Chapter XXI: Section D: Shell-Shock Treatment and Results (17)

The physician found him to be in a state of exhaustion, pulse 108, and had him brought to the nearest station. There Donath found increased tendon reflexes, some dermatographia and increased fatigueability of mind and body. He was especially fatigued by walking, though he had always been a good mountain climber. He was now unable to concentrate on reading, writing or calculating, though he had been accustomed to dictate letters and calculations in his official work in peace times. He had seizures of crying and trembling on September 10 and October 27, both quieted by bromides. There was diminution of sexual power.

Rest, lukewarm baths, cold compresses to the head, and psychotherapy improved his status rapidly.

This patient had never been epileptic or hysterical, subject to dazed states of any sort, was weak, delicate and anemic (three sisters leukemic), but had before the war been well.

Emotion of captain who saw men burned by bomb: Stupor “as if dead”; awakening “as if a German prisoner.” Recovery.

=Case 363.= (RÉGIS, May, 1915.)

A captain, one day seeing some of his men hit by incendiary bombs, felt the deepest kind of emotion. He threw his coat over one of his men and succeeded in smothering the fire. Of a sudden, he completely lost consciousness, only regaining contact with the outer world two days later, in the sanitary train. He did not know where he was, but thought himself a prisoner surrounded by Germans. The disorder of consciousness lasted three days, and the memory of what happened during those days never returned. In fact, the captain declared that he felt as if he had been dead during that time. His dreamlike state lasted for some time, and for several weeks he did not sleep without disturbing nightmares. It was always the same night attack, with the burned men and the anguish of feeling that his men were not about him and that he was alone in the skirmish. He later recovered entirely and made preparations to start for the front.

_Re_ feelings “as if dead,” see remarks of Régis under Case 293.

Emotions over battle scenes: Spontaneous hypnosis or SOMNAMBULISM lasting twenty-four days.

=Case 364.= (MILIAN, January, 1915.)

Upon recovery from a state of apparent hypnosis described below, the victim wrote, in part, as follows:

“After marching two days we reached a Breton village near
Virtou. Next day we were in a battle that lasted from seven in
the morning to eight in the evening. I was somewhat troubled by
the first balls and bullets that whistled by, but felt I had to
get used to them and we marched on, under our brave captain’s
orders. Then we really got under fire. It was sad to see my
comrades falling under the murderous bullets, and the captain
was soon mortally wounded; but we had reinforcements and went
on and chased the enemy from his positions. During the battle
I kept thinking of my old mother and father and I felt that
I should die without seeing them again. Little things about
the family came to my mind. I saw my father’s roof, and his
favorite garden seat, and I saw my mother weeping over her only
son, her only ambition in old age. The return from the battle
was very sad for me. Night began to fall on the frightful
field. I saw on the bare earth the bodies of poor comrades
whose joys and sorrows I had shared. There they were, cut down
in all the strength of youth, leaving their parents in trouble,
their widows in despair, and their poor orphans. I wanted to
carry them off and I could not. We had to march over their
glorious remains. I was able to give a word of encouragement
to one of my comrades who now probably is no more. We then
retired. Although I was very weary, I was unable to get any
rest. My mind was occupied with the frightful things I had
seen. I thought of the comrades over there and that no one
could help them. I remember I drank coffee the next morning and
talked with my relative. Then that is all. From that time I do
not know what happened.”

The writer was an infantryman, 20, who had been employed in civil life in the Crédit Lyonnais, and was brought August 24, 1914, to the Saint Nicolas Hospital in a state of hypnosis.

Once placed in the standing position he kept balancing back and forth, with head motionless, eyes fixed and directed to the left side. He did not speak in reply to a request for his name or facts about his life, but as soon as the battle was talked of he began an expressive pantomime, speaking in a very low voice a few words interrupted by sighs. “What were you doing in the fight?” He extended his arms, described a half circle with his hand, as if to show the extent of the field, thrust his hands forward with a finger outstretched, saying, “Zi, zi,” as if to indicate whistling bullets; plunged forward with hands in front of his chest, as if holding a gun in charge bayonet position, saying “Prussians, Prussians,” and threw himself down in a kneeling posture, saying, “Trenches, trenches.” “Do you remember the battle?” “Belgium, Belgium. Germans pushed back,” making a sign as if chasing them. “Captain dead. Two hundred men dead.” With a suitable gesture he sighed, and tears ran down his face.

August 28 the mutism was still almost complete, but he could say his name and lay stretched out on the bed.

September 4 the hypnosis was less, but the delirious state was more active. He got up in the night and tried to escape to help the wounded. In the daytime, if he saw a man lying down resting he went to him and unbuttoned his coat to see whether he was wounded. Upon seeing the physician he would cry, “Major! Wounded! wounded!” and then pull the physician by his coat. He could hardly be stopped from these maneuvers. He had to be fed like a child, but went alone to stool.

He began to be employed about the hospital a little September 14, in sweeping the room and in guarding another patient in complete somnambulism, over whom he watched as over a child, leading him by the hand and keeping him from bumping into objects.

September 16 he awoke suddenly. Some one had talked to him about his own village and his relatives. He was astonished to find himself in a hospital. He wrote out, on request, the above account of his recollections. The man was 177 cm. tall, well proportioned; showed a slight facial asymmetry and a few other facial features of a dystrophic nature, such as an adenoid appearance. There was no stigma of hysteria.

Putative loss of brother nearby in battle: Spontaneous hypnosis or somnambulism; mutism, except “Mamma, Mamma.” Sudden awakening after twenty-seven days.

=Case 365.= (MILIAN, January, 1915.)

A man, 22, was brought to the Saint Nicolas Hospital in a sort of coma August 24, 1914. He lay on the bed, eyes closed as if asleep, insensible to excitation, irresponsive. Flies crawled upon him with impunity. He did not wink. The arms raised fell back inert. The corneal reflex was absent on the left side, diminished on the right. The knee-jerks and the skin reflexes were normal.

