Chapter XXII: Section D: Shell-Shock Treatment and Results (18)

=Case 383.= (GUILLAIN and BARRÉ, November 1917.)

An infantryman, 27, underwent shell-shock August 16, 1916, at four o’clock, from the nearby explosion of a big shell. He lost consciousness for a period of ten minutes, was sent to the regimental aid post, and twelve hours later brought to a hospital center, in a state of profound muscular weakness. He could not walk although he could make every movement of the legs. There was a marked diffuse cutaneous hyperesthesia. The reflexes were normal; the pupils were unequal, the right myotic. The lumbar puncture yielded a clear fluid under normal pressure, but with an excess of albumin. For three days, retention of urine was absolute, requiring the catheter. There was neither sugar nor albumin in the urine withdrawn. On the fourth day he was able to urinate spontaneously; the asthenia and other symptoms had disappeared in two or three weeks.

Incontinence of urine after shell-shock and burial.

=Case 384.= (GUILLAIN and BARRÉ, November, 1917.)

An infantryman was subject to shell explosion and burial May 10, 1917. He lost consciousness for a few hours and spat blood for two days. He was carried to an evacuation hospital and thence to the neurological center at Amiens. Incontinence day and night lasted from the period of shock up to May 29, when the patient was transferred again, to another hospital. The man had never, either in childhood or adult life, had incontinence. He showed a slight tendency to latero-pulsion toward the left. Puncture fluid normal.

Guillain and Barré report but 12 cases of sphincter disorder following shell-shock without external wound among hundreds of cases, and among 12 instances of sphincter disorder there were but three of incontinence, of which the above is one example. Incontinence lasted longer in these cases than retention. Guillain and Barré are unable to assign a cause for the findings.

Struck in back by shell splinter: Crural monoplegia; absence of plantar reflex.

=Case 385.= (PAULIAN, February, 1915.)

An infantryman, 20, was struck by a shell fragment in the small of the back while lying in the firing position, about 2 P.M. August 22, 1914, at Eth in Belgium. He felt as if he had been struck by the butt of a gun in the lumbar region. He was unable to get back with his comrades. His sack had been cut. He was without ammunition, and getting to a bridge he was able to jump a distance of about 8 meters. He fell and fainted. On coming to himself, his left side felt bad and he could not move his left leg. He dragged himself to the relief post which was being bombarded just as he arrived, and he got a bullet in the left frontal region.

He was evacuated to another ambulance and decided to go back to France. Supported by his Lieutenant, he walked all night making about 35 kilometers on foot. He arrived at Charancy and got by train to Mont-Midi. On alighting, he could not walk. He said he was bent in two, and shuffled on in this position.

The “bent-back” lasted about a month, when he began to stand up again. He passed through various hospitals and was evacuated to the Salpêtrière. He then walked with the left leg in extension on the thigh and the foot in external rotation. He was hardly able to stand on either foot, and especially fell if he tried to stand on the left foot. He made no resistance to passive movements of the left lower extremity. The reflexes were normal except that the left plantar reflex was abolished. On the right, the plantar reflex was normal, and an attempt to elicit this reflex was followed by strong defensive movements. There was a tactile, thermic, and pain anesthesia of the foot and leg as far up as the lower third of the thigh. Above this anesthesia, there was a zone of hypesthesia. Position sense was also abolished in this region, and there was a bony hypesthesia likewise. A slight muscular atrophy (2 cm.) affected the lower leg and thigh.

There were no hereditary or acquired features of importance in the case except that there had been at 14 a chorea for a year. In particular this man appears not to have been an emotional person.

The point in the case is the abolition of the plantar reflex on the left side, in association with a functional paraplegia and hemianesthesia.

_Re_ plantar reflex modification in hysteria, Babinski believes that the same law which holds that hysteria is not in line to alter either the tendon reflexes or the pupil reflexes, is true for the skin reflexes. Dejerine brought forward three cases which appeared to him, however, to demonstrate absolutely that functional anesthesia might abolish or greatly diminish the skin reactions of the sole of the foot, that is, the plantar reflexes and movements of defense. Case 385 was alleged in support of Dejerine, as also were cases of Jeanselme and Huet, and of Sollier. Babinski’s critique of Dejerine’s cases ran to the effect that two of them showed contractures, and accordingly were not pure cases in which to demonstrate plantar reflexes or movements of defense. In the third case, Babinski at a meeting of the Neurological Society, himself obtained definite flexion of the little toes by stimulating the planta. According to Babinski, therefore, Dejerine’s cases, far from proving that hysterical anesthesia could abolish the plantar cutaneous reflexes, proved that hysterical contracture might mask reflex movements. Hysterical contracture, therefore, may be as important a factor to consider _re_ reflexes as voluntary muscular contracture itself. As Babinski pointed out, many normal persons can keep the leg immobile when the sole is stimulated. Moreover, Babinski pointed out, many cases regarded as hysterical were actually cases of a physiopathic or reflex nature which had actually undergone trauma. It will be noted that the above case of Paulian is just such a case of trauma.

Shell-shock; unconsciousness: Crural monoplegia; sciatica (neural changes).

=Case 386.= (SOUQUES, February, 1915.)

A reserve lieutenant, September, 1914, was blown up by a shell and lost consciousness for an hour. On coming to, he felt pains in the loins, right thigh, knee and heel, and found himself unable to move the right leg at all. Urinary incontinence lasted three or four days. Violent pains lasted weeks, now and then actual crises (sleep only with hypnotics).

The pains then passed off. The flaccid crural monoplegia lasted. There was a hydrarthrosis of the right knee and a sciatica (physical nerve changes?) and a crural monoplegia without trophic, electrical, reflex or vesico-rectal trouble. Lumbar puncture showed no lymphocytes or excess of albumin. It would, of course, be difficult to tell whether this case was hysteria or simulation.

