There was doubt as to the diagnosis, which lay between fracture and

concussion. The persistent agitation and oniric delirium pointed rather

to concussion. Without further sign, however, the patient died on the

night of June 20.

The autopsy was extremely careful and showed no sign of cranial

fracture of vault or base. The cerebrospinal fluid was strongly

bloodstained. The inner surface of the dura mater had a thin sheet

of hemorrhage, hardly 1 mm. thick, covering both hemispheres and the

cerebellum and spreading over the bulb. There was no distension of the

lateral ventricles. Serial sections of the brain showed no lesions of

the substance, except for slight hemorrhagic points.

According to Chavigny, so slight a meningeal hemorrhage is incapable

of producing a mechanical disturbance of the brain and the cause of

death could not be said to be meningeal hemorrhage. Massive multiple

gas embolism through sudden decompression is not a suitable explanation

of a case with death delayed, as in this instance, even if Arnoux’s

explanation is suitable for cases of immediate death.

Mine explosion: no skin, bone, or visceral consequences seen at AUTOPSY

(death in seven days) except slight LOCALIZED MENINGEAL HEMORRHAGE.

=Case 199.= (ROUSSY AND BOISSEAU, August, 1916.)

A soldier entered Val-de-Grâce February 27, 1915, in a state

of confusion following mine explosion the night before. He was

delirious, thought himself on leave, and had spells of excitement.

Lumbar puncture, February 29, showed a slightly darkened fluid, with

approximately normal amount of albumin, one or two lymphocytes and rare

red blood cells.

A brief period of slight improvement followed, but the restlessness

and delirium increased once more, became particularly severe March 3,

and the patient died on the night of the third, seven days after the

explosion.

The autopsy showed slightly congested lungs; no other lesion except a

sharply defined hemorrhage in the cervical spinal meninges and over the

meninges of the temporal and occipital lobes. Microscopic section of

the brain failed to show any hemorrhages within the brain substance.

Here is a case of death following explosion without external wound.

The meningeal hemorrhages are hardly enough to explain the death. The

explanation of the death must probably be made after histological

examination.

Concussion of spinal cord from shell burst--WITHOUT spinal fracture,

WITHOUT penetration of splinters of shell or bone into canal or cord

substance: Microscopic demonstration of intraspinal AREAS OF SOFTENING

with classical secondary degenerations. Such a case forms a link in the

argument that serious lesions of the nervous system may develop as a

result of VIOLENCE directly TRANSMITTED through investing tissues EN

BLOC.

=Case 200.= (CLAUDE and LHERMITTE, October, 1915.)

A man, 23, was struck in the left thorax and shoulder, in both thighs

and the neck, by fragments from a bursting shell March 27, 1915. One

fragment was imbedded near the vertebral column.

Twenty days later there was an absolute, flaccid paraplegia, yet

the legs occasionally gave spontaneous, jerky movements. Tactile

anesthesia reached the fourth dorsal root-level, except that the

perineoscrotal region and the penis were somewhat sensitive. There was

anesthesia to pain and heat, as well as in bones and joints, along

with the tactile anesthesia. There was a hyperesthetic region on the

right side, corresponding with the distribution of the fourth dorsal

root. All the cutaneous reflexes up to the abdominals were gone; but

defense reflexes could be brought out in foot and leg by skin, bone

or joint stimulation. The deep reflexes of the legs were also lost,

whereas those of the arms were increased. Retention of urine without

incontinence; no retention of feces. Sacral, trochanteric and heel

decubitus had developed in the course of the three weeks following

injury. A lymphangitis ran all the way up the right thigh from one of

the sores, with a corresponding hyperpyrexia.

Surgical intervention was indicated from the evidence of spinal

compression at a definite level, but the lymphangitis grew worse.

Oniric delirium, and finally a stuporous state, set in, with death May

6, forty days after the wound, a death due to septicemia, without

special alteration in the paraplegia itself or in the sensory and

reflex situation.

At autopsy the spine and dura mater proved normal; but microscopically

serial sections through the fourth and fifth dorsal segments showed

softening of the right anterior horn and posterior columns, with

cavitation in the radicular zones, and the white matter of the fifth

dorsal segment was in a state of acute degeneration. There were also

ependymal changes, namely, at the fifth dorsal level a dilatation with

deposit of albumin; in the lumbar region, breakage of the ependymal

wall, with cellular gliosis. The dilated ependyma was surrounded by

an area of fibrillary gliosis which had proliferated in the form

of a septum in the interior of the canal. (According to Claude and

Lhermitte, these data concerning hydromyelia, which they regard as

secondary to trauma, are an argument in favor of the traumatic origin

of certain syringomyelias. They regard the breakage of the ependymal

wall as due to hypertension of the spinal fluid due to mechanical

lesions.) Their interpretation of such acute degeneration as was found

in the fifth segment is that this degeneration, as well as that of the

posterior roots, is due to the direct impact of the cerebrospinal fluid

upon the cord structure. As for the softenings with cavitation, they

regard them as surely due to spinal concussion and as very possibly due

to an ischemic necrosis, suggesting that older work by Duret and Michel

on concussion of the brain indicates the possibility of a temporary

ischemia of the spinal cord from the violent impact of the spinal

fluid upon the cord due to shock of the spinal column. The transient

hypertension of the spinal fluid might well induce, they believe, a

vascular spasm with anemia, to which the gray matter is well known to

be especially sensitive. In the present case, a period of somewhat less

than six weeks had sufficed to produce secondary degenerations above

and below the fifth dorsal segment, of a quite classical sort.

Accordingly, we here deal with a severe form of spinal concussion due

to a shellburst, in which intraspinal lesions were produced without

spinal fracture or penetration either of bone or of shell fragments

into the spinal cord or the spinal fluid.

Shell explosion (1 meter distant) kills a soldier by bursting both

lungs within the intact thoracic cage.

=Case 201.= (SENCERT, January, 1915.)

A man of the 26th Regiment of Infantry was brought October 26, 1914,

to Ambulance No. 6 of the Twentieth Army Corps at the Chateau d’Henu.

Weakly and jerkily the man was able to tell how, as he was going

forward, a large calibre shell fell less than a meter in front of him

and exploded. He fell back and lost consciousness, was picked up in the

evening and carried to the relief post and then to the ambulance, where

he arrived ten hours after the fall. There were signs of a considerable

shakeup, with pale and anxious face, nose pinched, hollow eyes, rapid

superficial respiration, small pulse, 120, and a feeble voice. There

were small skin wounds of the right arm, a finger, and ear, but there

was otherwise no wound. The thorax and abdomen were somewhat painful

all over, but there was no especial point of pain. The chest showed

a slight dulness at the bases. Examination of the abdomen produced

defensive movements and the man vomited blood during examination. He

was put on his back, kept warm, given artificial serum, hypodermic

injections of camphorated oil and caffeine, and carefully watched. In

the night he had another bloody vomiting, his pulse became smaller and

smaller, dyspnea became more and more intense, and he died late in the

night.

The autopsy showed that the abdomen was free of lesions and that all

the organs were of a normal appearance and color. There was no sign

of perforation or of peritonitis. The stomach itself was filled with

blood and there was a generalized ecchymotic appearance of the mucosa,

with small, submucous hematomata and a number of tears in the pyloric

portion.

The pleurae were found filled with blood, almost a quart in each

cavity. The right lung showed a large tear at the level of the middle

lobe, 15 cm. long. An orange-size, black bit of lung protruded through

the tear. There was no sign of rib fracture opposite this tear, and no

subpleural, intercostal or subcutaneous contusion. The thorax wall was

perfectly normal.

The left lung showed, in the middle portion of the upper lobe, a

somewhat analogous pleural tear, almost as big as that on the right,

with another large hernia of black lung. Bits of the herniated lung

sank in water. The thorax wall was intact. The pericardium was free

from blood. There was nothing else abnormal about the body.

_Re_ effects of an explosion upon structures with intervening objects

left intact, Fauntleroy notes that a shell bursting three yards from

an aneroid barometer may force its levers into an abnormal position.

A further fact will indicate how permanent is the physical state into

which the levers are forced; for when the barometer with its levers

placed right was placed under a bell-jar and the pressure therein was

reduced to 410 mm., the levers resumed the position into which the

explosion of the big shell had thrown them.

_Re_ windage and internal effects in the human body, Ravaut recalls the

fact that the internal and intraneural hemorrhages of Caisson disease

(“bends”) are well known. The external hemorrhages of aeronauts and

mountain climbers belong in the same physical class. Dynamite exploded

in a pond kills fish. Dynamite may break pillars inside a building

without damaging its front. Cases like Chavigny’s (198), Roussy and

Boisseau’s (199), Claude and Lhermitte’s (200), as well as Ravaut’s own

case (202) are in point.

Shell explosion near by: Paraplegia, interpreted as due to windage. Two

foci of HEMORRHAGE (SPINAL CANAL, BLADDER) clinically proved to exist

in a case without external sign of injury.

=Case 202.= (RAVAUT, February, 1915.)

An infantry sergeant was brought to the ambulance, one day in November,

1914, with a paralysis which had set in immediately upon the explosion

of a large shell a short distance away. Both legs were paralyzed and

there was anesthesia to the navel. He could not urinate. It was early

in the war, and Ravaut thought he would find an injury to the vertebral

column, but on undressing the soldier there was no wound. The skin was

intact, and there was not even an ecchymosis. The patient was suffering

not at all, but said that after the shell exploded he felt a forcible

shock, was stunned for a moment, and when he wanted to rise, found

that his legs were inert. His state did not change during the day and

he did not urinate. Catheterization showed a urine full of blood. This

indicated a lumbar puncture, and a bloody fluid emerged under great

pressure. Thus two foci of hemorrhage were proven to exist in this

patient despite the fact that there was no external lesion.

_Re_ windage effects, see suggestions of Ravaut under Case 201. Ravaut

also suggests that certain cases of emotional jaundice may be similarly

explained on the basis of internal lesion due to windage. Sundry cases

of gastro-intestinal disorder and of hemoptysis fall into the same

class; possibly the cases of death in a fixed posture belong there,

too. Ravaut thinks, despite the look of hysteria about the shell-shock

cases of paraplegia, deafness, mutism, and the like, that the cases

are actually ones in which there has been at the beginning a slight or

severe hemorrhage, clearing up in a few days. He states that there is a

pretty definite parallelism between the course of the clinical symptoms

and the chemical characteristics of the spinal fluid.

Shell-explosion in confined space; paraplegia after fifteen minutes;

slight hemorrhage and LYMPHOCYTOSIS of spinal fluid; Hematomyelia.

=Case 203.= (FROMENT, July, 1915.)

A Sergeant lying down in a small dugout space, 2 × 1 m. high, had a

77 shell burst behind his head and between his head and the back of

the dugout. The patient was not moved by the explosion, but was buried

in a small amount of earth and stones to a depth of about 20 cm. He

was not wounded and showed no ecchymoses either then or later. Aided

by stretcher bearers, he was able to walk to the relief post about

400 meters from the trench. He did not lose consciousness, and got

to the relief post about a quarter of an hour after the shell burst.

Thereafter, however, he was unable to move his legs. The accident

happened February 6 at 4 o’clock. He was examined 24 hours after the

trauma. The accompanying diagrams show the variations in sensory

disorder at intervals during six months.

A lumbar puncture, February 8, 1915, showed hypertensive clear fluid

without macroscopic clot on centrifuging, but showing a number of red

blood cells and lymphocytes--3 or 4 to the microscopic field. There

was a slight hyperalbuminosis. The development of the muscular atrophy

and hypo-excitability of the left lower extremity, the exaggeration of

the left knee-jerk, together with the spinal fluid appearances, seemed

to prove the organic nature of the paraplegia. There was an intense

rhachialgia, with radiation along the sciatic nerve. This outlasted

all other symptoms. Thermo-analgesia was the most prominent sensory

disorder. There were no sphincter disorders.

During the first days, the anesthesia was of a pure segmentary type,

with nothing about it to suggest that it was later to be supplanted

by a radicular type of disorder. Hematomyelia was, years ago,

thought--according to Froment--to tend to yield sensory disorders

of a segmentary nature. At the outset this anesthesia was total,

though there was a vague, poorly localized feeling on intense

painful excitations,--as with energetic pricking or burning. Thus the

protopathic sensibility of Head had remained, whereas the epicritic

sensibility had disappeared.

Detailed examination of this case showed extreme errors in the position

sense. For example, pricking the foot might be localized as pinching

above the knee. The cremaster reflex was extremely marked and would

appear upon even slight excitation of any part of the lower extremity,

even at times when the patient declared he felt nothing. These

phenomena at the beginning early gave place to a syringomyelic type of

anesthesia.