Next day he had to be fed like a child and looked after. Lifted from bed, once on the ground he stood up with flexed legs, as if to crouch. It seemed as if he was about to fall, but he did not.

The next day he was in the same immobile state. Upon removal from bed he again made as if to fall, but got his balance. He kept his legs flexed, his head lowered in a fixed posture, with his eyes on the ground. He would walk quickly without falling, if taken by the hand, feet dragging, and even holding back with a certain amount of force. His walk suggested that of a somnambulist. He was left in a standing posture by his bed throughout the medical visit. After a few minutes he began to flex his legs progressively and slowly. The attendant cried out, “He is going to fall.” Instead of falling, he sat down upon the floor near the bed. He was in the same immobile, somnolent state September 1, eyes half open, hidden under long lashes. Flies walked over his eyes and lids, but he did not wink. He would rise only when pushed and walk only when pulled, but had begun to eat a little better. To all questions he replied, from between his teeth, “Mamma. Mamma.”

The next day there was a bit more spontaneity in his walking.

Lumbar puncture showed a slight hypertension. There were traces of albumin and very few lymphocytes.

September 6, he was able to eat soup alone, but kept the same immobile posture, with eyes fixed on the ground, eyelids not winking, in a posture suggesting Parkinson’s disease, but without rigidity. He still replied only, “Mamma. Mamma.”

September 19 the patient suddenly waked up completely. Douches and external irritations had not served to wake him up, but a soldier told him upon this day that his brother was not dead, as he believed, but was alive and he then began to speak, opened his eyes, and began to talk. He told how he had been by the side of his brother in battle. Germans had taken them in the flank and opened machine guns upon them. Two men had fallen by his side, and, catching at his garments, kept him from retiring when the order was given. He got loose, looked for his brother among the corpses, could not find him, thought him dead, and from that point forward had been without memory. He shortly became perfectly normal.

Shell-shock; slight trauma; windage felt; fall; loss of consciousness; wandering, conscious, over night; shrapnel burst: Spontaneous hypnosis or somnambulism, lasting four days. Return to the corps.

=Case 366.= (MILIAN, January, 1915.)

An infantryman, 20, boxer by profession, was brought with other wounded, in the night, to Saint Nicolas Hospital and was seen next morning, August 24, in bed, lying motionless on his back, eyes open, fixed, eyelids not winking. No reply was got to questions. The arm lifted fell back upon the bed, although slowly and not heavily as in apoplexy. There was no catalepsy. The patient was taken from his bed and put upright. In this position he remained immobile, hands at side, head bent forward, eyes fixed on the ground. The eyelids did not move upon approach of the finger or a lighted candle, unless there was a fine beginning of movement. If he was pushed, he made two or three steps forward, with eyes fixed on the ground and head bent forward. The only spontaneous movement was carrying the left hand back to the side as if to take the bayonet. He got into bed alone.

Next day the patient could walk better and began to talk, but preserved the same absorbed attitude. He told, in monotonous voice, of the shells that his squad had received and of the dead that he saw about him. August 27 he woke up and was unable to tell how he had come to the hospital. He told how the regiment had been bombarded for a time and how a shell burst near him; how he got a splinter in the buttock (of which the contusion was still visible); and how he had been thrown down by the windage of the shell. His sack had been torn from his shoulders. He had lost consciousness, he thought, for a short time, anyhow he could not find his regiment. He passed the night near Longuyon and next day looked for his regiment again. Shrapnel burst near him, and from that time forward he had lost memory. August 27, at his express request, he started back for his corps. There was no stigma of degeneration or hysteria.

Burial; struck in head by beam; overcome by gas: Tremors, convulsive movements, confusion, flight toward enemy.

=Case 367.= (CONSIGLIO, 1916.)

An Italian private, 28, of meager build (infantile eclampsia; brother epileptic) was buried by a shell explosion and overcome by gas. After a month’s leave he went back to the trenches.

But now, whenever a shell burst, he fell into irresistible terror and made convulsive movements which he forgot afterwards. He could not sleep. The mere memory of the scene would throw him into terror. He was tremulous, developed asymmetrical innervation of his face, was generally hypesthetic and mentally blocked.

In the midst of convulsive tremors he fled towards the enemy. He was stopped and brought back, and remained for two days confused and hallucinated.

In the original accident he had been struck in the head by a beam.

_Re_ this Italian’s flight toward the enemy, see various cases of fugue. Clinically and medico-legally, Roussy and Lhermitte remark that these confusional escapades are of great interest, and that many cases are encountered near the front line, put under trial by court-martial, and handed over to specialists. The dream is being lived through. Such a case as this of Consiglio recalls the hystero-emotional psychoses of Claude, Dide, and Lejonne. The relation of oniric delirium to mental confusion is still a matter of polemic. According to Régis, however, the common oniric delirium of toxic or infectious origin is nothing more than a sort of somnambulism. The retrograde amnesia which follows toxic delirium is the same in principle as that which follows hysterical delirium. Régis pointed out that suggestive hypnosis could bring back the memories in both types of disease, as well as from the toxic delirium as from the hysterical somnambulism. However, the differential diagnosis between onirism and hysteria is not easy. Alcoholism and actual brain trauma need to be excluded.

Shell-shock; windage; unconsciousness: Carried on with fugue tendencies. Variety of hysterical symptoms. Fit for garrison duty four months from explosion.

=Case 368.= (BINSWANGER, July, 1915.)

A non-commissioned officer, 22, entered service at 20, went into the artillery and had been advanced repeatedly. There was no heredity; the man had been a moderately good scholar. It appears that he had had at 17 a febrile angina with delirium.