_Re_ hysterical monoplegia, Babinski inquires whether a hysterical monoplegia can automatically appear as a result of emotion without any intellectual element whatever. Emotion produces sweat, diarrhea or erythema, without any intellectual intermediate. Can emotion--that is, emotional shock--produce a monoplegia in the same way as it produces an erythema? The narratives of patients might indicate that emotion can do such things. But according to Babinski there is no genuine case of monoplegia or paraplegia directly produced by emotional shock. One must be careful in this discussion not to confuse emotional shock and emotion of a gradual nature. Babinski wishes to define emotion as a violent affective change as a result of a sudden mental shock upsetting physiologic or psychic balance during a usually brief period. As for the more gradual affective states or emotions, there is obviously so much of the imaginative and intellectual compounded therewith, that plenty of opportunity exists for the production by suggestion of such phenomena as monoplegia, paraplegia, hemi-anesthesia.

_Re_ sciatica, see remarks above under Case 329.

Functional paraplegia and internal popliteal neuritis.

=Case 387.= (ROUSSY, February, 1915.)

A Zouave was taken out from under a trench shelter beam, the night of December 21, 1914, at Tracy-le-Mont. The beam had fallen upon eight men, killing one, and striking the Zouave in the hypogastrium. He was pulled out two hours later, unable to take a step. He was evacuated on his back, to Paris; stayed a month in the hospital at Croix-Rouge, bedfast. According to the patient, he was entirely anesthetic in the legs. He went to Villejuif, January 22, with the diagnosis of spinal contusion and hemiplegia. He could then walk on crutches, leaning on the left leg. He felt a sharp pain at the level of the spinous process of the first lumbar vertebra and all along the sacrum. Spontaneous movements of the left leg were possible, but they were slow and weak. The hypesthesia rose to the navel. There was a suggestion of a cauda syndrome. The knee-jerks were normal, but on the left side the Achilles jerk was absent. There was a partial R. D. in the posterior muscles of the left leg.

The diagnosis was functional paraplegia plus left internal popliteal neuritis. The crutches were removed, he was isolated, and given motor reëducation. In a week he was able to walk alone with ease.

_Re_ popliteal nerve lesions, Athanassio-Benisty remarks that the external popliteal nerve of the leg resembles pathologically the musculospiral nerve of the arm, whereas the internal popliteal behaves like the median. The musculospiral nerve of the arm shows very variable and usually slight sensory changes. The median nerve more than any other nerve in the arm yields painful sensations during its recovery from section.

_Re_ differentiation of peripheral neuritis and hysterical paralysis, Babinski gives as signs peculiar to neuritis, and never found in hysterical paralysis, the following: (_a_) diminution or loss of bone and tendon reflexes; (_b_) muscular atrophy (except for slight amyotrophy exceptionally found in hysteria); (_c_) the reaction of degeneration (only of value after eight or ten days); (_d_) hypotonus; (_e_) distribution characteristic of peripheral motor sensory and trophic disorder.

_Re_ diagnosis of organic paraplegia as against hysterical paraplegia, the latter is to be recognized chiefly by the absence of the organic signs, as (_a_) alteration of tendon reflexes, (_b_) the Babinski sign (toe phenomenon), (_c_) exaggeration of defense reflexes (dorsal flexion of foot on sharp pinching of dorsum of foot or leg), (_d_) muscular atrophy with R. D., (_e_) sphincter disorder, (_f_) skin changes, such as decubitus.

Bullet in hip: Local “stupor” of leg.

=Case 388.= (SEBILEAU, November, 1914.)

A Moroccan sharpshooter, 20, was wounded September 27, at Soissons. One bullet scratched the left thigh. A second entered below the anterosuperior iliac spine at least 6 cm. outside the femoral artery and emerged above the ischiotrochanteric line, 2 cm. above and 4 cm. behind the upper extremity of the great trochanter, thus passing through the tensor of the fascia lata and without breaking a bone.

There was a complete paralysis of the left leg. The man had to walk with a crutch and a cane, dragging the leg like a weight. There was no active or passive movement of thigh, lower leg and foot muscles, except that there was a slight tendency to abduction of the toes, from innervation of the dorsal interossei of the foot. The iliopsoas was also involved, as well as the gluteal and pelvic trochanteric muscles. There was a certain amount of muscular tone preserved, so that the bony elements of the skeleton were held together. The foot did not fall and the leg did not elongate, as it might have in a case of paralysis of the sciatic nerve. Electro-diagnosis showed an early reaction of degeneration according to one examiner, but Sebileau believes that there was no R. D. There was anesthesia of a large part of the leg, which stretched over the anterior and internal aspects of the thigh, covered the entire territory of obturator and crural nerves but did not stretch above the fold of the groin. The region of the femorocutaneous nerve was slightly sensitive and the posterior aspect of the thigh and buttock was sensitive. There was a slight sensation on the external aspect of the lower leg. Foot and toes were entirely insensitive. The anesthesia was for all forms of common sensation. No vasomotor, thermic or trophic disorder. The reflexes were all abolished, except for a tendency to cremasteric reflex. It is clear that these conditions cannot be simulated. Possibly they are hysteric and to be explained on the basis of a kind of autosuggestion or perhaps, according to Sebileau, the local and nervous apparatus under the mechanical and caloric effects of the fragment had undergone a sort of local stupor. No large nerve could have been affected by the injury, according to the analysis made by Sebileau.

_Re_ stupor, see Case 253 of Tinel. _Re_ such local “stupor” it may be noted that this case was published in 1914, before Babinski’s larger publications on reflex disorders. As for the loss of cutaneous reflexes, Babinski remarks that immersion in hot water may cause the cutaneous reflexes in the so-called physiopathic cases to reappear for a time. He regards the loss of cutaneous reflexes in the physiopathic cases as due to a circulatory disturbance, and recalls the fact that compression by an Esmarch bandage can cause the tendon reflexes to vanish for a time, and can even cause pathologically excessive reflexes to disappear. The cutaneous reflexes have also been caused to disappear by compression.