At the time of report, July 29, 1915, Froment regarded this case as

analogous to hematomyelias of divers, although there is not such a

degree of decompression; the suddenness of the decompression is more

marked in these Shell-shock cases than in divers.

Shell explosion; bowled over; loss of consciousness: Hemiplegia

with reflex signs thought to be organic; hypertensive spinal fluid;

LYMPHOCYTOSIS.

=Case 204.= (GUILLAIN, August, 1915.)

A corporal in the engineers was going the night of June 7th to a

creneau of mitrailleuses, when he was bowled over by a bursting

shell. He lost consciousness and was carried to the cantonment by

his comrades. Next morning he complained of headache and pain in the

back; had a convulsion; and proved on examination to have a left-sided

hemiplegia. He was given the diagnosis of hysterical hemiplegia.

He was sent to the 6th Army neurological center, and there showed a

complete left-sided hemiplegia with tendency to contracture. The left

knee-jerk and arm reflexes were exaggerated, and there was ankle and

patella clonus with Babinski sign. There was a dysesthesia on the

left side, with wrong interpretation and poor localization of painful

stimuli, and non-recognition of cold and heat sensations. Muscle sense

and stereognosis were impaired. There was a slight dysarthria. Lumbar

puncture yielded a clear hypertensive fluid with a slight lymphocytosis.

The situation remained without change for a month, when the patient

was evacuated to the rear. Thus, a shell-burst can produce destructive

nerve lesions without evidence of external injury.

_Re_ hypertensive spinal fluid, Sollier and Chartier cite Dejerine as

having brought the proof of hypertension in the cerebrospinal fluid in

Shell-shock cases. They also believe that the Shell-shock hysteria is

built up on a physical basis, more or less after the model of Charcot’s

hysterotraumatism. Shock, windage, and gas may bring about the same

kind of result. They rely especially on the cases of Sencert (201)

and Ravaut (202) for their argument (1915). They recall the fact that

Charcot found a hysteria due to lightning stroke and to high tension

electric accidents. They quote Lermoyez as attributing like results in

ear cases to labyrinthine shock, tympanic rupture, and ear hemorrhages.

Shell-shock: Hemiparesis, amnesia. Lumbar punctures early (but here as

late as one month after shock and after disappearance of hemiparesis)

showed PLEOCYTOSIS and hyperalbuminosis.

=Case 205.= (SOUQUES, MEGEVAND and DONNET, October, 1915.)

A French sergeant, a machine gunner, was the victim of shell-burst

September 25, 1915, was evacuated with a diagnosis of commotio cerebri,

and, when examined at Paul-Brousse October 5, showed a right-sided

hemiparesis, clouding of consciousness and somnolence, the hemiparesis

involving the face, with deviation of tongue to right, Babinski reflex

right, cremasteric and abdominal reflexes abolished on right. Normal

respiration and pulse.

Lumbar puncture October 7, that is, thirteen days after the injury,

yielded a clear fluid with an excess of albumin, 144 small lymphocytes

(some degenerate) and a single endothelial cell.

October 12, the knee-jerk was a little less lively on the right side.

The plantar reflex varied between extension and flexion on the right

side. The cremasteric reflex had been weakly regained on the right side.

The patient was now less stupid and could tell how he jumped when

the shell burst, and how he had been in the air ten minutes (!) and

fell, getting up at once, with nothing wrong except nosebleed. After a

half-hour he felt weaker and was ordered to leave the post, whereupon,

on the road, his weakness increased and he tended to fall to the right,

but reached the ambulance on foot.

October 23, there was no longer any evidence of hemiparesis, the

Babinski reflex had entirely disappeared; there was no complaint except

of dizziness and headaches. He got back his autocritique on the matter

of remaining in the air ten minutes, but there was still an amnesia for

the ten day period between the shock and his arrival at Paul-Brousse.

He forgot that he had had a lumbar puncture October 7.

Another puncture, October 25, yielded some 14 or 15 lymphocytes to the

cmm. There was still an excess of albumin. The lymphocytes decreased

further according to a puncture November 2. Had this patient been

examined some weeks after the shock there would have been no signs of

an organic paresis, no special modification of the spinal fluid, and no

reason for regarding the man as other than an hysteric. Early spinal

puncture is, accordingly, important.

Of course, the question whether the lymphocytes and hyperalbuminosis

of the fluid might not be syphilitic must be raised. At the Hospital

Medical Society meeting, October 29, 1915, Souques states that

Ravaut and Guillain believe that simple shell-shock often produces

“syphilitic” chemical, physical or cytological changes in the spinal

fluid. Roussy is cited as thinking such changes rare.

Shell-shock; burial: Coma and semicoma; BLOOD-STAINED SPINAL FLUID.

Improvement on puncture. Persistent astasia abasia with spasticity.

=Case 206.= (LERICHE, September, 1915.)

A man was buried March 15, 1915, following the bursting of a large

calibre shell. He is said to have had hemoptysis and arrived at

hospital March 17 in coma. He kept moaning while asleep. March 18, he

was still stupid and as if stunned. He did not talk or understand what

was said, but was able to write a few words. The knee-jerks were a

little exaggerated. There was a slight spasticity of the limbs, which

was exaggerated on emotion into a sort of spasmodic crisis.

Lumbar puncture gave a reddish fluid under strong tension. After lumbar

puncture the man came out of coma and the next day, after another

puncture (fluid slightly yellowish), there was further improvement and

the patient spoke. The third puncture, March 20, yielded yellow fluid.

The spastic phenomena still persisted, however. The patient could not

walk or stand. Every time he touched the ground he had a clonic crisis.

He was evacuated to a neurological center.

_Re_ astasia-abasia, Nonne found these cases heading a group of 63

cases of war hysteria treated in a twelvemonth. Figures as follows:

Astasia-abasia 14

Generalized tremor 12

Brachial monoplegia 11

Isolated contracture 6

Crural paraplegia 5

Mutism 5

Isolated tic 4

Hemiplegia 3

Isolated respiratory convulsions 2

Isolated sensory disorder 1

Fifty-one of the 63 cases were freed by therapy from their main

symptoms (twenty-eight cases cured in one or two hypnotic sittings).

Prolonged bombardment; shell explosion (nearby?): Depression; suicidal

attempt; hypertensive spinal fluid.

=Case 207.= (LERICHE, September, 1915.)

A patient entered an evacuation hospital June 27, having come from

an ambulance with a ticket reading, “Melancholic depression, with

stupor--attempt at suicide (threw himself into a pond)--sprained

ankle--to be evacuated, lying down, on a milk diet.” The patient was

depressed, indifferent to surroundings, irresponsive, and did not even

look at an interlocutor. There was no other somatic sign except a pulse

of 62. He did not eat, and remained lying down, without movement.

Lumbar puncture in a sitting posture yielded a clear liquid under

pressure of 34. June 30, another lumbar puncture yielded clear fluid of

a dichroic appearance when looked at from above. 25 c.c. were removed.

July 1, there had been a good deal of improvement. The patient said he

was better and began to take a little milk. July 2, there was still

some improvement. Pulse 60. He said that his condition had lasted a

month and that it followed a violent and prolonged bombardment for ten

days in his sector. July 3, he was much better, began to look about,

talk, and eat a little. July 4, lumbar puncture yielded a clear fluid

with a pressure of 30, reduced to 22 after withdrawal of 20 c.c.

According to Leriche, explosion of large calibre shells or of a mine

can produce cerebral or spinal symptoms, some of which are removed

by lumbar puncture. The fluid is red shortly after the explosion and

under hypertension for some days. Such hypertension may be found even

in shell cases that have no other sign of cerebral condition. This

particular melancholy patient had a relapse and another depression with

fugue.

Example of HEMATOMYELIA, indirect result of bullet wound. Partial

recovery.

=Case 208.= (MENDELSSOHN, January, 1916.)

An infantry subaltern, 23 years old, was injured September 24, 1914,

by a rifle bullet, which entered above the left clavicle and emerged

between the right scapula and the vertebral column. The patient

leaped into the air when he was struck, but fell at once and found

that his legs were paralyzed. A feeling of cold crept up from the

feet to the region of the umbilicus. Consciousness was preserved.

There was hemoptysis because of the bullet’s passing through the left

lung. The wounds all healed quickly. There was retention, followed by

incontinence, of urine and feces; and the situation was complicated by

eschars in the gluteal and trochanteric region.

For three months there was no change in the paraplegia, except that at

the beginning of the third month the patient could move his fingers a

little and raise his knees slightly. He was transferred back through

three hospital units, with a diagnosis of spinal cord lesion or

fracture due to a vertebral column lesion at the second and third

dorsal vertebrae.

Seven months after injury, he reached a Russian hospital for a

laminectomy, incapable of standing or walking without support,

although able to sit and rise with extreme difficulty. He could now

very slightly flex and extend the knees, and very slightly flex and

rotate the ankle, and weakly move the toes. Passive movements could be

carried out without much difficulty, though there was a slight joint

and muscle stiffness. Both quadriceps muscles were markedly atrophied.

There was slight amyotrophy of the lower legs. Tendon reflexes were

exaggerated, and there was a marked ankle clonus, a Babinski reflex,

and an abolition of the abdominal and cremasteric reflexes.

There was a sensory disorder of an incomplete syringomyelic pattern,

with diminished sensibility to heat and complete abolition of pain

sensibility. Touch and electric sensations were somewhat delayed.

There was a diminution in the faradic and galvanic excitability of

the legs and feet; vasomotor disturbance (slight hyperidrosis) of

the paralyzed limbs. Two of the eschars had not yet cicatrized. The

sphincteric disturbances had diminished. For the rest the patient

was normal. The second and third vertebrae showed deformity and were

painful to pressure and percussion of spinous processes.

The patient was treated by galvanization of the spine, with a current

descending at first and then ascending, and by faradization of the

paralyzed muscles. There was progressive improvement, irregular but

constant. At the time of report, July 1, 1915, he was perfectly well,

able to take long walks, and without sphincter or sensory disturbance.

The tendon reflexes were still exaggerated, and there was still a

slight ankle clonus and Babinski. The abdominal and cremasteric

reflexes were still abolished. The last of the seven eschars had not

yet healed over.

For the organic nature of this lesion, the numerous early eschars, the

persistent sphincter disturbances, the limited paresis of the legs,

the reflex disorders, and the dissociation of sensations seem abundant

evidence. It is probable that there was no fracture of the vertebrae

(X-ray confirmation), and it is probable that there was a meningeal

hemorrhage, together with some hemorrhagic foci in the spinal cord

substance, especially in the gray matter. A good deal remains doubtful:

Mendelssohn remarks that the sphincter disturbances ought to be related

to disorder of the fourth and fifth sacral segments, and the knee-jerk

and Achilles jerk absence with disorder of the lower lumbar, and sacral

region; the abdominal reflex disorder with the low thoracic lesion;

the distribution of the anesthesia ought to indicate a lesion in the

lower part of the spinal cord. Was not the hemorrhage therefore lower

down than the spot where the vertebrae were displaced? It is surely of

prognostic note that the eschars did not necessarily foretell a fatal

outcome; in fact, the patient had become functionally well before the

seventh eschar was healed over.

Shell explosion with subject lying down applied to machine-gun; no

contusion: HEMATOMYELIA. Partial recovery.

=Case 209.= (BABINSKI, June, 1915.)

A veterinary student, six months captive in Germany, wrote out for

Babinski the following:

“September 1, 1914, I was about to operate a machine gun when

a shrapnel shell exploded very near me,--probably about two or

three metres overhead. I base this estimate on comparisons made

with shells I saw exploded beside me before this one.

“Just after the explosion, which deafened me and at the same

time took my breath away a little, from the powder, I felt a

rather severe pain in the kidney region,--a pain which then

persisted without interruption. I moved my left arm, to find

the effect produced by a bullet which I heard whistle by my ear

and which struck the upper part of the left shoulder without

entering. At the same time, I tried to turn to see what had

become of my legs, and had a feeling that they had vanished.

Almost immediately I felt little prickings, not very painful,

in the lumbar region and in the upper part of the thighs. Just

then, seeing my comrades going away I tried to imitate them,

but could not. All these feelings passed very rapidly.

“A comrade then came near to tell me to go back. I told him

that I could not move and that I must have been wounded in the

lumbar region. He looked at my kit and my coat and said there

was no trace of shot or tear. Not wanting to leave me, he

lifted me by the armpits and knees. I could not help him get

me up, and my legs hung flexed and inert. After a few steps he

had to put me down, and tried to stand me up. I immediately

crumpled. I had no sensation of my feet touching the ground. I

sent my comrade back, asking him to tell my brother, who was

in my squad. I did not lose consciousness or any feeling of my

situation, or of the danger being run by my comrade.”