September 25, 1914, a big shell load for a cannon was exploded by the enemy. All the men about the cannon were thrown to the ground by air pressure, and the officer became unconscious. On awaking, he had headache, dizziness, and vomiting. There were many corpses lying about him.

He resumed work at once, but in the evening his headache and dizziness increased and there was “a feeling inside as if he had to run away.” This feeling appeared to come from the heart; it was an oppressive feeling, running to the head. On the next day he did gun duty, noticing, however, that every shot he fired caused him a sharp pain. He was relieved from work at 11 A.M., and was declared ill by the physician. His comrades told him that he had often been noticed trying to run away, but about this he himself declared he knew nothing.

He was received at the Jena Hospital, October 9, 1914, a very strongly built and well-nourished man. Neurologically, he showed a marked dermatographia; knee-jerks were obtainable only on reinforcement; Achilles jerks somewhat more marked; there was a weakly positive Oppenheim reflex. The abdominal reflex on the left side was greater than that on the right; and this was also true of the cremaster reflex. Percussion of the head was extremely painful; and there were painful points on pressure of the spine and head.

Touch was poor on the entire left side of the body; but there was no diminution of sensibility to pain. There was a fine static tremor of the hands. The strength of both hands appeared to be decreased (dynamometer). Gait was unsteady and stiff; Romberg sign was positive; the patient fell over backward. Hearing was greatly diminished, ordinary speech being heard only close to the ear.

Toward evening of the second day after admission, there was a marked attack of dizziness while the patient was lying on his back in bed. During this attack the face was very red. It lasted two or three minutes. Hearing was remarkably improved on the left side for some time after the attack. The ear clinic examination, October 19, showed much disturbance of hearing on the right side (direct injury of the vestibular apparatus in both ears).

Headaches continued, radiating from the orbit to the top of the head, and sensitiveness to pressure at the exit point of the upper branch of the right trigeminal. The whole of the forehead was somewhat red and swollen (neuralgia of the frontalis). The patient wore dark goggles on account of his marked photophobia.

Improvement was gradual; there was a transient slight swelling and a venous hyperemia of the nasal mucosa, which was treated in the nose clinic. The impairment of hearing was quite gone in two months’ time, though buzzing was now and then heard in the right ear. The supersensitiveness in the right upper trigeminal region vanished also. The patient was discharged January 21, 1915, fit for garrison duty. Later he went into the field again.

Burial: Dissociation of personality.

=Case 369.= (FEILING, July, 1915.)

The following are some stories told by a “lost personality” under hypnosis.

The patient, aged 24, was a bandsman in the Second Battalion Wiltshire Regiment, who sometime near the end of October 1914, was buried in a trench near Ypres. This is his account:

“I was dug out at night and taken to a dressing station; it was cold and dark. Then I went on to a hospital at Ypres; it was really a convent, and there were a lot of nuns about, dressed in dark robes with white hats; some of them spoke English. I stopped there for a night and a day. There were a lot of wounded there. Then I was sent on by train; I lay down all the way on a seat in the carriage; we took the whole day to get to ----, and kept on stopping at stations. I was at ---- about ten days; I don’t know what hospital it was, but there were English doctors and nurses. It was near the harbor. We came over to England in a hospital ship, the _Arethusa_; I went straight on to Manchester by train. The hospital there was really a school turned into a hospital.”

Here is a brief account of a scrap with some Uhlans.

Q. Did you see any Uhlans? Yes.

Q. What are they like? They’ve got no guts. One time 30 of them were against 8 of us infantry, and they “done a bunk.” Their horses were not bad. They wore helmets with a double eagle on the front.

He was asked to describe the country round the trenches and to give some account of the fighting there:

“It’s agricultural land, ploughed fields. There were two farms in front of us. One day we saw an old cow between our trenches and the Germans, and we all had pot shots at it. Once the Germans rushed our trenches; we killed hundreds, bayoneted them mostly, and hit them over the heads with the butts of our rifles. It was hellish. The British were all shouting. I saw a German officer behind with a sword and a revolver. I saw a lot of French soldiers, too; they wore long coats with the corners turned back; some had blue and some had red trousers. The French dragoons are like Life Guards, with big steel breastplates and brass helmets with a long plume; they carried swords and rifles and a few had lances.”

He was asked to mention some of his impressions in Belgium and what he thought of the manners and customs of the French and Belgians.

“We cut off all our buttons and gave them to the French girls. The French cigarettes are muck; you buy them in little blue packets; the tobacco is rather dark and strong. When we bivouacked on the march at night we were not allowed any lights, but you could smoke by digging a hole in the ground with your bayonet and smoking into that.”

The following are some of his remarks about his stay at Gibraltar.

“Gibraltar’s like a great big rock; the steep side looks toward Spain. I was in barracks there, and used to spend a lot of time in the band-room practicing. Sometimes we bathed in the sea. I went to Spain two or three times and saw some bull-fights; they were very exciting, but rather too cruel for my taste. They used to kill six or seven bulls a day. The horses got fearfully cut about.”

This bandsman showed what Feiling calls dissociation of personality. There was an amnesia of such degree that all conscious memories of the patient’s life, as well as all memory of letters, objects, and life in general, were suppressed. The patient was brought, after the burial above noted, to the hospital for epilepsy and paralysis at Maida Vale, January 21, 1915. After his experience, he had been transferred to the Second Western General Hospital, Manchester, where he spoke sensibly, understood and was able to remember things since the burial. His mind was a complete blank for all previous experience. He was unable to recognize his own father or relatives. He was slightly deaf for a time but this defect disappeared.

At Maida Vale he showed a nervous twitching of eyelids and facial muscles; otherwise he was neurologically and physically normal, dreamless, without complaints, and straightforward about all experiences since coming to himself in the hospital at Manchester. He took his parents on trust. “I don’t know if I ever went to school.” “A bayonet is like a knife; you see soldiers with them on their rifles. I have never seen a bullet.” His memory for recent events was also not good. He once recognized a single tune played at a concert.