According to Babinski, Sebileau’s explanation that such matters as loss of reflexes could be explained by autosuggestion is erroneous.

_Re_ muscular hypertonus in reflex cases, Babinski remarks that though it may be very pronounced, it is as a rule restricted in area. _Re_ sensory disorders in reflex cases, pains are found (they were very slight ones in the present case); hypesthesia has also been found by Babinski.

Localized catalepsy: Hysterotraumatic.

=Case 389.= (SOLLIER, January, 1917.)

An invalided soldier had been suffering for a year with marked atrophies and the right knee in extension. There had been a bullet wound of the upper third of the tibia, which did not affect the joint. There was a total anesthesia, both superficial and deep, which stopped sharply at the upper part of the thigh. At the time of the very first examination, this apparent ankylosis was reduced, to the great stupefaction of the patient. There was, however, a peculiar phenomenon in this subject. There was a localized catalepsy of the limb, which was able to preserve any desired attitude in which it was placed; and this attitude could be indefinitely prolonged, just as in cataleptic hysterics. Here, then, was a case of localized hystero-traumatism precisely imitating the classical hysteria of Charcot except for its localization.

_Re_ hysterotraumatism, Charcot developed ideas concerning trauma and localized hysteria in 1886, thereby overthrowing the ideas of Erichsen concerning the organic nature of “railway spine” and “railway brain” as developed twenty years before. In a case of local trauma such as the bullet-wound of Case 388, Babinski’s explanation would be that the pain and inhibition of movement resulting from the bullet wound at the time of injury, formed the focus of a process of autosuggestion. According to Babinski’s figure, the organic factor acts as a _bait_ for the hysterical symptoms. According to the Salpêtrière experience, hysteria is incapable of producing a real superficial and deep anesthesia such as is mentioned for this case. For example, no hysterical patient in the Charcot clinic, according to Sicard, could undergo a scalpel operation without some general or local anesthetic. When, therefore, a true deep anesthesia occurs, Sicard’s conception would be that the anesthesia is not a truly hysterical one but belongs to the group of physiopathic phenomena.

Contracture: Hysterotraumatic.

=Case 390.= (SOLLIER, January, 1917.)

A sailor, 41, got hygroma of the right knee in 1915, was operated on in July, returned to his dépôt a month later, and thence to Vizille Urage by reason of contracture in extension of the right leg. It was thought he was simulating (since there was no muscular atrophy), and he was sent to the neurological center, where under anesthesia the joint was found free. This man developed, when the knee was bent, extraordinary cracklings in the joint, and he showed pain unequivocally, making a defensive movement, partly reflex, partly voluntary, when the leg was flexed beyond a certain point. There was 3.5 cm. atrophy in the thigh, a reflex atrophy due to the joint disorder. There were no other signs of hysterotraumatic contracture.

According to Sollier, the diagnosis of hysterotraumatic contractures depends upon: first, a characteristic special attitude of the contractured limb; secondly, the participation of the antagonists as a group (_global_); thirdly, the superposition of sensory disorder upon motor disorder (Charcot’s law); fourthly, the segmentary topography of sensory disorder; fifthly, the extension of the contractured joint; sixthly, the persistence of the contracture in the same form, whether at rest or in attempted movements; seventhly, muscular rigidity; eighthly, normal tendon reflexes; ninthly, normal electrical reactions (though R. D. is hard to determine in muscles contracted to the maximum); tenthly, special reactions during attempts to reduce, such as pains, and equal and regular resistance to changed attitude, pseudoclonus in cases of foot contracture; eleventhly, immediate reproduction of the contracture after reduction under chloroform; twelfthly, co-existence of various hysterical stigmata.

Crural monoplegia, tetanic. Recovery.

=Case 391.= (ROUTIER, 1915.)

An ensign was wounded by a shell splinter in the right scapular region September 25, 1915. A large hematoma was drawn off and drains inserted. Antitetanic serum was given 24 hours after the trauma. The wound looked well. The patient complained merely of the heaviness of his arm, and after September 27, the temperature fell to normal. Magnesium chloride solution was applied every other day, and progress was so good that evacuation was ordered.

However, October 8, the patient suddenly began to complain of a sharp pain in the right thigh, which next day became intolerable and threw the muscles into a slight contracture, the adductors being extremely stiff. Headache developed in the course of the day, with slight stiffness of neck, exaggeration of reflexes in the right leg, and ankle clonus. Temperature: 37.6 morning, 38.5 evening. The patient was isolated and given chloral.

October 10, paroxysmal crises of pain, more marked stiff neck, and lumbar stiffness appeared, with nervousness, photophobia, and hyperesthesia to noise. The wound seemed to be doing well. Chloral was given.

Slight trismus developed October 11. The tongue became dry and the patient drank little. The condition held and the same treatments were repeated up to October 15, when the temperature fell and the contractures and pains were diminished. The chloral was continued. There were still a few cramps in the neck. October 22, however, the patient was practically well.

We are here dealing with an instance of local tetanus of monoplegic form, developing a fortnight after the wound (there is an early group developing, as a rule, from the fifth to the tenth day, and a group of later development, after the twentieth day; the interval in this case was of intermediate duration). According to Courtois-Suffit and Giroux, the differential diagnosis is not easy, since, besides tetanus, must be considered tetany, spastic monoplegia of cerebral or spinal origin, partial hemiplegia, peripheral neuritis, contractures due to bone, joint, muscle or tendon lesions, strychnine intoxication and hysterical contractures. Three cases out of six described by Routier were fatal.

