the arms. Gait was _trippelnd_. There were tremors of the whole body. There was also a slight hemi-hyperesthesia. The tendon reflexes were very lively; vasomotor disorders (feelings of cold and perspiration).

Seven months later the phenomena had all disappeared except for slight tic-like frontalis contractions.

_Re_ heredity and soil, Mairet investigated 22 cases of Shell-shock, and found a hereditary taint in eight, and an acquired predisposition in nine. He found hereditary taint definitely absent in seven, and acquired soil definitely absent in six; whereas the rest of the cases were doubtful. He found both the taint and the soil in five cases; two cases with hereditary taint alone; no case acquired, non-hereditary.

In eight cases with head trauma, Mairet found three with hereditary taint, four without such; against one with an acquired predisposition, four without such, others doubtful.

_Re_ cases of somatic trauma (not affecting the head), among five examined, there were none with hereditary taint, three definitely without taint, and five definitely without predisposition. According to Babinski, neither hereditary taint nor prepared _terrain_ needs be found in hysterics.

A predisposition is not thought important by Oppenheim, especially as so many normal persons are predisposed.

War strain (fatigue, emotion): Hysterical hemiplegia. Precisely similar hemiplegia ANTEBELLUM.

=Case 291.= (ROUSSY AND LHERMITTE, 1917.)

A sergeant in a regiment of cuirassiers was observed at Villejuif, January 25, 1915. He had lost power on the left side as a result of fatigue and emotion, November, 1914. He had a complete paralysis of the left arm and a paresis of the left leg. There was an anesthesia of hysterical type in the left arm, and also of the left leg as far as the middle of the thigh. He dragged his leg in walking (_démarche en draguant_: the toe is dragged along the ground, the trunk is bent forward, and at every step plunges somewhat toward the paralyzed side. The patient is able to walk, however, by means of a cane or crutches. This walk is characteristic of hysterical hemiplegia. According to Roussy and Lhermitte, the number of cases of hysterical hemiplegia (better, hemiparesis) is not large). The plantar reflexes on both sides were those of flexion. Upon treatment (not specified), at the end of six months he went back to service in the cavalry.

The point of note in this case is that this patient had had a precisely similar phenomenon on the same side, which lasted a month, at the age of sixteen years and a half. It is noteworthy that in this case there was no traumatism and only the factors of fatigue and emotion to serve as an occasion for the hemiplegia. In fact, hysterical hemiplegia is said very rarely to follow physical trauma to an extremity. There are, however, some cases in which hemiparesis follows a slight head wound, particularly if over the region controlling the paralyzed limbs.

During the six-months’ course of successful treatment, no atrophy of limbs appeared, and there was never any inequality of the reflexes.

A good soldier (son of a tabetic sometimes hemiplegic), at 17 victim of hysterical hemiplegia, has AT 24 A RECURRENCE after two months’ field service. “Functional excommunication” of left arm and leg.

=Case 292.= (DUPRÉS AND RIST, November, 1914.)

A cuirassier, 24, one month in the field, began to feel in September, 1914, crawling sensations in left arm and leg; then fingers, later hand and forearm, and finally upper arm began to work awkwardly and feel heavy, and there was a little of the same sort of thing in the leg. Hand and forearm were by the middle of October completely paralyzed, whereas the arm and shoulder were only paretic. Anesthesia at this time reached the elbow. The man had to be evacuated, after two months’ active and skilful field service, in one instance (September 19) carrying out a clever and useful interception of hostile telephone messages.

It seems that at the age of 17 also the man had had a left-sided hemiplegia, with sensory and motor symptoms, lasting two months, cured by electricity applied with a small electrode in his village. The war situation was therefore actually a recurrence of the transient hysterical paraplegia.

Moreover, the patient’s father, 52, an old tabetic, had also several times shown a hemiplegia (however on the right side), a phenomenon which had strongly affected his son.

It was curious that the slight residuals of movement which the cuirassier could perform could be made only while he was looking at the parts he was requested to move, and were impossible with eyes closed. The anesthesia was a total one when observed in November, 1914, coming to a sharp and circular termination at the shoulder and garter-wise above the knee--tuning fork insensibility in the same areas. The left patellar reflex was diminished when the eyes of the patient were leveled at the knee; but a surprise test brought the knee-jerk out normally. The hand and fingers were a little darker in color, and the whole left arm a little colder than the right. There was also a slight amblyopia on the left side.

This hysterical paraplegia proved rather resistant to psychotherapy. The patient seems to have systematically eliminated from consciousness and from action the entire function of the left arm and a good deal of the left leg. Duprés and Rist speak of this as a kind of functional excommunication of the parts.

_Re_ relapses, Wiltshire remarks that the frequency of relapses and the ways in which they are produced favor the conception that the original cause of Shell-shock must be psychic. Sir George Savage remarks that cases of Shell-shock should not return to the service under a period of six months on account of the frequency of relapse. Others have recently argued that such cases should not be sent back to the front at all. Harris notes that relapse may follow so apparently slight a factor as a vivid dream. Remarks concerning the true nature of relapses are made by Russell. Russell, for example, disapproves anesthetics in curing such a hysterical phenomenon as deafmutism. This sort of treatment does not get at the real cause of the condition, so that the man is very liable to relapse with the same symptoms. Ballet and de Fursac note the many cases of relapse after treatment and after discharge. Sometimes the relapses were due to some unfortunate happening, but in other instances no external cause could be made out. Fear of having to return to the front is a factor in certain cases, so that the true answer to the relapse question may not come until after the war.