Suspected of malingering, he was tried out in various ways. He was told that an elephant was a little furry animal and shown a little 6 inch toy sample. On going to the zoo he was greatly astonished at seeing a real elephant. He did not know what the war was about and he had no interest therein.

March 10 he was hypnotized and proved an easy subject. Powerful suggestions that lost memories would return were unavailing. The next day, during hypnosis, it was found that his previous experience could be readily tapped, and a history of his family, schooling, running away, and eventual enlistment was told. He had been at Gibraltar when war broke out. He was at the first battle at Ypres, and was for ten days in severe trench fighting, and was finally buried in the mud and débris of a trench blown in by a high explosive shell. He had been buried for about 12 hours, was dug out at night, and (according to his father) remained unconscious 24 hours, and deaf and dumb three days. He was transferred to another hospital and then to Manchester, where he came to himself.

Only during the first few sittings did the patient lie with eyes closed. Later, during hypnosis, he behaved exactly like a normal person. The fact came to light that when hypnotized the patient returned to the personality that possessed him just before awakening in Manchester, and accordingly during hypnosis, he had to become acquainted again with his hypnotizer. Maida Vale astonished him, as it should have been Manchester. Thus there were two personalities: No. 1: The personality since the date of the Manchester awakening; No. 2: The personality containing all the memories of the past life as well as the more recent Flanders memories. In State No. 1, the manner was jaunty and cocksure. In State No. 2, the man was more modest and less loud. Moreover, though in State No. 1 he spoke with a Lancashire accent, in State No. 2 his speech was in the West Country dialect--a strange observation, confirmed by several observers. He was asked to write down the answers to questions, and on awakening from hypnosis was shown the things written; whereupon he laughed and said, “Why, that’s not my writing.” On writing out the same sentences again, various minor points of difference were apparent. Hypnotized in the presence of his father, in whom in State No. 1 he took no great interest, he showed every sign of joy, causing his father to think that in State No. 2, his son had “come all right again.” In State No. 2 he could play a euphonium better than in State No. 1; but after practicing in State No. 1 he rapidly became as expert as in the hypnotic state.

If the patient were left for some time before being awaked by a previously-arranged method of counting three, he would experience disturbed dreams, with clenched hands, snarling lips, and muttered phrases, “Give it them,” etc.

Twenty-five hypnotic sittings were given but no improvement took place and the patient was discharged May 5. May 25 there had been no further change and he remained in State No. 1, in which state he was invalided from the service by a medical board, May 28.

Ear complications and hysteria.

=Case 370.= (BUSCAINO AND COPPOLA, 1916.)

An infantryman, 22 (father and mother quite normal; patient showed slight convulsions, attributed to worms, from which he actually suffered; was malarial from 9 to 15; had otitis media and lost hearing completely at 11; had suffered from 9 onwards with joint pains; as an adult had no convulsions), was called to arms August, 1914, and sent to the front May 2, 1915. About the end of August, in a water-filled trench by Monte San Michele, he was covered with mud from a shell explosion, lost consciousness, and in some way got back to the second line. He was told that blood had flowed from the right ear, and on recovery he found himself unable to hear with that ear, although it was the left in which he had had otitis. There were continual noises in the ear. He was, however, sent back to the front line. By mistake, one day, he got with companions in the midst of the enemy’s barbed wire, saw sparks from the guns, heard no shots, saw comrades fall, and threw himself instinctively into the wire network. Leaving the food kettles, he finally got back to the trenches. He was sent to the hospital at Legnano for his ear pains, and was treated by leeches, which he could not feel. He began to hear a little more. Flies walked on the left cheek without being felt. This anesthesia had begun a few days after the shell explosion. He was transferred to a military hospital at Florence.

One day he wedged a toothpick in cotton into his left ear and was charged with simulation, though he had been absolutely deaf in his left ear since childhood. From the moment the military surgeon told him he would be denounced for simulation, he lost his memory. Reports indicate that he had headache and delirious dreams (October 30), and suddenly he became furious (October 31), about three hours later going into severe collapse, for which camphor injections were given.

November 1 he had battle dreams and lumbar puncture had to be given up as he was in the midst of an attack. A hypodermic injection was interpreted by the patient as a wound, and he cried as if he were being abandoned on the battle-field. At one point he woke up from his hallucination and asked where he was and shortly relapsed into stupor. November 2, the patient was slightly bewildered and felt pains where the lumbar puncture needle had been tried the previous day. November 5, he was disoriented, thinking himself still at Legnano. The pupils were throughout dilated. November 6, confused and dreamy; November 7, he soiled his bed, was somewhat disoriented, immediately corrected himself; oculo-cardiac reflex 64 full compression, 62 during compression. November 11, headache; November 12, a slight bewilderment reappeared; November 13, remembered for the first time having been stunned by shell explosion, and this day got up and wrote home. November 14, complained of pains in muscles and weariness. Pupils still dilated. November 16, pulse 86; a gradual increase from 50 to 60 during previous days. November 17, patient had begun to remember facts that preceded the dream syndrome. November 18, pulse standing 88; November 20, pulse standing 120. This day cried when he remembered having been suspected of simulation. November 22 and 23, aches in joints and intense otalgia; pulse 86. November 24, diarrhea; deafness somewhat diminished; 26, diarrhea; looked as if he were about to have a new hallucinatory episode. This, however, did not come about until December 1, when he heard cannonading and knew the regiment was near. Next day he had forgotten the cannonading. December 14, the patient had become entirely tranquil and lucid and was able to give his entire history. December 16 and 17 he was given a systematic neurological examination, which showed on the left side complete anesthesia, hyperesthesia to pressure, thermanesthesia, analgesia, loss of bone, tendon, and muscle sensation. Vision was diminished more on the right side than on the left, and the visual fields on this side were more contracted. During examination, the fields became still more tubular. There was complete deafness, anosmia, and ageusia on the left side. On the right side there was a slight diminution of hearing. The pharyngeal reflex was abolished; the cremasteric reflex was somewhat less on the left than the right; and the defensor reflexes of the left leg were less marked than those of the right. There was no clonus or Babinski. The dynamometer grasp on the right was 37; on the left 18; and on this side there was a limitation of voluntary movements.