_Re_ differential diagnosis of tetanic conditions, see Courtois-Suffit and Giroux in the _Collection Horizon_. The cases as a rule appear in subjects that have had serum treatment, and may occur in subjects in whom no trismus ever develops (the above case showed slight trismus).

The recognition of localized tetanic contracture is based upon (_a_) the intensity of the contracture, which causes the limb to feel wooden (in one case the foot, leg, and thigh were welded to the pelvis like an iron bar); (_b_) paroxysmal contractions resembling those of tetanus, confined to one limb, and started by a variety of external causes, forming the principal symptom in the disease; (_c_) contracture of comparatively brief duration (hardly ever over two or three weeks). A slight fever may help in the differential diagnosis.

Wound of left leg: Local spasms, later contracture, and painful crises (these associated with suppuration), the whole treated as tetanic.

=Case 392.= (MÉRIEL, 1916.)

An infantryman was wounded by shell fragments September 28, 1915, at Virginy and was given a first dressing an hour later and a second at the ambulance, where antitetanic injection was also made. October 3, the patient arrived at Foix, showing a superficial wound of the left frontal region, a penetrating wound of the upper third of the left thigh, and another in the lower third of the left lower leg.

The evening of October 8, the man began to feel pain in the left leg, though the wounds looked well and there was no fever. October 9, sudden involuntary contractions of the left leg developed, and these increased in amplitude if the limb was touched. The other extremities were normal. Temperature 38.2; pulse 102. Restlessness at night.

Next day 10 c.c. of antitetanic serum was administered and more on the 11th, with chloral and isolation; but on the evening of the 11th, with the contractions still completely localized to the left lower extremity, came an extremely painful crisis interfering with sleep and at last requiring morphine. Up to the 15th the antitetanic injections, chloral and morphine were continued, but on the 15th the contractions were replaced in part by a contracture affecting the muscles of the posterior aspect of the thigh. In the meantime, the patient howled with pain, especially in the night. Chloral and morphine were given.

During the next five days the contractures and pains became still more violent, and on the 21st the antitetanic injections were begun once more and kept up through the 26th in 5 c.c. doses.

The patient began to urinate in bed and to be delirious. The contractions now disappeared, but the contracture persisted. Antitetanic serum was given every other day from October 28 to November 2; every third day from November 4 to November 19; every fourth day from November 22 to December 3; and every fifth day from December 3 to December 17. The chloral was diminished from 15 to 5 grams per diem and by the 20th of December all administration of chloral had ceased. The morphine was given up December 25.

The tetanic symptoms of the left leg now gradually diminished. The leg, which had been flexed at a right angle, began to extend little by little, and the toes, which had been strongly flexed, reassumed their normal position. The wounds suppurated freely during the tetanic crises, but then healed. In January the man could get up and walk, dragging his leg somewhat, and January 20 a complete recovery had been obtained. There was no hysteria in the history of this patient, although the man was subject to “professional” alcoholism, being carter for a wholesale wine dealer, drinking 5 liters of wine a day.

Shell-shock by windage: Hysterical paraplegia, flaccid type, develops 10 days later, after strain, capture, privation, recapture. Paraplegia at first complete. Recovery by suggestion (one séance).

=Case 393.= (LÉRI, February, 1915.)

A corporal, 21, told how at Goselmind, during the Sarrebourg retreat, August 20, 1914, a shell burst a meter behind him, flattening his knapsack, throwing him to the ground, blowing him forward (as he said, by the pressure of the air) seven or eight meters, leaving him stunned though conscious for about twenty minutes. Uhlans fell upon him but did not trouble themselves further with him as he could not walk. He crawled along on elbows and knees about a kilometer and a half to some Frenchmen in a wood. He now found himself able to walk a whole day supported by two comrades, making about 12 kilometers. He got by carriage to Gerbéviller, but here fell again into the hands of Germans, who left him nine days in the corner of a barn without care. Gerbéviller was retaken, and he was evacuated to Bayon.

He had now had for some time pains in the kidney region below the point struck, some difficulty in turning his head, and some numbness and jerkings in the legs; and the legs that had carried him 14 kilometers were unable to move at all, even in bed. It was only 8 days later that he could perform the slightest movement, and two months followed before he could go a few steps on crutches. December 14, three months and a half after his accident,--he was demonstrated as “spinal contusion.” Upon examination, however, there were no reflex disorders, no sensory disorders, and the muscular weakness was equal in all parts of the lower extremities and trunk. On crutches, he lunged the trunk forward, painfully dragging his legs one after the other, the right foot in external rotation, never passing the left foot, toes scraping ground,--a functional flaccid paraplegia, completely dissolved by suggestion at a single sitting.

Scalp wound; probably no loss of consciousness: Quadriparesis, later paraplegia; tremors; profound sensory disorders, some apparently hysterical; cataleptic rigidity of (anesthetic) legs on passive movement. Diagnosis?

=Case 394.= (CLARKE, July, 1916.)

A soldier, 40, got a scalp wound but probably did not lose consciousness. However, when observed three months after the injury, though fat and well-looking, the patient could not stand or walk, and his hands and arms were feeble. He complained of headache, insomnia and anorexia, and remained in a state of mental inertia. All efforts to read and write produced fatigue. Memory was bad both for remote and for recent events. He was able to feed himself slowly, execute a few movements of arms and hands, and raise his feet from the bed. Upon passive movement, there was a sort of spastic state, which did not amount to a true rigidity. Now and then a clonic spasm was induced by such passive movements. After the repetition of those few voluntary movements which were possible, the muscles passed into a flaccid condition. There was a tremor of a type called swooping; the tremor resembled that of Friedreich’s disease, such as is thought to occur in cases of marked loss of muscular sense. The deep reflexes were exaggerated. Concentric narrowing of the visual fields was easily induced by testing them. There was a general slight dulness of perception on sensory tests. There was astereognosis, and apparently an absolute loss of position sense. Movements of the large joints through an angle of 90 degrees were, however, vaguely recognized. Although the patient could not touch, for example, his left forefinger with his right, yet, if he had once seen the position of a limb and it was not moved, he could remember its position and touch it after some time. His localizing sense was from two to four inches out in the hands, the localization being generally of points proximal to the point tested.