The man remained four days on the battle field without food. He

was on the edge of a stream. He did not defecate, nor for two days

did he urinate. Eventually the bladder and rectal functions were

re-established, though they remained irregular. Catheterization was

never resorted to. The lumbar pains were diffuse, fixing themselves a

few days after the accident in the region below the umbilicus. There

were pains at the waist predominating on the left side. The paralysis

of the lower extremities grew rapidly better. Movements in the right

leg reappeared, and 27 days after the accident the man was able to

stand and walk around his bed. Still further movement followed (left

leg weaker).

At the time of the report, May 28, 1915, the patient could walk without

a cane, but he could get about only slowly. The left toes would rub

against the ground, and he could not support himself for any length of

time on his legs. The knee-jerks were exaggerated, especially the left.

The Achilles jerks were increased. There was a Babinski reflex on the

left side and an abduction of the fifth toe on plantar stimulation. The

same reflexes were found on the right side, but less marked. Abdominal

reflexes absent, except the right superior reflex, which was distinctly

present. Cremasteric reflexes absent. Anal reflexes preserved. The

defense reflexes were exaggerated, but more markedly on the left side.

The zone from which the defense reflexes could be elicited on the left

side included the whole lower extremity and rose as far as 2 or 3 cm.

above the nipple. Stimulation of the lateral parts of the left lower

extremity would even produce defense reflex movements on both sides

of the body. On the right side, however, the defense reflex movements

could only be tried out by scratching the anterior surface of the

ankle, which was then followed by a flexion of the foot.

Sensibility to touch and deep sensibility were preserved; but

sensibility to temperature and pain, normal on the left,--_i.e._,

paralyzed--side, was weak in the right leg. There was a marked sudation

on the left side, limited by the white line, the inguinal fold, the

iliac spines, and a horizontal line passing through the umbilicus.

Here, then, paralysis followed a shell explosion while the subject was

lying down. No contusion therefore was possible. According to Babinski,

we are dealing probably with a hematomyelia, the result of shell

explosion.

Struck by missile in back; unconsciousness; no wound: Hysterical

paraplegia? HERPES and SEGMENTARY Hyperalgesia suggest radicular and

spinal injury. Recovery.

=Case 210.= (ELLIOT, December, 1914.)

November 1, 1914, a sergeant in the 20th Hussars, with other dismounted

cavalrymen, was chasing Germans with a bayonet, over turnip fields

pitted by shells. Several hours later, he found himself in a house in

a nearby village, to which he had been carried unconscious. Probably

he had been struck by some missile in the back, as the bottom of his

haversack had been torn off. His face was blackened with smoke, and his

clothes were muddy. He had no wound. His left arm was weak and his legs

powerless and numb. The passing of water was painful, but there was no

blood in the water and no hemoptysis.

Five days later, he was examined at a base hospital and found to be

paralyzed and numb in the legs. The knee-jerk and ankle-jerk were

retained upon the right side only. Pain occurred on passive movements

of the legs, which were flaccid; there was a hyperalgesia about

Poupart’s ligament, more marked on the left side. Lower abdominal

reflexes were weak on the left side; pain in lower abdomen with bladder

full and at outset of micturition. Pain and paresis also affected the

left arm, but there was no numbness. Pain on pressure over lumbar and

cervical vertebral spines. There was no evidence of bruising.

The physicians were inclined to regard the phenomena as hysterical.

Three days later, the arm movements became much freer, and after

another three days, the arm movements were fairly powerful, and the

legs much stronger, although the patient could not yet stand or walk.

He still had pain if his bladder was full.

CHART 9

CAUSES OF SHELL-SHOCK

HEAD INJURY

ATMOSPHERIC CONCUSSION

MENTAL STRAIN

NON-NERVOUS TRAUMA

NEUROPATHIC HEREDITY

After Ballard

As against the diagnosis of hysteria, three herpetic clusters appeared

on the skin of the left thigh, from three to six inches above the

knee. Elliot regards it as certain that the posterior root ganglia

were injured. He regards the case as one of injury to the spinal nerve

roots. The hyperalgesia about the body of course suggested damage to

the spinal cord. According to Elliot, therefore, this case is one of

organic disease; whether of the roots or of the cord was uncertain. At

any rate the cases of this type, though not functional, recovered.

Mine-explosion; burial; labyrinthine lesions and head bruises, more

marked on left side: Focal canities (WHITE HAIR developing OVERNIGHT)

on left side.

=Case 211.= (LEBAR, June, 1915.)

A soldier, 23, in the Argonne was blown up by a mine in a trench, fell,

and was covered by a mass of earth, from which he extricated himself.

He immediately became deaf from what was medically determined to be a

double hemorrhagic labyrinthitis. There were also superficial powder

burns of the face, as well as several bruises on the head, especially

on the left side.

The next day, at the English hospital at Arc-en-Barrois, the patient

noticed tufts of white hair on the left side of the head. There were

four islets of gray hair in the left fronto-parieto-occipital region,

separated from one another by normal hairs. The gray hairs were gray

completely from the roots to the ends of the hair. The longest hairs

were as white as the shortest. There was not a brown hair amongst them.

The gray hairs were solidly implanted, and could be pulled out only by

strong traction. There was a discoloration also of the bulbar swelling

of the hair. The rest of the head hair was dark brown. His hair was

described in the military description: “deep chestnut brown.” There was

no other symptom aside from an incessant twitching of the left eyelids.

The place of whitening was apparently determined by the region of the

scalp injured. Not only were the bruises on the left side of the head

and face, but the labyrinthine lesions were more marked on this side

and the twitching of the eye-lids was confined to the left side.

Shrapnel wound of skull; focal canities over wound; shell-shock and

shrapnel wound of right leg. Head tremors and contractions, changing in

relation to posture; glove anesthesia and local anesthesia of trunk.

=Case 212.= (ARINSTEIN, September, 1915.)

A Russian private, 24, was wounded twice: once in the head by a bullet,

and at another time by a bit of shrapnel that imbedded itself in the

skull. The hair over the injured spot became gray.

Later, September 16, 1915, the soldier was subjected to shell-shock,

and at the same time wounded by shrapnel fragment in the right leg

(operated next day).

Upon examination at Petrograd, the hearing was found diminished and the

eardrum was pulled in. At first the patient could not speak or open

his eyes, and made incessant lateral movements of the head, jerking

backwards and to the right. The right half of the face gave convulsive

movements, which began at the lip and spread upwards. During sleep,

there was an entire cessation of these head shakings and jerks. In

the lying posture, the head shook at a rate of 100 to 120 per minute.

The jerking movements became more marked when the patient sat up or

walked. He carried his head bent toward the right shoulder. When he sat

down, the side-shaking movements disappeared, only to reappear when he

lay down. The swallowing reflexes were absent. The sensitiveness to

touch, pain, and temperature was lost in the upper part of the trunk

including the neck, to the level of the tenth dorsal vertebra. There

was anesthesia of the arms as far as the elbow on the right, and as far

as the shoulder on the left. The mucosae of the mouth were anesthetic.

Dermatographia was strongly marked.

Shell explosion; burial: Hemiplegia, probably organic.

=Case 213.= (MARIE and LEVY, January, 1917.)

A soldier was blown up by a shell and then buried at Vaux, March 29,

1916, and entered the Salpêtrière, July, 1916, with a right-sided

hemiplegia and contracture without evidence of wound. He remembered

nothing for the first fortnight after the trauma. When he came to

himself, he was paralyzed and was unable to say more than a few words,

but at the end of a month his aphasia ceased and he began to walk.

The hemiplegia was spastic. There was pronounced contracture. The

arm was extended, hand open, fingers stretched. Finger movements

were diminished, as well as extension of the wrist, but the arm was

otherwise normal. The leg was not so stiff. The great toe was in a

state of continuous extension. The toes could not be moved, and the

foot scarcely; but the leg could be strongly flexed and extended on the

thigh. The tendon reflexes of the right side were more lively than on

the left. Cloniform movements followed tapping the patellar tendon on

the right side, and a patellar clonus and ankle clonus could also be

demonstrated. Plantar reflex, flexor on the right. Distinct adduction

of the foot. Slight disturbance of tactile sensibility in the paralyzed

limbs; marked disorder of position sense and gross disturbance of

stereognostic sense. Moderate dysarthria.

Ten months after the traumatism, the hemiplegia and spastic walk

remained. The upper limb was now carried in extension back of the

body, with hand supinated, fingers sometimes in extension, sometimes

in flexion, index finger separately from the others. Finger movements

difficult and shoulder movements limited. The leg, however, was almost

normal except that the toes could not be moved. The tendon reflexes

were more lively and cloniform on the right, but there was no longer

patellar or ankle clonus. Stereognosis slow, but finger movements were

naturally difficult. W. R. of blood, negative. Probably this is an

organic case.

Blown up by a shell; no skin or bone lesion: Mixture of organic

(_e.g._, lost knee-jerks) and functional (_e.g._, urinary retention)

disorders.

=Case 214.= (CLAUDE and LHERMITTE, October, 1915.)

A man, 38, was blown up in a trench without sustaining skin or skeletal

lesions, April 5, 1915. He lost consciousness for a half hour and,

coming to, found a crural paraplegia and urinary retention. Examined

July 24, in addition to the paraplegia were found tactile and algesic

hypesthesia of the legs with preservation of deep sensibility. Pains

were felt in the legs, especially in the hips. The knee-jerks were

abolished; the Achilles jerks were preserved, as well as the flexor

plantar reflexes and somewhat weakened cremasteric and abdominal

reflexes. Micturition was difficult. Constipation. Slight paresis of

left arm. Lumbar puncture, July 28, yielded a clear fluid of normal

tension without chemical or cytological changes.

The sphincter disorders gradually disappeared. The knee-jerks

reappeared in a weakened form August 31. The legs could, at the time of

report, be moved somewhat, though not above the level of the bed.

We here deal, presumably, with a mild form of concussion of the spinal

cord, in which, however, some of the transient symptoms are very

possibly merely functional in origin.

_Re_ complicated pictures of organic and functional nature, some

experimental work has been carried out. Mairet and Durante set off

explosives, such as melinite, at a distance of 1 to 1.5 metres, near

rabbits. Some died at intervals from an hour to thirteen days; others

lived. Pulmonary apoplexy was found in the cases dying early. Spinal

cord and root hemorrhages, hemorrhages in the cortical and bulbar gray,

perivascular and ependymal hemorrhages were found, always small and

without diffusion, suggesting rupture by rapid decompression following

the first wave of aerial compression. The functional effects are

thought to be brought about through the anemia of the areas supplied by

the ruptured vessels. Russca of Berne got similar results and notes

direct and contrecoup brain lesions, tympanic perforations, intra- and

extra-ocular hemorrhages, thoracic, cardiac, and splenic hemorrhages,

ruptures of kidney, stomach, intestine, and diaphragm. As in the work

of Mairet and Durante, the lung proved the most sensitive organ.

(Compare also the human case of Sencert [Case 201].) Some experiments

with fishes yielded lesions of the swimming bladder. Persalite and

other explosives were used.

GASSING: Organic-looking picture.

=Case 215.= (NEIDING, May, 1917.)

A German soldier, 21, was a serious case of gassing. He was unconscious

two days (venesection twice). When he came to, he could not walk and

felt as if he were drunk. October 22, 1916, he was incoördinate in

walking and tended to fall forward when standing with eyes closed.

The ataxia of the legs was demonstrable in the position of dorsal

decubitus, and there was also a slight ataxia of the arms. The pupils

were dilated and reacted poorly to light.

December 12, all symptoms had disappeared. The clinical picture in

this case was somewhat like that of a multiple sclerosis. According to

Neiding, the disorder is not a functional one but an organic cerebellar

disorder.

_Re_ the neurology of gas poisoning, Neiding regards the condition as

a new nosological unit. We do not know what the ultimate results of

apparently cured cases will be. Court questions of importance will

doubtless arise with reference to their compensation. Ninety-six

of Neiding’s 274 cases failed to show any nerve symptoms whatever;

forty-six cases showed one symptom only, such as headache, dizziness,

abnormality of reflexes, or abnormality in sensation. One hundred and

thirty-two cases presented a fairly full picture. The picture of a

complete traumatic neurosis not infrequently appears, aided perhaps by

the psychic features of the gas attacks; and possibly some cases are

entirely psychogenic from the beginning. Such symptoms, for example, as

dermatographia, rapid and irregular heart, hyperidrosis, blepharospasm,

mental perturbation, hypochondria, etc., do not necessarily point to

any directly toxic effect of the gases. Thirty-seven of Neiding’s cases

showed pupillary changes, hyperreflexia, and analgesia. Thirty-one

showed analgesia and absence of laryngeal and corneal reflexes.