CHART 10

ETIOLOGY OF SHELL-SHOCK

WOUNDS 14 of 150

PHYSICAL
EXHAUSTION FROM EXPOSURE, HARDSHIP (all neuropaths) 3 of 142
CONCUSSION 52 of 142

CHEMICAL--SHELL GAS 3 of 150

PSYCHIC
GRADUAL EXHAUSTION, PREDISPOSING (43 neuropaths) 51 of 132
SAME, ACTING PER SE (patients chiefly neuropaths)
SUDDEN SHOCK
HORRIBLE SIGHTS 51 of 142
LOSSES OF COMPANIONS
FRIGHT NEAR EXPLOSION (one neuropath)
SOUNDS (a few neuropaths)

RELAPSES (41 of 150 observed, three-quarters neuropaths)

After Wiltshire

C. THE DIAGNOSIS OF SHELL-SHOCK

Chè non è impresa da pigliare a gabbo
descriver fondo a tutto l’universo,
nè da lingua che chiami mamma e babbo.

For to describe the bottom of all the universe
is not an enterprise for being taken up in sport,
nor for a tongue that cries mamma and papa.

Inferno, Canto XXXII, 7-9.

In the course of our study of psychoses incidental in the war (Section A) and especially of Shell-shock’s nature and causes (Section B), we have naturally met most if not all of the major diagnostic difficulties. In the present Section we shall study cases for the light they may throw on the more technical troubles of the diagnostician. Who would _à priori_ have felt that such diseases as tetanus, rabies, malaria, would produce practical difficulties in clinical diagnosis in the field of Shell-shock?

Mayhap there was no need to emphasize further the values of lumbar puncture fluid examination. Yet the admixture of “functional” and “organic” symptoms in numerous puzzling cases can hardly be over-emphasized.

But the interpolation, through the ingenious inquiries of Babinski, of a new or but vaguely suspected series of “reflex” (“physiopathic”) troubles between the organic neuropathic disorders on the one hand and the hysterical psychopathic disorders on the other--the result of these observations, sampled only in Section B, is given more in detail in the present Section. What a split in therapeutic method a recognition of this new group of “physiopathic” disorders might entail is seen also in further cases in the Section that follows this (Section D on Treatment and Results).

A number of simulation cases has been added.

CHART 11

ETIOLOGICAL GROUPING OF WAR PSYCHONEUROSES

I. NEUROSO-ORGANIC ASSOCIATION (NO CAUSAL NEXUS)

II. REFLEX NEUROSES (LESION DISPROPORTIONATELY SLIGHT BY
COMPARISON WITH PSYCHONEUROSIS)

III. NEUROSO-SOMATIC ASSOCIATION (TRENCH FOOT, NEURITIS,
RADICULITIS)

IV. FATIGUE OR EMOTIONAL PSYCHONEUROSES (CONSIDER EFFECTS OF
PSYCHIC CONTAGION, EDUCATION)

V. PSYCHONEUROSES ON ANTEBELLUM BASIS

After Grasset

CHART 12

WAR PSYCHONEUROSES

SYMPTOMATIC GROUPS

I. EMOTIONAL (HYPER- HYPO- PARA-)

II. CONFUSIONAL (ATTENTION AND MEMORY DISORDER, DREAM STATES;
DELIRIA)

III. CONVULSIVE AND PITHIATIC (HYSTERICAL)

IV. NEURASTHENIC AND PSYCHASTHENIC

V. SENSITIVOMOTOR AND SENSORIMOTOR--_e.g._, LIMITED PARALYSES,
CONTRACTURES, DEAF-MUTISM

VI. COMPLEX

VII. PHYSIOPATHIC (BABINSKI)

After Grasset

Value of lumbar puncture.

=Case 371.= (SOUQUES and DONNET, October, 1915.)

A colonial soldier arrived at Paul-Brousse Hospital with a hospital ticket showing that ten days before he had had _commotio cerebri_. He was dull, had a fixed stare, held his head in his hands, was disoriented for time and place, and had lost memory for everything that had happened for eighteen months. There was no sign of wound. There was no motor disorder save that walking was a bit slow and uncertain. Perhaps the right knee-jerk was stronger than the left. Percussion of the right Achilles tendon produced tremor. The plantar reflexes were flexor on both sides; flexion lasted longer right than left. The cremasteric and abdominal reflexes were a little weaker on the right. Arm reflexes were lively. Sensations proved normal. Complaint of headache, frontal and vertical.

Lumbar puncture October 7, that is, on the thirteenth day after the shell-shock, yielded a transparent, slightly greenish fluid, with 92 cells per cm. (lymphocytes with one or two large mononuclear cells and a few sometimes degenerated endothelial cells) and hyperalbuminosis.

October 9, the clouding of consciousness was less marked. The headaches and amnesia were constantly complained of; the reflexes were normal. October 12, there was less headache. October 25, another lumbar puncture showed but 14 or 15 lymphocytes per cm. and hyperalbuminosis. There was now no longer any clouding of consciousness. The amnesia, retrograde and anterograde back to May 9, 1914 (date of his daughter’s birth), and up to September 25, 1915, persisted. The man did not remember the declaration of war, or the mobilization, or his regiment, and the like. Meantime, the man’s judgment and reasoning powers were normal.