Two months later the patient was somewhat less dull and apathetic. His memory had improved. He was able to read, and he was successfully making a rug; but the legs were worse, having become anesthetic to touch and pain. When the legs were placed in any position, they would assume a cataleptic rigidity, and remain rigidly fixed in any position for some time. The patient could sit up in bed. The muscles were well nourished and the electric reactions were normal.

_Re_ catatonic rigidity, see Case 389 (Sollier).

Shell explosion; pitched in air: Spasmodic contractions of sartorii, persistent in sleep.

=Case 395.= (MYERS, January, 1916.)

A private, 23, was admitted to a casualty clearing station and the next day told the examiner, Major Myers, that the Germans had been sending whizz-bangs and coal-boxes over, and the last he remembered was being on guard and then digging himself out of fallen sandbags. His comrades told him that he had been pitched in the air, but this he did not remember. He remembered running to the shell trench, but finding this “too hot,” he returned to the firing trench, noticing on the way that he could not see well. He lay in the dug-out, flinching at each shell, and “trying to get into the smallest possible corner.” He tried to do guard duty that night, but, when some one noticed involuntary spasmodic movements, he was ordered to go back to the dug-out, was helped to the regimental aid post by two men, and was sent to hospital. He had been in France eight months and had been shaken up somewhat four months before, when bombs threw dirt in his face. At that time, his hands and handwriting had become tremulous, but he had not reported sick. He was depressed and wanted Major Myers to make him well. It seems that he had shrugged his shoulders and made leg movements, diving beneath the bedclothes, and bringing his knees to his chin. When Major Myers examined him, the leg movements were due solely “to strong periodic simultaneous contractions of the two sartorius muscles, the rate of contraction of which varied from 60 to 70 per minute, increasing to 90 during the excitement of examination.” There were special changes of sensibility in the right leg and arm and right side of the face and chest, not involving the abdomen. The patellar reflex was exaggerated; plantar reflexes could not be obtained. The legs were tremulous, especially when the patient lifted them, whereas the hands and tongue were only faintly tremulous.

Under light hypnosis, events in the amnestic period were recalled, and details as to the shell’s direction, process of lifting up, and fall. Under deeper hypnosis, the sartorius contractions diminished but did not disappear. Appropriate suggestion was made, and upon arousal from hypnosis, the movements ceased, the headache disappeared, memory was recovered, and the unilateral disturbances of sensibility had vanished.

As to the possibility of malingering in this case, Major Myers calls attention to the disorders of sensibility which he believes could hardly have been simulated, to the persistence of spasmodic movements during sleep, to their confinement to the sartorii, and to the spastic condition of legs, such that when the thighs were passively raised the knees remained extended.

_Re_ persistence of hysterical phenomena in sleep, Ballet felt that he could prove that some hysterical contractures persisted during sleep, and Sollier has written a special article to the same effect. Ballet’s case had a contracture developing after an operation on the first metacarpal bone. The contracture which followed would be then probably, upon Babinski’s analysis, a reflex contracture and not a hysterical one. Duvernay, Sicard, and Babinski himself have noted the persistence of reflex contractures during sleep, to say nothing of their persistence under an advanced stage of chloroform narcosis. In fact, these reflex contractures are exactly as fixed and persistent as contractures of clearly organic origin. It is probable that Babinski would define Myers’ case (395) as a physiopathic one; yet against this diagnosis would be the disappearance of the movements after hypnosis. As against hysteria, it will be noted that the patellar reflex was exaggerated, and that the plantar reflexes could not be obtained.

Shell-shock: Brown-Séquard syndrome, hematomyelic?

=Case 396.= (BALLET, August, 1915.)

A soldier, 24, went to the front November 12, 1914, and June 1, 1915, had a shell burst near him in the trench, on the occasion of which he felt a violent shock, as if a blow in the kidneys. He felt suddenly paralyzed in both legs. He was crouching at the time of the shell burst. His legs felt dead, and he had such violent pain in the thorax as to make breathing difficult. He was carried to a shelter. After a few hours, the left leg began to move again.

He was carried to the ambulance, remaining there five days, unable to walk, though able to move and turn in bed, slightly constipated, with persistent pains in back. He was then carried to Auxiliary Hospital 231, at Paris, and a bullet (!) was found superficially lodged in the region of the left scapula. Neither patient nor physicians had hitherto observed the bullet, which could have had nothing to do with any spinal lesion.

The pains, in the course of a month, grew less, and at the end of two or three weeks he began to walk and was sent to the psychoneurosis service at Ville-Évrard, July 10. He then complained of pain in the right thorax, especially on movement or after sitting up some time. He could hardly bring himself to the sitting posture from the bed, and found difficulty in raising the right leg therefrom. In walking, the _right leg_ was dragged behind. The reflexes were increased on the right side. There was ankle clonus without Babinski sign. Anesthesia to touch over the whole of the _left leg_. Anesthesia to pin prick and temperature as far as the umbilicus. Cold was not felt on the left side.

The water of a bath seemed lukewarm on the left side and warm on the right. The left side of the scrotum and the left half of the penis showed the same disorder of sensibility. There was a zone of hypesthesia on the _right_ side of the thorax in the region of the lower ribs. The patient compared his sensations while at rest and without contact to a sensation of painful pressure occurring intermittently, or rather in paroxysms, not advancing beyond the median line of the back. Here was a question of Brown-Séquard syndrome, probably due to a slight hematomyelia, but associated with no external lesion or any injury to the vertebral column.