Twenty-six showed pupillary changes and hyperreflexia, four of these

latter showing also an absence of laryngeal and corneal reflexes. One

case yielded hyperalgesia alone; ten yielded headache, dizziness, and

analgesia.

GASSING: Mutism, tremors, depression, battle dreams.

=Case 216.= (WILTSHIRE, June, 1916.)

An infantryman, aged 27, had been at the front for three months. He was

wounded a month before coming to hospital; but when the wound healed he

went back to the front, quite mute but intelligent and able to write

the following:

“We were on our way to the trenches, and as we were going

through the railway cutting they started to shell us, with gas

shells mostly, and we had not been there more than quarter

of an hour when I was compelled to lie down from temporary

blindness and weakness through getting a dose of gas through my

mouth and eyes. I was lying down for about ten minutes when a

shell came somewhere near, and was struck by something in the

face and on my left knee and I remembered no more until I found

myself in hospital. I was all of a shake and while lying down

would frequently jump up and wonder where I was.”

The patient had been mute thereafter, depressed, and given to dreams

about fighting and shells. There was a fine tremor controllable by the

will; the knee-jerks were increased. On lateral deviation, there was

difficulty in fixing the eyes. There was a slight deafness due to an

old discharging left ear. According to Wiltshire, Shell-shock is only

exceptionally caused by chemical poisoning from gas.

_Re_ poisoning by certain German asphyxiating gases, Sereysky reports

in 1917 that these gases contained, among other poisons, a nerve

poison. He found that poor heredity was a favorable soil for the action

of this nerve poison. The clinical pictures in the gassed soldiers

rather suggested cerebral arteriosclerosis. He remarks that the logical

distance between the “exogenous” and “endogenous” is greatly reduced

in these gassed cases, as the syndrome of “exogenous” gassing closely

approximates that of various “endogenous” disorders.

Hysterical speech disorder related to mechanical disorder of auditory

apparatus.

=Case 217.= (BINSWANGER, July, 1915.)

Whenever a German officer’s servant, 23 years, was addressed on the

ward in the Jena Nerve Hospital, his hands would tremble and the

muscles of his face would fall into grimacing associated movements. He

had a peculiar infantile type of speech, talking with a fixed glance

and an anxious mien. He would carefully utter, as a rule, separate

words, chiefly only nouns or infinitives. He would gesticulate with

both hands to make what he said understood. Thus (freely translating

the German) runs his description of a battle:

“Well--because--I--we had--no artillery and so many losses--then got

in position again, then we--laid down a long time--perhaps until four

o’clock in the afternoon--five--and--and it happened that--lay in

Rübenfeld--couldn’t go back--then shell near me--fell in and I right

near, how--how far--I don’t know and--grown better. Comrade said--10

meters--don’t know--un--unconscious.”

Long compound German words could not be repeated, since after the first

or second syllable there was a severe emotional excitement; syllable

articulation and phonation ceased. Finally, however, the patient

could be gotten to pronounce the whole word. Reading aloud was very

difficult: syllable sounding and omission of difficult syllables; after

a time, weeping.

The patient was a somewhat small, muscular, well-nourished man, with

a murmur at the apex, a somewhat rapid pulse, increased reflexes,

especially skin reflexes, painful supra- and infra-orbital points,

temples painful to percussion, pressure over spine painful from

second thoracic to third lumbar vertebrae. There was an increased

sensitiveness to touch and pain over the whole body. There was a

bilateral, somewhat marked tremor, more marked on the left side than on

the right. Swaying in Romberg position was slight. Tremor of tongue.

This patient was first brought to Jena November 23, 1914. An

illegitimate child, a moderately good scholar, he had worked as a mason

until he went into the army, in 1912. He worked as a soldier chiefly in

the officers’ casino because he got pains in his legs and knees in long

drills. At the outset of the campaign, however, he withstood the heavy

marching, although with difficulty. He was in his first actual skirmish

September 20. A shell struck nearby and threw him several meters;

whereupon he became unconscious and was carried away by the hospital

corps. When he woke up he could not speak or hear. Ten days later,

however, speech returned, and hearing returned in right ear; October,

deaf in the left ear, and he could not hear a watch tick on the right

side at a distance of 16 centimeters. He was examined at the otological

clinic in Jena October 12, where the drum membranes were both found

opaque, without reflexes or normal contours; hysterical attack on the

caloric test. The next day, on the medical visit, there was a screaming

attack. His plight seemed not so much simulation as one of traumatic

hysteria.

Again, after his stay at the nerve hospital, another hysterical

outburst was produced by a hearing test with vestibular apparatus, in

the ear clinic, February 6, 1915. The diagnosis was nervous deafness

with involvement of left ear.

The insomnia was successfully treated by sodium bicarbonate. There was

a slight improvement in speech. In March body weight had improved, but

there was a marked tremor of the right hand. In the next few months

there was a progressive improvement in general well-being, in speech

disorder, and in tremor. The auditory disorder remained unchanged. The

man now works in his father’s garden.

This case appears to show a combination of psychic and mechanical

injury. There are severe hysterical auditory and speech disorders.

Although the auditory disorder is of mechanical origin, the speech

disorder appears to be of psychogenic nature. It is somewhat remarkable

that the ear tests almost every time produce hysterical attacks in the

form of convulsive crying. Rather unusual is the general cutaneous

hyperalgesia, more marked about the ears.

Shell-shock (distant, neither seen nor heard); left tympanum ruptured;

semicoma eight days: Cerebellar syndrome and hemianesthesia. Recovery,

nine months.

=Case 218.= (PITRES and MARCHAND, November, 1916.)

A lieutenant underwent “shell-shock” either at night or in the early

morning, September, 1915, the shell bursting at a distance. He neither

saw nor heard the shell, lost consciousness and was eight days

semicomatose, failing to recognize his wife.

On recovering his senses, he could not get about, as he had lost his

memory, having to write down his room number and be warned of meal

times. He was led about like a child. He had a continuous headache on

the right side and pains in the occiput and along the spinal column,

as well as in the right leg as far as the heel. These leg pains were

lightning pains. Walking was difficult, staggering, leaning to left.

Weakness of right arm and leg; right-sided hemianalgesia. Complete

insomnia. During November there were frequent urgent desires to urinate

day or night. Evacuated to the oto-rhino-laryngological center in

Bordeaux, December 13, for examination of ears. The right ear was

found normal, but there was a rupture of the left tympanum. There was

at this time a trismus. The jaws were opened with the dilator and the

man had a syncope during this operation. The question of surgical

intervention for a cerebral lesion was raised, but he was first sent to

the neurologists at Bordeaux. There, December 31, he was found with a

facies of anguish, unstable gait, inclination to the left in walking;

no Rombergism; occasional dizzy spells. In walking, the right foot was

pointed outward and on request to direct it forward he complained of

pain in the loins, reaching as far as the scapula. Walking with eyes

closed, he leaned to the left and lost balance. With eyes open, no

disorder of balance. With eyes closed, the body leaned backward. If

requested to go back, he failed to flex his legs to keep balance. If he

was asked to put a foot upon the chair in front of him, he immediately

fell backwards. He could not support his body on the right leg more

than a few moments. He had difficulty in raising both legs from the bed

at one time and he could lift the right leg not so high as the left.

Movements of the legs were performed hesitatingly and slowly and with

greater difficulty with eyes closed.

He could not thread a needle and could hardly dress himself. Eyes

closed, he could with difficulty perform the finger to nose test; eyes

open, with much less difficulty. Adiadochokinesis; muscular strength

less in right than left; plantar reflexes absent; knee-jerks lively;

hemianalgesia, right side. Loss of deep and bony sensibility on right

side and diminution of testicular sensibility. Retraction of visual

field, right; diminution of smell and loss of hearing, right; position

sense absent on this side; stereognostic sense preserved. Mentally,

memory was poor; he was unable to read or do mental work. He slept

little and had bad battle dreams. He was very impressionable and

emotional and constantly complained of occipital pain. He had lost 8

kilos weight.

He grew gradually better. In May he could go out alone. The muscular

strength increased. The adiadochokinesis and synergic disturbances

lessened; the hemianesthesia persisted. In June there was greater

improvement; in fact, there was no sign of disorder left except

irregular sleep.

We here deal with a cerebellar syndrome plus a hemianesthesia.

Mine explosion: Tremors, mutism, hemiplegia. Tremors cleared by

hypnosis. Mutism replaced by stuttering. Persistent hemiplegia,

probably organic.

=Case 219.= (SMYLY, April, 1917.)

A soldier was blown up by a mine and rendered unconscious. Upon

recovery of consciousness, the patient was dumb, unable to work, very

nervous, paralyzed as to left arm and leg. The paralysis improved so

that in the hospital at home the patient became able to get about.

However, he threw his legs about in an unusual fashion. Several months

later the patient was much improved.

Shortly, there was a relapse. Transferred to a hospital for chronic

cases, the patient was unable to walk without assistance on account of

complete paralysis of the leg. There was insomnia, a general tremor,

bad stuttering, and a habit of starting in terror at the slightest

noise.

Hypnotic treatment was followed by almost complete disappearance

of the tremor. The patient began to sleep six or seven hours a

night; nervousness diminished, and the stuttering slowly improved;

but neither the paralysis nor the anesthesia of the left leg was

affected by suggestion. The leg remained cold, livid, anesthetic, and

flaccidly paralyzed to the hip. A slight improvement has followed upon

faradization but the patient still can walk only with assistance.

Smyly regards this case as probably not a true case of Shell-shock,

depending as he states “more on a lesion in the nervous system than in

the psyche.”

Shrapnel bullet WOUND of skull: Unconsciousness (three weeks), followed

by agraphia (three weeks), insomnia (six weeks), amnesia (six to

eight weeks), hemiplegia (twelve weeks), impairment of vision (twelve

to sixteen weeks), dreams (seven months). Recovery save for slight

overfatiguability.

=Case 220.= (BINSWANGER, October, 1917.)

A French tailor, aged 22, of healthy stock, was wounded in the left

frontal bone in August, 1914. The shrapnel bullet, from an unknown

distance, made a penetrative wound. The man was able to remember

how at the moment he was injured he felt a sort of strain in his

brain, felt his head with his hand, found he was bleeding, took out a

bandage from his kit, removed it from its cover and without unfolding

it put it on his head. At this moment he fell unconscious and there

was then complete loss of memory for three weeks. This patient, who

was intellectually keen, distinguished exactly between what he could

himself remember and what he was told by his comrades. One of these had

told him that he had cried out indistinctly that in a matter of fifteen

days he would be well. He estimated the interval between his wound and

the loss of consciousness as about five minutes.

After three weeks, the tailor came to and remembers that the first word

he heard was Munich. Astonished to be in Bavaria he asked for paper and

pen to write to his people, but found he could not write, though still

able to dictate a little to his comrades. Besides agraphia there was

hemiplegia on the right side, marked exhaustion, rapid fatiguability of

vision, power of concentration but slightly diminished, and apathy for

his surroundings; emotions normal.

Three weeks later the power to write returned; after six weeks,

sleep; memory was restored in from six to eight weeks; the paralysis

disappeared in twelve weeks; vision became normal in three or four

months; the dreams ceased after seven months. The mood for the first

two months after regaining consciousness was slightly elevated; for

another two months slightly depressed. The mood then became normal.

There was, then, in this case complete recovery save for slight

overfatiguability in a period of seven months. There were still a few

residuals of hemiplegia. An operation in November, 1916, removed a

shrapnel ball, one centimeter in diameter, from a dural scar.

This is a case of acute reaction psychosis of exogenous origin lasting

three weeks and leading to complete recovery in an after phase of from

four to seven months.

Normal subject, wounded and thrown to ground by shell explosion:

Recurring MEMORIES of battle scene; persistently HYPERESTHETIC healed

shell WOUND, with pupil and pulse changes on pressure of the scar.

=Case 221.= (BENNATI, October, 1916.)

A lieutenant of artillery, student (one of his brothers dead of

meningitis), suffered somewhat from diarrhœa on the battlefield.

He was, however, always able to obtain the best of food. External

conditions did not seriously interfere with sleep. In particular

there was no excessive dampness where he was. He was preoccupied with

having to act as substitute for the commandant of the battery. He was

not afflicted by the thought of his parents far away; their financial

affairs were entirely satisfactory.

This almost normal man was wounded after a day of incessant fighting

five months after going to the front. When firing ceased, he withdrew

with his soldiers to a trench. Here he was followed by an enemy gas

shell which killed some and wounded others. While outside the trench

shifting mutilated soldiers to the rear, he was hit by another shell

of which a chip wounded him in the left thigh. He felt a terrible

spanking blow that threw him to the ground and gave him great pain.