If there had been no early spinal fluid examination of this patient, he might well have been considered an hysteric or even a simulator.

Meningeal and intraspinal hemorrhage: Lumbar puncture.

=Case 372.= (GUILLAIN, May, 1915.)

A gunner from Morocco, who lost consciousness for an hour March 28, 1915, upon the explosion of a large-calibre shell in his trench, was carried to the ambulance. He complained of headache and generalized pains. His status was scarcely modified during five weeks, and a generalized contracture of the body developed whenever movements were attempted. In horizontal decubitus, the muscles of the limbs and neck were of a normal tonicity, but the head went into hyperflexion if the patient was asked to sit. The eyes turned upward, and Kernig’s sign developed. The patient could walk only with short steps, with legs apart and arms held away from the body, the head in a sort of tetanoid dorsal hyperflexion. There was a right-sided hemiparesis with trepidation and the Babinski sign.

Lumbar puncture assured the diagnosis of something organic. The fluid contained blood cells and a marked lymphocytosis. The symptoms evidently depended upon hemorrhages in the meninges and the nervous system, affecting particularly the right pyramidal tract.

_Re_ hypothesis of organic changes in hysterical cases, Roussy and Lhermitte remark in comment upon albuminosis in the cerebrospinal fluid that the albumin is perhaps due (in cases of camptocormia) to the effect upon venous and lymphatic circulation of the spinal curvature. It was Sicard’s claim that camptocormia, or bent back, was due possibly to anatomical changes in the spinal column, that is, that camptocormia was in one sense a spondylitis. In other cases the camptocormia might be due to a ligamentous or muscular change; that is, to a syndesmitis or a psoitis. His idea was that the curvature was in a sense antalgic; that is, a response having the purpose of avoiding pain.

Slight hyperalbuminosis.

=Case 373.= (RAVAUT, August, 1915.)

A farmer, 32, in the 66th Infantry, was lying in a dug-out March 5, 1915, when a bomb threw him on the ground and covered him with earth. He was picked up unconscious, and remained so for an hour. In the ambulance it was found that he could hardly stand, could not speak, and appeared to be completely confused. There was no sign of wound. The next day he recovered consciousness and complained of a violent headache. He was completely deaf in the left ear, and vision was also a little impaired on that side. The puncture fluid was clear, and there was a very slight excess of albumin by the heat test. The next day the headache had entirely disappeared, the left ear was absolutely deaf, but the patient complained of buzzing. Lumbar puncture the following day showed a normal amount of albumin.

March 16 the patient was evacuated to the rear presenting no abnormal symptom except deafness.

_Re_ the spinal fluid, Armstrong-Jones considers that a shock directly sustained by the spinal apparatus through sudden impact to the surrounding cerebrospinal fluid, ought to be felt more by the anterior horn cells than by the spinal root ganglia, since the latter are shielded by the sheath in the intervertebral spaces. Motor symptoms would, naturally, then be more frequent than sensory symptoms. He also believes that the controlling neurones in the intermedio-lateral tracts that have to do with the sympathetic system, would be affected just as anterior horn cells are. Accordingly, the dilated pupils, rapid heart, dyspnoea, and a variety of precordial pains and disorder of the viscera would ensue. The jar would thus be communicated to the neuronic cells of origin of two types: spinomuscular and preganglionic, leaving the gangliospinal neurones relatively intact.

Paraplegia, organic: Lumbar puncture.

=Case 374.= (JOUBERT, October, 1915.)

A gunner, 23, was thrown to the ground, according to his story, by the explosion of a large-calibre shell, at eight o’clock in the morning of September 10, 1914. He could not get up but thought he had not lost consciousness. September 13, he arrived at hospital, looking like a man with dorsolumbar fracture of the spine. There was, however, no external injury. There was a marked paresis of the right upper extremity, with diminished sensibility, weakened reflexes, numbness, formication. The right lower extremity was subject to complete flaccid paralysis, with lost reflexes, and anesthesia in all respects reached to the belt level, and stopped sharply at the median line of the abdomen. The left leg, also, was paretic but the muscles could be contracted weakly; the knee-jerk was exaggerated; there was a tendency to epileptoid trepidation, and the sensations were only slightly diminished. There was a Babinski reflex on the right side; the abdominal reflex was absent on the left side; both cremasteric reflexes were present. The feet at times gave formication. Rectal, bladder, and sphincter paralysis. Dark albuminous urine, with a few blood cells, was obtained on catheterization. There was an early sacral decubitus; consciousness was somewhat clouded. The man made no requests except for something to drink, and seemed apathetic.

Lumbar puncture, September 14, yielded hemorrhagic fluid. Three days later, the upper extremity regained its powers and sensations, but the paraplegia had become complete, with abolition of reflexes on both sides, and absolute anesthesia. The feet yielded formication at times, however. Sacral decubitus increased and healed not. The temperature varied between 38 and 39. The patient died September 24, in coma, with anuria and Cheyne-Stokes breathing.

Gunshot wound of spinal column; no penetration or injury of dura mater: At first quadriplegia; later cerebellospasmodic type of disorder.

=Case 375.= (CLAUDE and LHERMITTE, July, 1917.)

A soldier, 22, sustained a gunshot wound in the neck about the level of the fourth cervical vertebra. He immediately became quadriplegic. He recovered arm motion in two months and some weeks later ability to stand and walk.