_Re_ Brown-Séquard’s syndrome, see Athanassio-Benisty with respect to spinal cord symptoms associated with lesions of the brachial plexus. It appears that the combination of spinal cord and brachial plexus injury is not uncommon. Note in this case that a bullet was found in the left scapula region. According to Ballet, this bullet could have had nothing to do with a spinal lesion.

Violence to back: Dysbasia. Antebellum injury.

=Case 397.= (SMYLY, April, 1917.)

A man (also injured in 1906 by the fall of a heavy weight on his back) went to France in 1914 as a soldier, and eight months later was hurled into a shell hole so that his back struck the edge. He was rendered unconscious. Upon recovery of consciousness, the right leg was found to be swollen, and there were severe pains in the legs and back.

Upon return home the patient went from one hospital to another, for the most part unable to walk, suffering from agonizing pain in head and eyes. Insomnia and waking dreams.

He was able to bring himself to an upright position and to rush a few steps. He has now acquired considerable control of the feet by the aid of crutches. Insomnia persisted.

Dysbasia: Psychogenic (cerebellar nucleus (?))

=Case 398.= (CASSIRER, February, 1916.)

On March 9, 1915, a shell wounded a man slightly, and burned off some of the hair of his head. He was unconscious two days, and on waking vomited for a time. Shortly after the injury difficulties in standing and walking set in, with headache, noises in the left ear, difficulty in the intake of ideas, excitability, and poor memory. Then, slight improvement. About the middle of June he was no longer closely confined to bed and could take a few steps with two canes; but the gait was still unsteady and the left leg tended to make abnormal-looking movements. There was nystagmus, rapid, though constant, on looking to the left,--more in the left eye; and nystagmus on looking to the right,--more in the right eye. Adiadochokinesis absent. Vestibular nerve somewhat excitable. Deviation outward in finger-pointing test.

According to Cassirer, this case is one largely of psychogenic origin, with possibly an organic cerebellar nucleus. The knee-jerks absent (even up to March 31). W. R. negative.

Shell-shock; unconsciousness: Dysbasia, in part hysterical, in part organic (?).

=Case 399.= (HURST, May, 1915.)

A private, 29, was knocked over by a shell explosion December, 1914. He was unconscious two days, found that he could not move either right arm or left leg, got some power back shortly, but, if he tried to stand, experienced involuntary violent movements in the left leg.

April 1, 1915, response to questions was slow and speech slow. The right arm and grip were weak. If the left hand was clenched, there was an associated movement of the right hand; but on clenching the right hand, no associated movement was produced in the left. The musculature was equal on the two sides, and the tendon reflexes of the arms were brisk and equal. Light tactile stimuli were hard to localize. Movements of the left leg were somewhat weak, though the musculature was equal on the two sides. The knee-jerks were brisk, the left slightly brisker. Sometimes a well-marked ankle clonus could be obtained on the left side, but sometimes not. The plantar reflex was constantly flexor. Babinski’s second sign (combined flexion of thigh and pelvis) was well marked on the left side.

On attempts to walk, the left leg would move rapidly from side to side, round the point of contact of toes with ground. When a step forward was taken with the right leg, the left one dragged, and made irregular movements.

This gait seemed obviously hysterical. The patient was kept in hospital for a month. He was very easily hypnotizable, but even in deep hypnosis leg movements could not be controlled when he was told to walk. The first whiff of ether hypnotized but did not cure him.

On the whole, upon review, Hurst believes that there may have been organic brain changes, which (_a_) the associated movement of the paralyzed hand when the normal hand was contracting, (_b_) the slightly increased left knee-jerk, (_c_) tendency to ankle-clonus, and (_d_) Babinski’s second sign, may show.

Peculiar walking tic.

=Case 400.= (CHAVIGNY, April, 1917.)

A soldier was found with a peculiar walking tic. He would rest a good deal longer on the left leg than on the right. He would make a sudden movement of the right leg forward, as if on a spring. At the same time, the man’s head would give a violent movement to the right just as the right leg was receiving the weight of the body. The idea of this movement seemed to be that the center of gravity would be shifted and the work of the right leg would be relieved. This peculiar walk was naturally very slow. If the walk was slowed down, it became quite normal. There was no pain at the basis of this walk. If the man hopped, he hopped no more painfully on the right leg, nor with greater difficulty, than upon the left.

This man was guilty of desertion in the face of the enemy, and of desertion in the interior in time of war. He said he could not walk well and that he needed to take care of himself at his mother’s house, as he was not considered sick in his regiment. He had been wounded with two bullets, September 28, 1914, which struck him on the internal aspects of the knees. He was treated in hospital from October to the end of November, 1914; was held at the dépôt of his regiment from December to August, 1915. He was then put in hospital a month, and returned to his dépôt for three more months. He was examined by three physicians in August, 1915, and the commission decided that he was fit for service, and a simulator.

Thorough examination, including electrical and X-ray examinations, showed no lesion. Chavigny observed the patient for a long time, from the 21st of November, 1916, to January 5, 1917. Shells dropped near the hospital, December 2, and, following orders, the patients were taken into a vaulted cellar, and they ran thither very rapidly; but this patient could not hurry. He walked slowly, with the same tic. Surely the tic would be rather a difficult one to imagine, and a somewhat more probable set of symptoms would ordinarily be chosen. The man has not the unstable nature of the ordinary victim of tic. On the contrary, he has rather the invincible obstinacy of a hysterotraumatic. On being shown that he could walk properly without these “para” movements, he would reply, “I can’t do anything else,” and he shook his head upon being told that he could be cured.

Reëducation of his anesthetic areas (there was a zone of diminution in sensibility to pin-prick in the knee region, and a complete anesthesia of the sole of the foot, with abolition of the plantar reflex), reëducation by appropriate gymnastics, and mental reëducation, might be attempted in a special neurological hospital.