He was carried on a stretcher to the medical post across the zone of

fire; thence to a field hospital and from there to a hospital further

from the front. He had been for almost seven hours in a sector of the

fighting line which had been almost continuously active.

The wound healed in less than a week. But what he had seen and felt

kept tormenting his mind. There remained slight numbness in the wound

where there was to be seen a spot of pigment, the size of a two-cent

coin, with somewhat obscure outlines. The pain was irritated by damp

weather, in certain positions, and by touch, and the pain on pressure

was reflected in the pupils and in the pulse.

No other disturbance, organic or functional, was found.

Wounds; operation: Hysterical FACIAL SPASM.

=Case 222.= (BATTEN, January, 1917.)

A 23-year old soldier was admitted to the National Hospital for the

Paralyzed and Epileptic, June 18, 1915, in the following state: He sat

in bed, gasping, with the left side of the face set in a strong tonic

spasm and jaws tightly set. The contraction of the masseters was such

that his mouth could not be forcibly opened. He himself could separate

his teeth for about a half a centimeter, but the jaws came together

when a spatula was brought for insertion and then failed to relax.

The facial spasm increased as the jaw was clenched more tightly. The

patient said he was unable to breathe excepting when sitting upright,

and when put into dorsal decubitus he breathed violently through his

clenched teeth and held his breath as long as he could, “assuming a

purple tinge,” as Dr. Batten states, “which was apt to be disconcerting

until one was accustomed to it.” Faradism and force permitted the

removal of false teeth but only to the accompaniment of shrieks,

foaming, and violent movements of the arms, lacrimation, and sweating.

During sleep, the face was at rest. The spasm of left face and of

jaw would come on a few seconds after waking, when an observer was

perceived. Attempts to force the mouth open invoked the same procedure

as before in spite of the fact that the patient ate well. In a month he

was virtually normal.

It appears that May 13, about five weeks before, the patient had been

struck by shrapnel on the right hand, forearm, and shoulder, and base

of the nose, while in France. He had been dazed but had not lost

consciousness, and the wounds had completely healed before arrival at

hospital. It was about a week after being wounded that the patient was

operated upon for removal of shrapnel from the face. Upon recovery from

the anesthetic, the patient found himself unable to move the right side

of the face. Unable to remove his teeth, he had been fed by rubber

tube.

Shell-shock: Hyperesthesia and over-reaction.

=Case 223.= (MYERS, March, 1916.)

A stretcher-bearer, 19, who had had 18 months’ service and 6 months’

service in France, sent to Lieut-Col. Myers the day after admission to

a base hospital, showed a remarkable condition of hyperesthesia and

over-reaction.

It appears that four days before, he had been blown up three times by

aero torpedo mortar shells while attending the wounded. One had blown

him into the air, another had blown him into a dug-out, and a third

had knocked him down. Two or three hours later, having finished the

job of carrying wounded to the dressing station, everything seemed to

“go black” in the dug-out where he was resting, and from that time on

he had been shaky. It seemed that he had hardly slept for several days

before he finally gave in.

There were irregular spasmodic movements of the head, arms (especially

the right), and legs (especially the left). There were coarse tremors

and incoördination in moving the arms. With eyes closed, he touched

his nose with uncertainty. Cotton-wool touch on arms or head provoked

lively movements. “I was always ticklish,” he explained, “but

never like this; I can’t stand it, Sir.” Pinpricks produced almost

convulsions. There was perspiration, rigidity of legs, and spasm such

that knee-jerks were unobtainable. Plantar reaction, flexor. There were

also visual hallucinations of bursting shells, and these were also

heard when dozing.

Improvement followed with rest, but about two weeks later, on waking

to find himself being carried back to his tent to avoid a shower, he

was so terrified that a special nurse became necessary. He was still

jumpy the next day, alarmed at footsteps, and afflicted with headache.

He improved further in three days; remained two months in hospital in

England, had one month’s leave, and then returned to light duty.

Shell-shock; thrown against wall; comrades killed; no visible trauma,

or loss of consciousness: Persistent TREMORS, augmented in intentional

movements; CRISES of agitation following noise or emotion.

=Case 224.= (MEIGE, February, 1916.)

A corporal (an expert gunner) and his squad had just entered a mine

shaft on Nouvron Plateau, January 13, 1915, when a shell, bursting

above them, threw him violently against the wall and killed or wounded

several of his comrades. The corporal himself was not wounded, nor is

it clear that consciousness was lost. The man lay waiting on the ground

for some time until a communication trench could be finished and he

could be evacuated without much danger from the mine shaft. He had

already begun to tremble, and trembled still more while going back in

the trench.

He carried on there for a fortnight, always trembling, but not eating

and no longer able to handle a gun. He was evacuated a month later

and sent successively to Villers-Cotterets, to Meaux, to Courneuve

(a month), again to Meaux, and finally to the neurological center at

Villers-Cotterets, where he remained for two months (April 13 to June

15, 1915). Here he was given the diagnosis of hysterical chorea by

Guillain, and showed lively knee-jerks and Achilles jerks and great

emotionality. The tremors were greatly increased when the cannon grew

loud or bombs burst nearby. Lumbar puncture here showed a perfectly

normal spinal fluid. He was then sent to the Salpêtrière, June 19,

1915, and was evacuated July 13 to a civil hospital until September 24,

whence he was sent for convalescence to his home village, October 6 to

December 15, from which he was returned to the Salpêtrière.

Throughout these transfers there had been no change whatever in his

status. For almost a year, as the result of a shell explosion, he had

been trembling in precisely the same way. All four extremities trembled

equally, unless the right arm and the left leg might be thought to

tremble a bit more. The tremor was equally pronounced in dorsal

decubitus as in the sitting or upright postures, but ceased during

sleep. The tremors were worse in the evening and it was hard for the

man to get to sleep. The eyelids and tongue showed a few irregular,

jerking movements, not synchronous with the tremor of the extremities.

The head showed few tremors. The patient was able to diminish the

trembling of the arms somewhat by keeping the elbows flexed at a right

angle and held firmly to his body. If the tremor of the legs got more

energetic, the patient would get up and take a few steps. Any movement,

such as laying hold of an object, carrying a spoon or a glass to the

mouth, led to an exaggeration of the tremors in such wise that the

tremor of multiple sclerosis in its most extreme form was recalled.

It was very hard for the man to eat. If the eyes were closed, the

tremors grew more marked. The emotion caused by sudden noise or sharp

command or memory of his trench life caused motor crises, with coarse,

generalized movements, and even loss of balance. This agitation grew

gradually less marked, but the tremors persisted. An attempt to test

reflexes led to violent generalized contractions. There was no sensory

disorder. The pulse was variable; at rest it stood at 60; if a table

near by was struck suddenly, the pulse would go up to 120.

Sharp gunfire: TREMORS; TREMOPHOBIA. A patient’s (an artist)

description of his feelings.

=Case 225.= (MEIGE, February, 1916.)

One of Meige’s victims of shell-shock tremors was an artist. He stood

the hardest sort of trench life for many months without disorder. Under

particularly sharp fire, “the machine went off the track,” as the

artist said, and he began to tremble. Both arms and head trembled, but

especially the head, which was subject to small sidewise oscillations,

variable in degree, and almost permanent,--a sort of vibration which

the patient could diminish somewhat by stiffening his neck muscles. His

manual tremor was not exaggerated by voluntary movements. Superficially

he resembled a Parkinsonian case. He presented a curious appearance of

combined vibrations and stiffness.

There was no doubt that this tremor had an emotional origin. In fact,

the psychopathic status of the patient was described by the artist

himself. “My nervous state, which I thought ought to last not more

than a fortnight, still persists more than three, or almost four,

months after being evacuated, although the trembling is a little

less. I am calmer and palpitate less, and my hands perspire less when

I am emotional or making an effort. At first, the slightest shock

immediately ran through me, followed by an uncontrollable trembling.

Now there is an appreciable delay between the shock and the trembling;

I can control it for a few seconds but not longer. The subway gate

noises, a flaring light, a locomotive whistle, the barking of a dog,

or some boyish prank is enough to set off the trembling; going to the

theater, listening to music, reading a poem, or being present at a

religious ceremony, acts the same way. Recently when a flag was being

raised at the Invalides, I thought at first that I was going to be

cured by so moving a spectacle, but then I suddenly began to tremble so

violently that I had to cry out, and I had to sit down, weeping like a

child. Sometimes the trembling comes on suddenly without any cause. I

went to a novelty shop to do some errands with my wife. The crowd, the

lights, the rustling of the silk, the colors of the goods--everything

was a delight to me to look upon,--a contrast to our trench misery. I

was happy and chatted merrily, like a schoolboy on a vacation. All of

a sudden I felt that my strength was leaving me. I stopped talking;

I felt a bad sensation in my back; I felt my cheeks hollowing in. I

began to stare, and the trembling came on again, together with a great

feeling of discomfort. If I can lean against something, sit down, or

better, lie down, the trembling gets better and pretty soon stops.

There are three conditions in which I feel well: first, upon waking

after 11 or 12 hours’ sleep; next, after a meal, especially if it is a

good one; and lastly, and above all, when I get the electric douche.

Then, as if by magic, my ideas get clear, cheerful, and regain color; I

feel myself again. That lasts for an hour or so; then I relapse into my

sad state.”

As to the tremophobia, this patient says “In the tramway or in the

subway, I perceive that people are looking at me, and that gives me a

terrible feeling. I feel that I am inspiring pity. Some excellent woman

offers me her seat. I am deeply touched; but if they look at me and say

nothing, what are they thinking of me? This anxiety makes me suffer a

good deal. If I am able to speak it is less painful to me, for then it

is obvious that, despite my trembling, I am not a coward. What a sad

situation this is!”

Meige remarks that therapeutics is not especially successful in these

cases of tremor. Sedative drugs, hyoscyamin, hyoscin, duboisin, and

scopolamin, do not last long and should be used cautiously. Static

electricity works well in some cases. Rest, isolation, and calm.

As for the military prognosis, a period of observation of some three to

four months may be necessary to learn the nature of the tremor. If the

tremor then fails to alter, a convalescent leave for one or two months

may be given. The patient should then be re-observed _by the same

physician_. Upon persistence of tremor, temporary invaliding. Tremors

may be wittingly cultivated for medicolegal purposes (Brissaud’s

sinistrosis.)

Letters of a German soldier about his shell-shock.

=Case 226.= (GAUPP, April, 1915.)

A volunteer, 21, who had been in civil life a lackey, wrote as follows

upon arrival in Gaupp’s clinic:

“On account of our privations and the various terrible scenes

that you have to see, my nerves went back on me. Like the rest

of the front, we too had to suffer terribly heavy artillery

fire from December 20 onwards. December 29 at eight o’clock

in the evening, when I was about to mount guard at the camp,

I was thrown down by a shell that unexpectedly struck near me

across the earth pushed out into a trench. I ran at once to

cover as some more shots followed directly. I couldn’t be made

to do anything on the thirtieth nor can I very clearly remember

the events of that day. There was a terrific cannonade again,

then cries of the wounded and the sight of the dead, etc. I was

told afterwards that I fell down, cried, struck about me, and

remained lying, dazed. The first that I can remember was that

I was lying on a floor. I was then carried into another house,

into a better room. Then I regained consciousness and could

hear again after the noise in the ears had stopped, but I could

not talk or walk. I was unconscious for two days. I got into

the hospital train at R. the next day but had to be carried

in as I could not walk. Travelling in the train made me quite

foolish in my head and gave me bad headaches; I could not form

any clear thoughts.”

It seems that this volunteer had not been quite up to the hardships

of the war from the beginning; always a weakling, he had to be spared

on the marches. In fact, he had been refused by the army at the first

examination as unfit. He had been a nervous, tender, somewhat anxious

fellow since childhood.

At the clinic there was an astasia and an abasia without any signs of

organic disease. The striking feature was mutism. He could understand

things spoken and written, but he was entirely mute, nodding and

shaking his head properly for affirmatives and negatives. He carried

with him a few slips of paper with written requests, like: “Please,

can I have salt; otherwise I can’t eat the soup;” “Are we going to ride

farther, I have such a bad headache. The doctor must not come. The one

who wanted to shoot me if I couldn’t speak. They are all bad.”

Treatment by suggestion (laryngeal faradization, lively verbal

suggestion to pronounce single vowels, syllables, and whole words and

sentences with enunciation of them) removed the mutism in a few days.

At first the man’s speech was low and somewhat retarded, but later it

became entirely normal. Within ten days the abasia cleared up and the

patient became lively and cheerful. He was depressed on finding that he

had lice, but after losing them became happy and childlike again.