Roussy and Boisseau insist upon the value of rapid cures (psychotherapy, electricity, cold shower, etc.), in diminishing the number of relapses. They maintain that these rapid cures abolish any chance for the man to brood over symptoms and thus to exaggerate and fixate them. These workers send their hospital return back to the regiments with a statement relative to diagnosis and the request that he be immediately returned to hospital if neurotic symptoms appear.

War strain; burial: Deafmutism. ANTEBELLUM speech difficulty.

=Case 293.= (MACCURDY, July, 1917.)

A private 20 (always rather tenderhearted, disliking to see animals killed; rather self-conscious; a bit seclusive; “rather more virtuous than his companions”; shy with girls; sore throat a year or more before the war, with inability to sing or talk; always a lisper) enlisted in May, 1916, spent five advantageous months in training and became increasingly sociable. However, on going to the front October, 1916, he was frightened by the first shell fire and horrorstricken by the sight of wounds and death. He grew accustomed to the horrors and five months later was sent to Armentières, where he had to fight for three days without sleep. He grew very tired and began to hope that he would receive wounds that might incapacitate him at least temporarily for service.

He was suddenly buried by a shell, did not lose consciousness, but on being dug out was found to be deaf and dumb. On the way to the field dressing station he had a fear of shells. The deafmutism persisted unchanged for a month and then was completely and permanently cured in less than five minutes. He was made to face a mirror and observe the start he gave when hands were clapped behind him. He was assured that this start was an evidence of hearing; that his hearing was not lost, nor was his speech. He had no relapses during two months.

According to MacCurdy, this case is a typical one of war neurosis of the type of a simple conversion hysteria. The man never suffered from anxiety or nightmares.

_Re_ burial cases, Grasset suggests that some of the patients probably think that they have actually died; both sensation and motion have been lost, and it is naturally these that permit a man to believe that he is still alive. The classical case is recalled, of the almost absolutely anesthetic boy who, with eyes closed, at once fell asleep. Foucault’s patient also said he actually thought he was dead after an explosion.

War strain: Shell-shock and psychotic symptoms, with determination to parts injured ANTEBELLUM.

=Case 294.= (ZANGER, July, 1915.)

Several years before the war, a cavalry officer had a severe concussion of the brain after a fall from his horse, but got no manifest symptoms therefrom except a mild transient deafness. There must have been a vestibular nerve injury, however, since there was a marked bilateral subexcitability of this apparatus later determined.

In September, 1914, as the result of strains and privation in the field, he got vertigo and lachrymose spells, with some obsessions as though he would have to shoot himself in the foot or spring out at the enemy from the trench.

In hospital at Jena, insomnia, anxiety, excessive perspiration and salivation, feelings of the death of various parts of the body, especially the forearms and hands, associated with hypesthesia of the parts, were determined. He had a feeling of vertigo on walking and was very sensitive to noise. He now developed a very intense and very variable degree of deafness on both sides, diagnosticated as nervous deafness. The caloric test demonstrated vestibular subexcitability above mentioned. We may suppose that in this already injured organism fresh disorder had set in on a psychogenic basis in the same region that had been injured years before.

Mine explosion; emotion at death of comrades: Unconsciousness eight days with hallucinatory delirium; later, dizziness. History of previous trauma to head with unconsciousness and dizziness.

=Case 295.= (LATTES AND GORIA, March, 1917.)

Sent at end of May to the front, an Italian soldier (Class 1895, laundryman) was placed in an advanced post where he at once sustained great hardships.

Father drunkard, mother healthy, sister nervous. Two brothers healthy, one brother died of tuberculosis. Patient had scrofula, scarlet fever, and bronchitis (tendency to rave intensely when in fever). At four, sustained a trauma on the head (skull depression), dizziness, loss of consciousness.

June 7, a mine exploded in his vicinity, smashing several of his comrades. He did not himself fall to the ground, but was overwhelmed by a violent feeling of anguish. After a while, he lost consciousness. He woke up at Bologna, June 15, as after a long sleep. During the interval he had been in a state of intense hallucinatory delirium day and night. Then his mind began gradually to clear, first with amnesia of the shock which had caused the trauma. Then he recalled this fact too. Dizziness, however, grew in intensity so that he fell to ground many times during the day. There were intermittent tremors in the limbs.

Under observation, August 7, a sturdy, robust man. Somewhat dull in demeanor. Senses intact. Cranial nerves negative. Tendon and skin reflexes lively, especially on the right. Memory intact, except for above-mentioned oniric delirium with restlessness and shouting at night, especially while falling asleep and waking up. Frequent intense dizziness.

The condition remained unchanged for a week. Patient transferred to another department, for acute catarrhal bronchitis with fever.

Sniper stricken blind in shooting eye.

=Case 296.= (EDER, March, 1916.)

An Australian, 19, was admitted to hospital for loss of sight in the right eye. There had been a _right ptosis_ from childhood. January 7 nothing could be perceived but light.