Three months after the injury, station was difficult, better on a broad base. Rombergism, even with eyes open. Cerebellospasmodic gait. There was no weakness of leg muscles, but there was a certain degree of weakness of the upper extremities, especially in finger flexion. There was hypertonia of the muscles of all the extremities and the hands showed the signs of Raimiste, of Klippel and Weil, and of Dejerine. Static equilibrium was preserved to the will, but the kinetic balance was affected, and as much in the upper as in the lower extremities. Ataxia, tremors, dysmetria, adiadocho-kinesia, and disorder of combined movements in thigh and trunk flexion were all in evidence. Meantime, there was no disorder of sensation whatever except that the ulnar border of the right hand showed a hypobaresthesia, and there was a disturbance of tactile discrimination and absolute astereognosis in the hands. The deep reflexes were everywhere increased, and ankle and patellar clonus were easy to excite, especially on the right side. Bilateral defense reflexes. Bilateral Babinski sign. The hypertonia and ataxia ebbed away during the following three months. Walking became normal, and there was little sign of difficulty except astereognosis of both hands, combined with slight disturbance of deep sensibility and poor response to compass test in palm.

We here deal with a case of spinal column injury without injury to the dura mater. This cerebellospasmodic form of the superior cervical type of spinal concussion is less frequent than a quadriplegic form with Brown-Séquard syndrome. It is striking that both types of concussion may recover.

Spinal column trauma, with local signs: Later, hysterical anesthesia and contracture of back muscles homolateral with the trauma.

=Case 376.= (OPPENHEIM, July, 1915.)

A musketeer, wounded August 20, 1914, by a shell splinter in right side of vertebral column, fell unconscious, but was able afterward to crawl on all-fours out of the firing line. Severe vomiting and epistaxis followed. August 23, there was pain in the small of the back; the last two ribs were painful on right side; and the muscles were slightly swollen up to the iliac crest. August 30, a slight rise of temperature (at first it had been above 38) still persisted, but the muscular swelling was diminished. Treatment by aspirin and baths. No further rise of temperature after early in September.

On October 9, patient was permitted to get up, whereupon he showed a peculiar curved attitude of the body, reduced almost completely by passive straightening. Swelling of the longitudinal muscles. Radiograph negative, except that one picture showed a change in left twelfth rib, near the transverse process. Pains in left lumbar region.

November 19, on examination, pulse 112. November 23, after massage, vomiting. Temporary use of plaster corset.

On admission to the nerve hospital December 22, the musketeer was unable to extend the trunk, and the long muscles of the back were on the stretch, often as hard as wood, especially those of the left (longissimus dorsi). Patient lay on right half of pelvis. Hemianesthesia and hemianalgesia, left side. Tachycardia. Formerly the patient had done hard work, especially carrying heavy bags. He declined to be examined under general anesthesia. He seemed to be of unreliable character, and his trouble did not prevent him from returning from leave of absence, on one occasion, drunk.

Mine explosion: Combined hysterical and lesional effects.

=Case 377.= (DUPOUY, September, 1915.)

A lieutenant, 23, was in a mine explosion June 23, coming out in complete torpor, with mutism and retention of urine. He was brought to hospital June 26, with jactitation, irregular pulse, markedly exaggerated tendon reflexes, absent skin reflexes, sluggish, dilated pupils, especially right, and general anesthesia. The spinal fluid contained an excess of albumin, altered blood cells and many lymphocytes.

Several hours after puncture he suddenly demanded where he was, thought it was the year 1911 when he was in the Dragoons, talked about his camp, and was confused, irritable and stereotyped in questions. There was no verbal amnesia. Speech was hesitant, explosive and scanning, suggestive of multiple sclerosis. Next day there was still retrograde amnesia. He clung to the belief that it was July, 1911, and asked wearisome, stereotyped questions. The words, “German house” caused a jactitation, stiffening and relapse into a _second état_, out of which he came with hiccoughs and sighs, and amnestic for this conversation. There was general hypesthesia and muscular weakness especially of legs. The reflexes were as before.

The morning of June 28, he heard the hum of an airplane, whereupon his memory returned. It seems that he had himself once ascended. The memory gap was now limited to the time immediately preceding the mine explosion and the days following, up to the time of hearing the airplane. He told about his military life and also about incidents immediately preceding his blowing up. He complained of malaise and of pains in the vertebral column and limbs.

There was a quadriparesis, more marked, however, on the left; walking with falls to the left; astasia with left foot; double facial paresis; inability to whistle and to close eyes completely; intestinal and bladder paralysis; nocturnal emissions non-pleasurable; partial anesthesia of right leg, of arm and of hand, with hyperesthesia of thigh, of forearm and of the posterior aspect of the upper arm; anesthesia of the left side, including thorax and abdomen, excepting that the arm was hypesthetic only. Face hyperesthetic. Complete anesthesia of nipple and testis; hypesthesia of neck; anesthesia of tongue, nose and vertex; plantar, cremasteric, abdominal reflexes absent; exaggerated tendon reflexes; pupil reflexes normal; painful heat flashes and profuse sweating on the slightest movement; vertigo and tendencies to syncope after effort; explosive, scanning speech; intermittent convulsive movements of the arms. Palpation and X-ray show separation of the spinous processes of the third cervical vertebra.

Improvement was marked and progressive in motor, sensory and reflex fields. At the time of report three months later, there was a definite paresis of the left leg, with anesthesia and absent plantar reflexes, and slight paresis of the orbicularis palpebrarum, scanning speech and syncopal tendencies. Here, then, due to diffuse, non-systematic lesions, with superadded hysterical manifestations, were probably some effects of a permanent nature due to destructive processes.

_Re_ combination of functional and lesional effects, Sollier and Chartier state that in Shell-shock hysteria, physical causes and conditions are the chief factors; that in the so-called hystero-traumatism of Charcot, the psychic and physical factors are of virtually equal importance, and that in ordinary cases of hysteria, the psychic is the chief genetic factor.

Shell explosion: Hysterical and organic symptoms.

=Case 378.= (HURST, 1917.)