February 1, however, on learning that he would be able to do garrison

duty again, he took the news very soberly, and grew more quiet,

trembled and seemed anxious.

February 7, he was sent to the garrison, increasingly excited. His own

account of it in a letter written to a hospital nurse, runs as follows:

“As you will see, I did not reach Dn. but only got as far

as here [Another hospital]. I will tell you how it happened.

Probably I ought to have remained in Tübingen for a while

longer and perhaps then nothing would have happened to me. You

will remember that I was more nervous and excited the last days

than I had been before, and the cause was also known to you. I

wanted to get home in some way and so I pretended to be as well

as possible. That crying attack, or whatever it was [an outcry

in a frightful dream] had not been thought of by the physician

any further, you know, and so I didn’t think anything about

it either. Then the head doctor asked me once if I had any

trouble left. Well, I spoke out everything I had to say, but

no further attention was paid to that either. Then when I took

a walk and after walking slowly two hours could hardly stand,

was trembling all over and had a high pulse and also a violent

acute pain in the region of the heart, that wasn’t of any

importance either. Well, then I just got better from day to day

and so I got what I wanted only too easily because they wanted

the space and I certainly would have gone home and not to Dn.

as I should have. [His reserve battalion was at Dn.] I got

into the wrong train at St. so as to go home. I kept saying to

myself, ‘You can’t do that, it will be punished.’ Nevertheless

I couldn’t act any other way because I was really sick from

longing for home.”

Here he described an episode in a comrade who had lain beside him in

the clinic, had gone off with him and had a hysterical excitement in

Heidelberg so that he had to be detrained.

“I was so awfully sorry to see him so miserable. I began to

cry and was startled by every train coming from the opposite

direction and by every loud noise. I was stared at by everybody

in Frankfort and I could only cry more. Then a soldier scolded

me because I was running senselessly up and down. Finally I got

into the Leipzig train. Another guard questioned me. Everything

then got more and more confused in me; I heard my mother

call; then I heard shooting again; and finally I was entirely

confused. I came to my senses in a room in the station toward

evening, and was frightened again at a loud noise somewhere

or a passing train. Then I was told what I had done in the

train. I had cried out and raved, tried to get out of the car,

called for my father and mother, wanted to go home, imitated

shooting; allowed myself to be calmed a little, but began to

shout again at every loud noise. When I was out of the train

I bit a soldier and tore his whole coat open, so then I was

carried to the hospital here in an auto. Up to this time I have

been able to calm myself very well. The physician said that it

was quite natural that I should not have very strong nerves

yet. I must have beaten about and got knocked against things a

good deal. There are bruises on my head and I am covered with

black-and-blue spots.”

A British soldier’s account of his shell-shock.

=Case 227.= (BATTEN, January, 1916.)

A British soldier, 22 years, who went out to France in November, 1914,

remained well until March 12, 1915, when after shell explosion, he

became unconscious for half an hour, and on recovery found he was deaf

and dumb. He was able to think of words but could not say them. He

remained dazed and frightened for a time, and still wakes up with a

start at night.

He was admitted to the National Hospital for the Paralyzed and

Epileptic, March 25, 1915, and on March 27 recovered his speech

suddenly and spontaneously. By March 29 he had completely recovered

and talked well. Dr. Batten remarks “how perfect the memory may be

up to the time of concussion, and how complete the mechanism is for

expressing the ideas in written words when that for spoken words is

abolished”; which may be seen from the patient’s own account, as

follows:

I went out to France on the 3/11/14 and I was two days at Le

Havre and then we went on to our 1st Batt. When we arrived at

our destination the regiment was in the trenches so we had to

go in. It was snowing hard and I felt it very cold. This was at

Givenchy. We were relieved the following night and we went back

for a rest. The next place we went to was just opposite Neuve

Chapelle on the La Bassée Road and it was awful, the trenches

were up to the knees in mud and water. The first night was

very quiet, but the following morning about 9 p.m. the Germans

started shelling and continued all day; the next was the same,

but about 1 o’clock the Germans were seen to be coming up in

masses. They got to within a distance of about twenty-five

yards, then they turned. They commenced shelling us again and

they had another try about three o’clock but they did not get

far. One of the men on my left had the half of his face blown

away and we had about ninety-two killed and wounded. We got

relieved after being in five days, then we went back for three

days’ rest. The next place we went to was Rue de l’Epinette

and we had an awful time there just before Christmas. We went

into the trenches and we were up to our middle in water and in

some places it would have taken you over the head. We were in

these trenches for twenty-four hours. There was nothing unusual

happened and we got relieved by the Royal North Lancs.; but

we did not get far away; we had just got into our billets and

were making some tea when the fall-in went and we were told

that the Germans had broken through the North Lancs. We went

away without any great-coats, and into the trenches we went

for other seventy-two hours, and if the Germans had attacked

again we could not have fired a shot as we were hardly able to

stand for the cold and with the wet kilts on our legs it was

awful. We got nothing to eat except three biscuits that some

of the men went out and got. When we came out of the trenches

on Christmas Eve we looked all like old men and a lot of them

had to be carried. We went back for a rest to (Nervaille?)

about thirty kilometers from the firing line for a month. When

we came back again we went to La Bassée and had a pretty hot

time there. The next place we were at was at that big fight at

Neuve Chapelle when 472 guns bombarded the German trench for

thirty-five minutes. At about 7 p.m. the word was passed along

that we were to charge the German trench in front supported by

the City of London Territorials. We got the trench all right

and I got orders about 4 p.m. to go back to our own trench and

bring along the belt-filling machine belonging to the machine

gun. There was not a proper communication trench, there was a

small dry ditch that ran out in the direction of the trench we

had taken for a distance of 150 yards, the other 100 yards you

had to come across the open. We got into our trench all right,

and I got this box on my back and started back to the trench.

I was just stepping out of the trench when a shell burst just

over my head and I went down. When I came to my senses I was

lying in our support trench where I had been carried by two

of the men of the 4th Black Watch. One of them said something

but I could not hear him and I tried to tell him so, then I

discovered that I could not speak.

Shell-shock by windage: Hysterical crural monoplegia, of gradual

development beginning four days after accident. Recovery by suggestion.

=Case 228.= (LÉRI, February, 1915.)

A number of chasseurs were doing the “tortoise-shell” under

bombardment, when the last chasseur in the line was blown forward

above his comrades by a shell bursting about a meter behind him. He

was projected some four or five meters, got up, walked four or five

kilometers, found an automobile, and was carried to Nancy. He passed,

according to his story, red urine three or four times. He was six days

at Nancy, where a slight abrasion of the side was treated. He began to

feel heavy in his left leg on the fourth day. At Vendôme, the paralysis

got worse, and by November 17 he had apparently a complete paralysis

of the left lower extremity, called “spinal contusion.” He walked upon

two canes, dragging left leg behind and had to be carried upstairs on

a stretcher. The reflexes were normal except that there might have

been a very slight excess of the left knee-jerk. There was a slight

hypesthesia of the left leg, sharply limited above.

These phenomena were strikingly modified, at a single sitting, by

verbal suggestion and faradism, but the man was one of those with

_mauvaise volonté_. He did not want to get well so quickly, so that his

complete cure was delayed a while.

NATURE OF SHELL-SHOCK: At the nerve clinic the patient presents,

_e.g._, sundry CONTRACTURES, of such a nature that they may be caused

to DISAPPEAR BY SUGGESTION, _e.g._, by mental influences during

recovery from chloroform narcosis (note battle-dreams). PAINS and

ANESTHESIAS disappear PARI PASSU with the contractures. The history

is of shell explosion so near as to burn patient’s clothing, fall

with nosebleed, eight hours unconsciousness, crural monoplegia with

anesthesia (crawled 3 meters, however).

=Case 229.= (BINSWANGER, July, 1915.)

The treatment of a German private, 22, for contracture of the left

leg and other phenomena, culminated in narcosis. Binswanger lays

stress upon the mental influence to be exerted upon the patient at

the conclusion of narcosis, at the moment in which the patient is

particularly accessible to verbal suggestion. Treatment (see diagnostic

details below) was carried out as follows:

After a few days of essentially suggestive treatment with continued

attempts at passive movements of the contracted joints (knee, ankle,

toe), with steady concentration of the patient’s attention upon the

joints, a slight mobility in the toe joint on passive movement was

obtained.

After a few more days, the ankle became passively mobile to some

degree; the patient exerted a certain resistance to passive flexion

of toes and ankle. A week later, reflex contractions of the toes

could be evoked by deep pin-prick. There had been an analgesia of

both lower thighs and of the soles of the feet, and this analgesia

remained unchanged. At this point, the subjective complaints of the

patient, namely, noises in the head, especially in the left ear, and

other cephalic sensations, tended to disappear and the patient felt

subjectively better; yet there was still an intolerable itching of the

head and spine.

A month after the admission of the patient to the nerve hospital of the

psychiatric clinic in Jena, there had been no essential change in the

immobility and contracture in extension in the left leg. Accordingly,

with the permission of the patient, he was placed in deep chloroform

narcosis, and the knee-joint was bent at a right angle and fixed in

approximately that position with a bandage. This experiment failed

because, while the patient was waking out of his narcosis, the leg

slipped back into extension, breaking the bandage. Accordingly, deeper

narcosis was undertaken, and the leg fixed at a right angle in a

plaster cast.

While the patient was coming out of narcosis, it was evident that he

had been dreaming of battle scenes. In fact, Binswanger remarks that

these dream pictures and the words spoken while going under and coming

out of narcosis, are curiously demonstrative of “_sympathy with the

enemy_,” for while waking out of narcosis, he cried: “Dost see, dost

see the enemy there? Has he a father and mother? Has he a wife? I’ll

not kill him.” At the same time, he cried hard and continually made

trigger-movements with his right forefinger.[6] In point of fact,

throughout his waking treatment, no one was able to learn what was

going on in his mind, his sleep was good and deep, and his emotional

state was entirely quiet and patient.

[6] Compare sentiments of a Russian in narcosis (Case 319,

Arinstein.) See also Case 181 (Steiner).

As the patient was coming out of chloroform and regaining consciousness

of his surroundings, he was repeatedly and persistently assured that

the bending of his leg was now accomplished and the cramp removed. All

that he would now have to do was to get back the strength of his leg.

During the next few days he complained of violent pains in his left

knee-joint and in the ankle-joint, but he remained in good spirits and

full of confidence. Accordingly, in five days the plaster was removed

and the contracture in the knee-joint was found to be completely

absent; the knee was easily movable. The ankle-joint was but slightly

movable. He could accomplish slight active flexion of the knee-joint

while lying in bed, and the toe-joint had already, before the narcosis,

been both actively and passively mobile. After a few days, exercises

in walking were begun. The patient had a little difficulty with his

left knee-joint in walking, walking in fact as if with knock-knee. The

foot was not well raised from the ground on account of the persistent

stiffness of the ankle-joint. Walking, however, improved daily. He

walked for three hours, resting at intervals.

A sensory examination showed that the upper limit of the analgesia

had come down five centimeters from its former level, now occupying

the left foot and leg up to the junction of the lower with the middle

third. There was now a zone of anesthesia interposed between the

normal skin of the upper thigh and the anesthetic-and-analgesic skin

of the lower thigh and leg. Upon the posterior aspect of the leg, the

analgesia and anesthesia had disappeared to a point at about the middle

of the upper thigh.

About five weeks after the narcotic experiment, the extended left leg

could be actively raised while lying in bed, up to the full extent,

with slight tremors. The patient described himself as fatigued by the

active movements of this leg. The ankle-joint remained less effective.

There was still a trace of resistance to passive movements. Although

the passive movements of the toes were normal, active movements of

these were weak and hard to execute. There was still a trace of

difficulty at the knee in walking and the gait was awkward, trepidant,

precipitate. He could get about without a cane, however. If unobserved,

his posture was more certain and free. If he exerted himself hard,

severe parietal headache on the right side would develop.

It was then proposed to the patient that another narcosis would rid

him of the stiffness in his ankle-joint. He feared narcosis and was

told that regular and energetic voluntary movements would also rid him

of the stiffness. These will exercises consisted in his directing his

whole attention to his left ankle-joint until he felt it. Then he was

given the command: “Let go the joint”--whereupon he would take his

attention away from the ankle-joint at once. In this way, he was told,

his will would make the ankle-joint mobile. Meantime he was given

twice daily a gram of bromophenacetine for his parietal headache.

The result was a rapid recovery. There were still a few traces of

difficulty at date of report. The zone of sensory loss had retreated to

the ankle, with a cuff-like zone of hypalgesia above the definite zone

of analgesia and anesthesia.