_Re_ disorders of gait, Laignel-Lavastine and Courbon divide functional gait disorders into three groups: (_a_) A group called dynamogenic; (_b_) an inhibitory group; and (_c_) a group showing both forms of disorder.

Roussy and Lhermitte have attempted to divide the gait disorders into two groups: (_a_) A group termed by them basophobic, in which there is a marked psychogenic and emotional basis; and (_b_) a dysbasic group, the basis of which is suggestion rather than emotion. Following is a skeleton of their classification:

1. Astasia-abasia and dysbasia group.

Astasia-abasia.
Pseudo tabetic dysbasia.
Pseudo polyneuritic dysbasia.
Tight-rope walker’s gait.
Scrubber’s gait.
Choreiform dysbasia.
Knock-kneed gait.
Walking as if on sticky surface.
Bather’s gait.

2. Stasobasophobia group.

3. Habit limping.

Mine explosion; unconsciousness: Camptocormia. Hospital rounder twenty months (bedfast five months) without complete neurological examination. Cure by persuasive electrotherapy in one hour.

=Case 401.= (MARIE, MEIGE, BÉHAGNE, February, 1917; SOUQUES and MÉGEVAND, February, 1917.)

A man became a hospital rounder to all points of the compass in France during a period of twenty months, with such diagnoses as myelopathic disorder, complex spinal trouble, ataxic phenomena.

As a matter of fact he was a camptocormic: trunk bent, knees semi-flexed, legs in external rotation. He used two canes in locomotion, made a bowing movement with each 20 cm. step, then another bowing movement, and another little step with the other foot. Made to lie down, his legs would elongate, the right completely but the left with some difficulty, the feet going into hyperextension, with the big toe raised, others flexed; the feet externally rotating, plantae turned in. In horizontal decubitus, there was only slight lumbar discomfort, but the legs stiffened and gave quick convulsive jerks. Taking the posture several times in succession would diminish these phenomena. Kneeling, he could bring his heels within 10 cm. of the buttock, whereas in spontaneous flexion of the leg on the thigh, the knee remained a distance of 40 cm. from the buttock.

A complete examination showed no joint disorder or any diminution in muscular strength, or any reflex disorder except that all the tendon reflexes were rather powerful. There was a question of possible X-ray demonstration of lesions and ankylosis of the fourth and fifth lumbar vertebrae, and there was a question of some incontinence of urine. On the basis of these phenomena apparently, this camptocormic patient had been saddled with the diagnosis of myelopathic and ataxic disorder for a period of 16 months. A neurologist was at last consulted, and on his advice, it proved possible to get the patient evacuated to a neurological center in a period of four months. Facts of this species are unfortunately still too common, state Marie, Meige and Béhagne, February 1, 1917, despite the remarkable and rapid cures obtained in camptocormia by Souques. In point of fact, no complete neurological examination had been performed upon this man during a period of 20 months.

This particular patient was given to Souques for treatment (Souques and Mégevand). His cure was completed by persuasive electrotherapy, in an hour.

It appears that the man was buried in a mine explosion, June 5, 1915, lost consciousness and came to twenty hours later, able to rise and take a few steps, but bent in two with a sharp dorsolumbar pain. The pain grew more violent and generalized during the next few days, and he began to lose all power in his legs, so that he could walk with the greatest difficulty. He was practically bedfast for five months. He then tried to rise and walk, but suffered so much that he could not get up except in a camptocormic position. It was in fact only January 23, 1917, at the Salpêtrière, that the diagnosis of camptocormia was made. The man complained of pains at the lower dorsal and lumbar regions of the spinal column with slight irradiation sidewise. The following diagnoses had been made:

June 8, 1915. Severe contusion of chest and back.

July 9, 1915. Multiple contusions, commotio spinalis; lesions and ankylosis of the 4th and 5th lumbar vertebrae (X-ray examination).

Sept. 3, 1916. Lumbar intervertebral arthritis with compression of roots.

Nov. 4, 1916. Myelopathic disorder.

Dec. 5, 1916. Old complex spinal disorder.

Souques remarks that these diagnoses show that knowledge about camptocormia has not penetrated into most of the sanitary formations (1917).

Astasia-Abasia.

=Case 402.= (GUILLAIN and BARRÉ, January, 1916.)

A soldier was evacuated to the 6th Army neurological center for paraplegia with tremor. He had been in various hospitals _for a period of a year_. The tendon reflexes of the arms appeared increased; there was a suspicion of patellar clonus and of foot clonus, and it had been proposed to invalid the man for spastic paralysis. In point of fact, the man was suffering from an epileptoid trepidation of the foot and of the patella. When he was lying down, his motor disorders practically passed away, though they had been very marked when he tried to stand upright or to walk. He had much trouble in walking, but could readily stand for some time on one leg.

The man was forthwith treated by persuasive methods. It is important to find out the organic lesion which in all probability served as a starting point for the functional disease, and important to remove or abolish this lesion however minute if a complete and lasting cure is to be obtained.

_Re_ astasia-abasia, writers have remarked that it is one of the commonest hysterical syndromes in the war, though somewhat rare in its complete form. Roussy and Lhermitte state that it usually follows the explosion of a large calibre projectile and has a rapid onset. It is often an isolated phenomenon, without emotional or other Shell-shock complications. The victim has been thrown to the ground and rolled into a trench or hollow. Sometimes the victim gets back to the first-aid post, only to find himself on arrival at the ambulance wholly unable to walk. The legs, however, are drawn along inertly, as in paraplegia, or a pronounced contracture interferes with walking.

Astasia-abasia is classified with hysteria major, hysterical hemiplegia, hysterotraumatic brachial monoplegia, glossolabial hemispasm, hysterical mutism, and rhythmic chorea, as so characteristic that differential diagnosis is superfluous. According to Babinski, no functional spasm and no organic disease can reproduce hysterical astasia-abasia.