A champion heavy-weight boxer, 29, was unconscious for two days after being knocked over by the explosion of a shell in December, 1914. He found at first that he could not move the right arm or left leg; and after power had returned to the limbs, he had forcible involuntary movements in the left leg whenever he tried to stand. Examined, April 1, 1915, he answered questions slowly and with slow words; the right arm was weak. When the left hand was clenched, an associated movement took place in the right hand, but not vice versa. There was, however, no diminution in the girth of the muscles. The man was unable to localize light tactile stimuli accurately. Movements of the left leg were somewhat weak, the left knee-jerk was slightly brisker than the right; ankle clonus could be obtained on the left side and Babinski second sign (paralyzed leg rising higher than the normal leg in combined flexion of thigh and pelvis). When the man tried to walk, the left leg moved rapidly from side to side round the point of contact of the toes. When the right leg moved forward, the left dragged behind in irregular movement.

Every effort to cure the patient by means of suggestion during hospital care for a month entirely failed. Although the man was easily hypnotizable, he could not be made to move his leg under the deepest hypnosis. The first whiff of ether hypnotized him, so that the method of etherization could not be used in the endeavor to control the leg movements. Over a year later, July, 1916, the patient had greatly improved mentally but was otherwise in precisely the condition that is above described.

Gunshot wound of buttocks with injury to cauda equina: Urinary disturbance; decubitus; anesthesia. Superimposed paraplegia, regarded as functional and cured by psychotherapy.

=Case 379.= (OPPENHEIM, July, 1915.)

A German grenadier, October 11, 1914, was wounded in the left buttock by a missile that passed out through the right buttock. Pains in the abdomen and legs followed. The man had to be catheterized on the battle-field.

October 23, he suddenly fell down with total paralysis of both legs.

November 3, numerous small furuncles appeared on the buttocks, and bedsores developed. The patient lay helpless in bed, was unable to sit up without support, or to turn from one side to the other, and had areas of anesthesia.

During November and December, there was persistent high temperature, between 38 and 40; but January 3 the temperature stood at 36.6.

January 7 the patient was admitted to a nerve hospital. At this time he was able to pass urine unaided, though with tenesmus and pain, sometimes nausea and a tendency to vomit. He complained of pain in the back and pelvic region; the legs lay as if paralyzed. No active movement whatever was performed. There was a marked increase of tendon reflexes (even including the semi-membranosus). The muscles were relaxed through disuse but there was no atrophy. The patient moved his legs about with his hands. Sensibility was preserved except in the region of the pubis. The plantar reflexes were absent. Electrical reactions normal.

The diagnosis was functional paralysis of the legs (previous gunshot injury of cauda equina).

Treatment with psychotherapy met with prompt results; within a few days, the patient learned to move his legs and to walk with support, though making enormous efforts which threw the pulse up to about 160 and made the face congested. The bladder disturbance and the sacral anesthesia persisted.

Spinal concussion with spinal cord lesion: Thermanesthesia and analgesia of right leg and side.

=Case 380.= (BUZZARD, December, 1916.)

An officer was hit in the back by a shrapnel fragment, fell paralyzed, but after a few minutes was able to walk more than a mile to the dressing station. Eventually arriving in London, he had nothing to complain of except the wound, as the foreign body had been removed in France. The wound healed and the patient went to a convalescent home.

However, when taking a bath he could not feel the temperature of the water with the right leg. Muscular power was perfect; reflexes normal; but the heat, cold and pain sense was lacking in the right leg and the right side of the body from the seventh costal cartilage downwards.

One may make a wrong diagnosis of “Shell-shock.”

=Case 381.= (BUZZARD, December, 1916.)

In August, 1915, an officer was blown many yards by a shell, lay unconscious a while, could find no bruises, and carried on for twenty-four hours. Then, finding legs unreliable, he reported sick and was sent home as “Shell-shock.” He remained “Shell-shock” until February, 1916, then being able to walk five or six miles on smooth ground. Going downstairs he took the step with left foot rather than with right, and the right was apt to turn in. The sense of position and movement in regard to the right foot proved to be faulty. He could not balance himself on the right foot, nor could he appreciate tuning fork vibrations as well on this foot as on the other.

An X-ray examination showed a slight fracture, without deformity, in the left post-Rolandic region near the median line. His helmet had been bashed in at this point, and the bruised brain yielded symptoms even eight months later.

Retention of urine after shell-shock.

=Case 382.= (GUILLAIN and BARRÉ, November, 1917.)

An infantryman underwent shell-shock December 19, 1915, from the explosion of a torpedo nearby. He arrived at the ambulance, unable to speak, and next day had a confusional crisis of convulsions with contractures. He had not urinated since the accident, and two liters of clear urine were withdrawn by catheter; after which, the patient rested quietly and gradually regained consciousness. He was catheterized again in the evening and clear urine withdrawn. He remained unable to urinate spontaneously until December 25, and was catheterized accordingly.

There was no motor, sensory, or reflex disorder in this patient. Lumbar puncture yielded a normal fluid; the pupils were normal, and the only appearance was that of a marked asthenia.

Three months after his shell-shock, in March, 1916, the soldier was once more examined and still complained of headache, weakness, and inability to walk more than four or five hundred meters without a certain trembling of the legs. The reflexes remained normal and no further bladder trouble had supervened.

_Re_ anuria, Babinski remarks that, in days of yore, hysteria was supposed to be able to produce anuria as well as albuminuria, and even such organic changes as vesicles of the skin, ulceration, hemorrhages in the skin or of the viscera, fever, and even gangrene. He remarks that of late years no single identifiable case of this sort proved to be hysterical, has been reported. This is aside, of course, from such superficial and quickly passing vasomotor disorders as erythema and dermatographia. Anuria and albuminuria have consequently passed from the textbooks on hysteria, just as Babinski believes that hysterical edema and hysterical exaggeration of the reflexes are bound to pass. Hysteria cannot imitate everything; it cannot reproduce the characteristic phenomena of organic paralysis.

Retention of urine after shell-shock.