As to the previous nature of this case, although there was neuropathic

heredity on the mother’s side, there had been no sign of any individual

neuropathic disposition. He had been a volunteer since 1911 in a guard

regiment of infantry. His military training had been well borne; in

the war he had fought through 20 battles. On November 11, 1914, in a

storming attack, he had had his breeches burned from the effects of a

shell. He had fallen, unconscious; the unconsciousness lasted about

eight hours. He found on awaking that he had had nosebleed. When he

wanted to get up, he found that his left leg was completely paralyzed

and insensible; in fact, he thought it had been cut away. He crawled

for about three meters to a trench in which there were several wounded.

In the evening he was taken by automobile to a field hospital, and on

the 17th was removed to a reserve hospital at Erfurt. Thence he was

transferred to the Jena Hospital, January 25, 1915.

A strongly built man, with many reflexes increased and a lively

dermatographia. The reflexes of the left, or contractured, leg were

lacking; the mastoid processes were painful, and the occiput and

temples were painful to percussion. The spinous processes of the

vertebral column in the lumbar region were painful. The other phenomena

have been sufficiently indicated above. The head sensations were

peculiar; there were no pains but a peculiar itching. Contraction of

the fingers of the left hand was painful. There was a feeling as if

there were lice under the skin in the left upper thigh. There was

itching in the nose, which the patient described as due to the sulphur

“out there,” meaning shell gases. Sleep and appetite were good. Memory

was imperfect: he could no longer remember the names of the battles,

and of late had had to count on his fingers to find out how much was

2 times 2. As to the curious parietal headache, contralateral to the

contractured leg, Binswanger inquires whether we may not here have to

do with localized vascular phenomena of the brain part which might

conceivably be related with the innervation of the leg. Binswanger

remarks that if the plaster cast be left on too long, it may happen

that hysterical contracture will take place in the new position.

As to the will exercises used in the present case, Binswanger remarks

that the patients must be intelligent and attentive, and naturally they

must desire to get well. Fortunately, many of the war hysterics do want

to get well, since the contrary experience is had in various industrial

cases.

Wound of thigh: Pseudocoxalgic monoplegia with anesthesia. Cure of

anesthesia by faradism at one sitting. Cure of lameness by reëducation

and electricity in one month.

=Case 230.= (ROUSSY and LHERMITTE, 1917.)

An infantryman, observed at Villejuif, February 9, 1915, was

suffering from a right-sided crural monoplegia of a pseudocoxalgic

type, following a wound September 9, 1914. The wound had been a

through-and-through one in the upper right thigh. Every active movement

could be performed as well on the right side as on the left; but the

strength of the movements was less on the right, especially that of

leg-extension. The reflexes were normal, the lameness was slight, with

toeing out; the sole came down flat upon the ground. There was an

absolutely complete anesthesia of the entire right leg and side up to

the umbilicus.

Energetic faradization of the skin caused the anesthesia to disappear

the day the patient was brought to the hospital. The cure of the

lameness required a month of reëducation and electricity.

According to Roussy and Lhermitte, crural monoplegia is less frequent

than brachial monoplegia. The flaccid form is rare, and when it occurs,

complete, though the patient always remains capable of executing

some voluntary movements and can walk with crutches or cane. During

the automatic movements of walking, some muscles may be observed to

contract that remain immobile when the patient is being examined

recumbent. Naturally such a difference in contractions standing and

lying, would be very exceptional in a case of organic monoplegia.

Contusion of thigh: HYSTERICAL right crural MONOPLEGIA. An ORGANIC

CRUTCH PARALYSIS develops in the right arm, unobserved by the patient

whose main concern is his useless leg. Cure of leg by psychotherapy.

=Case 231.= (BABINSKI, 1917.)

A certain lieutenant, following contusion of the right thigh, developed

a crural monoplegia of hysterical nature. In fact, although the

paralysis had lasted several months, the tendon reflexes, the skin

reflexes, and the electrical responses of the muscles, were absolutely

normal. Moreover, the good effects of psychotherapy confirmed the

hypothesis. But besides the hysterical crural monoplegia, there was a

radial paralysis on the right side, clearly organic in nature, due to

the nerve compression by the crutch which the patient had employed on

account of the paralysis of his leg.

Babinski notes that this association of conditions was remarkable

in that it demonstrated that hysteria and simulation should not be

confounded with one another. To be sure, it is difficult to tell

simulation from suggested phenomena, for there are no objective

characters that demarcate the two. Babinski had himself said that

hysteria was a demi-simulation; but a demi-simulation is not a

simulation. The patient was in fact, sincere enough in his belief that

he could not move his leg. To obviate this paralysis, he had in fact

leaned so conscientiously upon his crutch that an organic paralysis

had resulted. In fact the radial palsy had only been discovered

incidentally, and the paradox appeared that a purely imaginary trouble

occupied in the patient’s mind for a long time a much more important

place than the genuine organic trouble which accompanied it.

Bombardment; war strain; gassing?; collapse; arthritis: Hysterical

MONOPLEGIA and ANESTHESIA of leg, interpreted as a “PROTECTIVE”

reaction. Later, monoplegia and anesthesia of arm.

=Case 232.= (MACCURDY, July, 1917.)

A corporal described as normal (“except for some shyness with the

opposite sex”) adapted himself well to training and went to France

in May, 1915, where he was at once thrown into 18 days of almost

continuous bombardment. After some initial fright, he settled down

to work well enough, but, when the weather got bad in September,

1915, grew tired of the situation. Bad dreams began (falling into a

deep hole; being shelled). He thought of suicide, wanted a shell to

incapacitate or kill him, began to have pains in the head, arms and

legs, and was already groggy when a gas attack came. Whether he got a

whiff of the gas or not, he at any rate felt giddy, got a swallow of

water, and when the gas passed got out of his dugout in the open air.

He was fatigued and much relieved when the company was ordered back.

Now, however, he got shaky and fell in a collapse on a pile of straw,

without, however, losing consciousness.

Apparently he had an attack of acute articular rheumatism. There was

a sore throat and a pain in the head, radiating to left shoulder and

to finger tips, with pain also in legs. The pain was worse in the

right leg on moving the knee-joint. These pains lasted for a month in

hospital. The leg had been like a log since the collapse on the pile

of straw. Even after the pains left him a month later, the right leg

was paralyzed and anesthetic. He walked with a crutch and developed a

crutch palsy. After a month a hysterical paralysis of the right arm,

with superficial anesthesia, supervened. During a period of eight

months thereafter improvement was steady under reëducative measures.

According to MacCurdy’s analysis, the acute arthritis led to paralysis

as a protective reaction. The paralyses are disabilities that would

ensure absence from the front.

Lance-thrust in back, rapidly healed. Paralysis of right leg,

disappearing with rest and exercises. Later, psychotic symptoms, with

recovery.

=Case 233.= (BINSWANGER, July, 1915.)

N. H., 21, a laborer, industrious and sober (mother healthy, father

insane and a suicide; patient somewhat sickly in childhood after

pneumonia, a good scholar) volunteered at the outbreak of the war.

Early in November he was on the Eastern front. November 17 to 22 he

was in a number of small reconnoitring skirmishes almost daily, as a

cavalryman. On the 22d, there was a clash with a Cossack patrol of far

superior numbers. Eight German horsemen cut their way through, riding

about 4 kilometers back to their squadron.

While dismounting, N. H. discovered that his back was wet. It occurred

to him at once that he had been wounded. However, he successfully

dismounted and then collapsed, feeling as if his right leg had fallen

asleep. His companions found a wound in his back, which had come from

a lance-thrust. The wound was bandaged. He was transported to Germany

on a peasant’s wagon, the trip occupying six days, and on December 6 he

came to the surgical clinic in Jena. The wound was insignificant and

healed quickly.

The leg remained motionless, and on December 10 the patient was

referred to the nerve hospital. He was a small, slenderly-built man,

with poor nutrition, weighing 108 pounds. The scar, about 1 cm. long,

alongside the thoracic vertebra, was still somewhat red and but

slightly sensitive to pressure. Neurologically, the knee-jerks and

Achilles jerks were greater on the right than on the left, and there

was on the right side a distinct patella and ankle clonus. There was no

Babinski reaction on either side.

The movements of the right leg were not of wide excursion, and flexion

and extension of the knee and ankle-joints, while lying on the back,

were slowly and hesitatingly performed, with an expression of pain, and

with visible effort by the quadriceps muscles. Flexion and extension

of the toes were likewise difficult, and when the toes were stretched

there was a distinct contraction of the tibialis anticus. Electrically

the muscles were normal. On passive motion, there was slight spastic

tension in the musculature of the right leg, and the patient said he

felt marked pain. In walking, the right leg was moved with a limp and

with the evident design of sparing it. The knee was imperfectly bent

and the sole of the foot was dragged along the ground. There were short

out-throwing movements of the lower leg.

Pain sense was normal, or possibly slightly in excess. There were

painful points on pressure on the lower part of the os sacrum and

coccyx and over the right sciatic and tibial nerves. Intelligence

examination showed school knowledge to be extremely poor and

calculation ability poor. Critical judgment and reasoning power were

deficient. Memory and perception were without marked disturbance.

The patient was dull and without interest in his surroundings. He

complained that his right leg was as if dead and that he felt great

pain in any attempt to move it. He also complained of pains at night

in the region of the right shoulder and neck. His nerves, he said, had

been very weak since his trip back from the front, during which trip he

had been very cold and poorly cared for.

Treatment consisted of rest in bed, application of moist packs to

the right leg, active and passive exercises of the right leg. After

ten days he made his first independent attempts to walk, and active

movements of the right leg in dorsal decubitus became unrestricted and

painless. He remained somewhat unsteady in station, showing bilateral

twitchings and movements of the right leg muscles. In walking the right

leg was dragged behind in a spastic-paretic fashion. Appetite improved;

spasms decreased; but at the end of December foot clonus was still

persistent.

Upon January 10 there was an odd mental change. He became seclusive and

suspicious. January 15 he expressed ideas of poisoning; his sister, he

said, wanted to poison him, and others were watching him suspiciously;

his room-mates were talking about him; in fact, he thought one comrade

was an Englishman. Sleep was poor. At the end of January, after a short

period of improvement, he again had ideas of being poisoned, and had

dream-like, unclear thoughts. His actions became incoherent: he would

undress suddenly in the daytime and go to bed, getting up five minutes

later and dressing. Senseless postcards were written.

This condition lasted a few days only, whereupon the mental and bodily

condition greatly improved. Daily walks were then taken in the garden

and in the city without exertion. The ankle-clonus on the right side

was now decidedly weaker but did not entirely disappear. The muscle

power on the right side was somewhat less than on the left.

The patient was very homesick, and on March 14 was sent home.

Shell-shock--six days later, crural monoplegia, cured by suggestion.

“Metatraumatic” hysteria. HYPERSENSITIVE PHASE AFTER SHELL-SHOCK.

=Case 234.= (SCHUSTER, January, 1916.)

On August 13, 1915, a soldier was knocked unconscious by the explosion

of a shell nearby. He woke up several hours later with headache, noises

in the ears, itching, but no trace of paralysis.

Six days later, on August 19, he was released from hospital, still

free from paralysis. On the railway journey he met some people of his

district by whom he sent greetings to his wife, meanwhile becoming

greatly excited. When he tried to get out of the train he noted a

weakness of the left arm and left leg; this weakness somewhat quickly

grew into a severe paralysis, so that when observed in Berlin the left

leg was entirely paralyzed, not a single muscle of which could be

moved when the patient was examined by Schuster one month after the

accident. There was also a hypesthesia on the left side with total

anesthesia of the left leg, which anesthesia was related stocking-wise

to the hypesthesia of the trunk. There was tremor of the hands as well

as generalized increase of reflexes. The plantar reflex, though weak,

was flexor. The pulse rapidly ran up under excitement. In short, the

patient seemed to be suffering from hysterical palsy. Waking suggestion

did so well with the man that after three weeks normal sensibility was

restored to the leg, and he could walk tolerably well without a cane.

The point of interest in this case is that the symptom of greatest

importance, namely paralysis of the left leg, did not arise until six

days after the shell explosion and then only after the man became

excited by thoughts of his home and family through meeting his town

people. The term _metatraumatic_ is suggested by Schuster for cases

of this sort. The emotions and stresses of war may be regarded as

_labilizing_ and _sensibilizing_ the nervous system sometimes for

months.

Wound of left foot: ACROCONTRACTURE. Psychoelectric cure, about seven

months later, at one sitting, except for some residuals that cleared

shortly afterwards.

=Case 235.= (ROUSSY and LHERMITTE, 1917.)

A soldier, 21 years, was observed at the Centre Neuropsychiatrique,

August 30, 1916. He had been wounded in battle, March 16, 1916, near

the left internal malleolus. Infection followed and inguinal adenitis,

for which he was in hospital a month.