Multiple shell wounds, with persistent slight suppuration of thigh: Abdominothoracic contracture, tetanic, four months after original injury.

=Case 403.= (MARIE, 1916.)

A soldier, 31, was wounded in the left arm January, 1915, and received 10 c.c. antitetanic serum; was wounded again July 10 in the face, scalp, upper part of the thorax, left arm and left leg by shell fragments, and again received, two days later, 10 c.c. antitetanic serum. July 13, at the ophthalmological center at Rouen the left eye was enucleated on account of a shell wound, and four days later a fragment was removed from a phlegmon of the forearm. Later a number of operations were made for blepharoplasty. The wounds all healed well except for an apparently insignificant, small suppuration of the thigh. November 10, four months after the shell wounds, while apparently in perfect health, the man began to complain of lancinating, intermittent pains in the abdomen, thorax and lumbar region. With these pains was associated a persistent abdominolumbar contracture.

On the suspicion of an abdominal form of local tetanus, chloral was given; but the condition grew worse. The sudden contractions spread from the waist to the feet, from November 20 onward, and were felt by the patient as electric shocks. The arms were not affected. Trouble with breathing supervened on the night of December 3. Sometimes there were respiratory pauses for as long as 15 seconds, followed by a slight polypnea. December 6 the man presented an intense contracture of the lower part of the trunk. The slightly retracted abdominal wall was of marbly hardness, but quite painless. Analgesic muscular rigidity took the place of the former crises of pain. The dorsolumbar contracture was so marked as to make an appreciable hollow in the back. The patient could pick up an object from the ground only by flexing his knees to the maximum, as the trunk could not be flexed. There was a very slight trismus, but he could open his mouth, drink, eat and talk without difficulty. There was no trace of neck stiffness or of Kernig’s sign. The tendon reflexes, normal in the arms, were exaggerated in the lower extremities, especially on the left (wounded) side. The skin reflexes were also more marked on the left side, especially the reflex of the tensor of the fascia lata. There was no longer any evidence of suppuration of the wound of the left thigh, which had been dried up for a fortnight. The pulse was somewhat exaggerated (92) and there was a general hyperidrosis, especially of the face.

Forty c.c. antitetanic serum were given without reaction, and 4 grams of chloral; five days later, 30 c.c. more serum. After ten days the abdomen remained hard, though there was a trifling improvement of the lumbar contracture. There were no longer any spasmodic crises or respiratory disturbances. There was a slight serous exudation from the wound. X-ray showed a small shell fragment 6 cm. below the orifice of the wound.

The third injection was given December 27 to prevent mobilization of the bacilli at operation, and on the 28th, the projectile was removed under local anesthesia from a small, walled-off, old pus pocket, from which were cultivated bacillus perfringens and other organisms.

December 31 a distinct improvement set in and January 13 there was little or no trace of previous disease, except that testing the plantar cutaneous reflex on the left side produced an exaggerated contraction of the tensor of the fascia lata. February 15 he was reëxamined and found quite normal.

This case of tetanus limited to the abdominothoracic muscles (except for a very mild contracture of the masticators) had as its locus of origin, doubtless, a wound of the thigh from which the toxin rose along branches of the lumbar plexus to impregnate the corresponding level of the spinal cord. Although there was no stiffness of the wounded leg, yet there was an exaggeration of the tendon reflexes thereof. The first phase of painful contractures and spasms with respiratory disorder was succeeded by an analgesic phase of characteristically tetanic rigidity. The nonfebrile nature of the disease and the preservation of good general health are worth noting.

Shoulder blade unslung in knock-down by shell splinter: Hysterical (!) paralysis of arm with anesthesia. Recovery by electricity, massage, and reëducation (dislocation remaining).

=Case 404.= (WALTHER, December, 1914.)

A soldier was struck September 27, near Berry au Bac, by a shell fragment in the right scapular region and was thrown, according to his story, 15 meters. Upon entrance at Val-de-Grâce, October 13, the shoulder-girdle was found intact. There was a very painful point in the spinous process of the scapula, suggesting a fracture; but the bone was proved intact on X-ray. The scapula was very mobile, as if unslung from the thorax. The arm was paralyzed. On raising the arm the scapula followed its movements and detached itself completely from the thorax, dislocating upwards with lively pain. The fingers could be pushed under the anterior surface of the scapula, and its internal border proved to be entirely free of attachment. Pressure along this internal border was very painful. It seems as if there had been a tearing of the rhomboid and serratus magnus muscles and probably a part of the latissimus dorsi under the influence of the violent shock conveyed by the shell fragment, which had pushed the scapula forward and upward without injuring the skin.

There was also a complete paralysis of sensation. Paralysis of motion was complete except for the extensor longus of the thumb. This motor paralysis had come on progressively three days after the accident. A radicular paralysis from an evulsion of the plexus was suspected.

Babinski, however, made the diagnosis of psychic paralysis, finding the muscles reacting perfectly to percussion. After a few electric tests with the faradic current voluntary movements were obtained in all the muscles of the arm and hand.

Treatment was then continued by electricity, massage and reëducation, so that all movements soon regained strength. The patient can now himself, by raising his arm, still produce his dislocation, which still provokes a lively pain.

Gunshot wound of left forearm: PARALYSIS of the arm gradually INCREASING IN DEGREE and extent and associated with pains and anesthesias.

=Case 405.= (OPPENHEIM, July, 1915.)

A reservist sustained, October 2, 1914, a gunshot wound of the left forearm from a distance of about 1400 meters. He fainted, lost much blood, and was treated surgically, October 7, in hospital (at this time no complete paralysis of the arm).

In November, however, an incomplete paralysis at first developed. November 12, the patient was able to flex his thumb but showed some anesthesia.