Even before the abscess began, the foot had begun to twist inward.

After the abscess had been cured, a contracture set in permanently, and

at entrance to hospital was irreducible. The knee-jerk and Achilles

jerk were more active on the side of the equinovarus contracture. There

was even a slight amyotrophy of the calf. There was no appreciable

vasomotor disorder. The foot and lower part of the leg were a little

warmer on the left side.

Cure followed a single sitting with psychoelectric treatment, at least

so far as the contracture went. Pain and swelling remained in the

evening, followed by fatigue. The patient was discharged cured, October

12, 1916.

Hysterical pes equinovarus shows the foot immobile as if frozen

(_figé_). The foot is extended with the toes lowered and the internal

border incurved, as if revolved about the axis of the leg. The surface

of the sole is directed inwards and much furrowed. The tendon of the

tibialis anticus is very prominent. The internal malleolus is hardly

visible, while the head of the astragalus is easily made out. No

passive movement is possible and the tibiotarsal and mediotarsal joints

are quite out of function. Upon palpation, the excessive contracture of

the anterior muscles of the leg is striking. Upon request to move the

foot, the foot is not moved, but muscles of the lower leg may contract,

and even those of the thigh.

There were no sensory disorders in the present case, though they often

do occur in this form of acrocontracture. It is doubtful whether

the skin changes sometimes seen, such as hypothermia, hyperidrosis,

cyanosis, and glossiness are due to circulatory disorder induced by

the contracture or to the prolonged immobility. It has been proved

by Meige, Benisty and Lévy, that even in a normal subject prolonged

immobility may cause a difference of temperature of several degrees.

Circulatory disorders sometimes cease immediately upon cessation of

the contracture. Roussy and Lhermitte insist upon energetic and early

treatment of these psychoneuropathic acrocontractures, which are apt

to proceed less favorably than the acroparalyses. If not treated

energetically and early, actual nerve, tendon, and bone lesions may

ensue.

Shell-shock; shell-wound; emotion: Hysterical paraplegia. Approximate

recovery.

=Case 236.= (ABRAHAMS, July, 1915.)

A private of the First East Lancs could remember a shell’s bursting and

striking a wagon near him when he was carrying food to the firing-line.

He also thought a spare wagon wheel might have fallen on him. A

period of unconsciousness of four or five days duration elapsed, on

recovery from which he found himself suffering from a shell-wound in

the left buttock, complete paralysis of both legs, and pain in the

back, by the fourth lumbar vertebra. He thought that he had suffered

from sphincteric paralysis for eleven days after the accident; but by

September 25, there was no sign of this. Besides the paraplegia, there

was complete loss of sensation below Poupart’s ligament in the right

leg, reaching as high as the iliac crest behind; and an anesthesia of

the left foot including heel and sole, with anesthesia to light touch

throughout the limb (pin-pricks being appreciated in a normal way as

far as the ankle); and there was an anesthesia to touch and pain in the

ulnar distribution.

April 20, 1915, the patient was found to be a robust, somewhat

microencephalic slowly cerebrating subject. Total flaccid paralysis

of legs; right knee-jerk slightly exaggerated; no plantar response of

any sort was obtainable. Right leg entirely anesthetic; left leg and

both arms showed a diminution of sensibility; suggestion of glove and

stocking anesthesia; trophic changes absent. The scar of the healed

bullet-wound lay over the trunk of the left sciatic nerve.

It seems that the man’s companion had both his legs blown off at

the time the shell burst. It is questionable whether the paraplegic

patient actually saw the legs blown off, or merely heard about the

accident. Another psychic feature lay in the fact that the patient had

a paralyzed sister--a possible financial burden.

April 30, nitrous acid anesthesia. During the temporary rigidity, the

legs were found to stiffen slightly; the legs were flexed. Upon the

return of consciousness, the patient was told that the legs had moved

during anesthesia, and was asked to place them in a more convenient

position. The thighs moved slightly, and throughout the day movements

were encouraged against resistance.

The next day he was gradually raised to the vertical position and

supported upright. But at this stage he had become mentally resistant

and resentful. During the day the upright position was at intervals

resumed, and the patient was made to walk between two attendants. The

next day he walked alone and his mental resistance had broken down.

There was no longer any evidence of exhaustion and effort in the

movements, and the patient began to take pleasure in his recovery.

Improvement was progressive. A pronounced hysterical element persisted,

encouraged by the perpetual attentions of visitors. When discharged,

there was a slight hemi-anesthesia throughout the right side, and a

doubtful patch of anesthesia on the dorsum of the foot, sole, and

plantar surface of the heel.

Shell-shock; burial; flexion of spine: Paraplegia.

=Case 237.= (ELLIOT, December, 1914.)

A reservist, 34, formerly army instructor in gymnastics, a member of

the 1st Battalion King’s Royal Rifles, was subject to injury from

the bursting of a “Black Maria” on his trench. He was sitting with

bent back in his shelter, with legs fully extended. He was in a small

dug-out, a recess excavated under the earth backward from a narrow

trench and not timbered. The “Black Maria” burst and covered him up

to the chin in a heavy clay soil. After building up the breach twenty

minutes later, his comrades dug him out.

He had received on his body the violent impact of the mass of earth

pushed laterally from the crater excavated by the bursting of the

shell. Accordingly his vertebral column was forcibly flexed, its

ligaments were stretched, and hemorrhages were produced in the great

muscles of the back. As the twelfth thoracic vertebra is the weakest

spot in the spine, the roots of the cauda equina opposite this weak

spot were probably injured. Such accidents are met in mines.

The legs were powerless and numb. There was nausea, no vomiting, no

gas, no dizziness or trouble in the head, not even pain in the small

of the back. The accident had occurred at 8 A.M. Upon nightfall, he

was removed on a stretcher to the field hospital, arriving at the base

hospital four days later; and on the fifth day power began to return

to the legs. Knees, ankles, and toes would move slightly November 6,

though passive movements of the legs caused pain in the back. The deep

reflexes were weak, the plantar reflexes flexor. The left cremasteric

reflex was weaker than the right. Impairment of sensation was slight

in both extremities, but the left leg was a little more numb than the

right. The left lower abdominal reflex was lost. A band of hyperalgesia

corresponded with the left eleventh and twelfth thoracic segments

November 12, slight reflex disorders and some degree of paresis of the

legs.

Shell explosion: Paraplegia; sensory symptoms.

=Case 238.= (HURST, January, 1915.)

A lieutenant, 23, came to the ambulance September 15, 1914, having the

morning before been to the firing-line with his company and thrown to

the ground on his back by the explosion of a shell which he had seen

falling behind him. He had not lost consciousness, but was unable to

rise. After a night in the relief post, he was brought by automobile

12 kilometers to the ambulance. He complained of pain in the back,

though no wound or ecchymosis could be found there, nor any painfulness

of spinous processes or irregularity of bone. He had not emptied

the bladder from the time of the shock. Preparations were made to

catheterize on the morning of the 16th, when the patient after effort

became able to micturate. There was crural paraplegia such that he

could not sit or walk even when supported. Lying down, he could move

his legs slightly sidewise. Anesthesia to pin-prick and temperature

was complete to the groin; but tactile anesthesia was found only in

the sacral root territory, namely in the feet, the outer aspect of

the legs, the posterior surface of the thighs, and the scrotum. There

was loss of sense of position for the toes. The plantar reflexes were

abolished; but there were no other reflex disorders; nor was there any

evidence of other disorder.

September 20, the man was evacuated by sanitary train in the same

status as at entry. January 27, 1915, the patient could walk on

crutches, supporting himself in part on the left leg. The lumbar pain

had largely disappeared.

Hurst regarded this case as one of organic origin due to commotio

spinalis.

Wet, cold, heavy marching; leg pains, rheumatic; no other somatic

factor or any emotional factor discoverable: Transient paraplegia; two

months after period of exposure, brachial tremor, hysterical. Recovery

incomplete.

=Case 239.= (BINSWANGER, July, 1915.)

A German soldier, 34 (non-alcoholic; married, father of five healthy

children; on military service 1901-3; regarded as a very good soldier;

father alcoholic), got bad leg pains from wet and cold in West front

trenches September 8-13, 1914. Still he was able to march some 30

kilometers. But two days later (he had lain down in wet clothes in a

barn), his legs became quite immobile. He was in a reserve hospital

from November 3. The rheumatism disappeared, and suddenly, early in the

morning of November 8, when he was washing, a lively tremor and shaking

of the right arm set in.

Examination at Jena January 30, 1915, showed no special physical

disorder. The sense of touch was slightly diminished on the right side;

the pain sense was normal; movements were free. While at rest there was

a continuous shaking tremor of the right arm and hand, which consisted

of very rapid pronations and supinations, and shaking movements of

the upper arm. At times the tremor would completely cease, and when

attention was diverted the tremor became slighter or quite disappeared.

The tremor increased when it was talked about in the man’s presence.

The left grip was stronger than the right.

January 31, after he had been in bed one day and treated with moist

packs, the shaking suddenly ceased. He then complained only of mild

pains in the right shoulder and wanted to get up.

February 23, he was given three days’ home leave, which he stood

very well. He now began to take part in the medical gymnastic work,

but complained afterwards of more pains in right shoulder and arm.

There was a lapse into the shaking tremor, which lasted with varying

intensity for several weeks. Loud noises or calling made it worse.

Hypnotism and suggestive treatment of the tremor were without effect

March 25. March 26, on passive extension of the right arm, patient

complained of pain in shoulder and arm. Next day the tremors were more

marked, but March 29, the tremors suddenly stopped altogether. April 4,

the pains stopped never to return. April 15, he was given leave to go

home for spring farm work.

Four weeks later he returned, sparing his right arm, which he held

stiffly beside his body when walking. If he let the arm hang free in

walking, rhythmical movements in it began. He complained of painful

involuntary contractions in the right arm even when in complete rest.

Nor did the condition afterward essentially change; the patient went

home at the beginning of July.

The remarkable feature of this case is the complete lack of any

emotional shock. The total genesis seems to have consisted in the

prolonged exposure to wet and cold, and the heavy marching. The

tremors, limited to the right upper extremity, occurred without

any demonstrable psychic or bodily trouble, and set in after the

disappearance of the so-called rheumatic disorder. Although there is

no one psychogenic factor to single out, the psychic influencibility

of the case is unmistakable; moreover, the incompleteness of the cure

is doubtless, according to Binswanger, a matter of the imperfect

suggestive therapy employed.

Fever patient watches barrage coming: unconsciousness, paraplegia:

recovery.

=Case 240.= (MANN, June, 1915.)

A lieutenant was lying with fever in a farmhouse in upper Alsace,

watching from his window the shelling of a battery about 400 meters

away. He saw that the enemy was to reach the farm with shell in due

course of time. The shells came nearer, say up to about 100 meters, and

the lieutenant was able to reckon closely when he would be reached. He

was quite defenseless and unable to get to safety. At the very moment,

he thinks, when the shells began to strike the house, the lieutenant

lost consciousness from fear. He was unconscious an hour before

being carried to the cellar. The shelling lasted several hours more.

Immediately upon coming to the patient found that, although he bore no

external wound, both legs and the right arm were paralyzed.

There were never any signs of organic disorder. The patient recovered

completely with purely suggestive treatment.

Incentives to paraplegia.

=Case 241.= (RUSSEL, August, 1917.)

A young Canadian paid $150 to have his teeth repaired to be accepted

for service and then married. The wife became pregnant. He reported

sick after falling out on a route march in a heavy rainstorm. The

medical officer said he had weak feet and ankles. He lay around the

huts, was excused duty, and got worse in the wet and cold. He was

admitted to hospital and came to Russel’s wards on a stretcher showing

paralysis of both legs with slight power of movement at the knee.

Stroking anesthesia to pin prick from the knee down. Reflexes not

abnormal. He walked back upstairs!

According to Russel the wife’s pregnancy had furnished a sufficient

incentive, and the M. O.’s suggestion had fallen on fertile soil.

[Illustration: CAMPTOCORMIA (MLLE. ROSANOFF-SALOFF)

WOUNDED SEPTEMBER 3, 1914. THROWN INTO AIR BY SHELL-BURST;

UNCONSCIOUS. FEBRUARY, 1915: PLASTER JACKET, 3 WEEKS; SECOND

JACKET, 3 WEEKS. CURED. SENT TO GRAND-PALAIS.]

Bullet wound of back: Hysterical bent-back--camptocormia.

=Case 242.= (SOUQUES, February, 1915.)

A man was wounded September 6, 1914, by a bullet that entered along

the axillary border of the scapula and emerged near the spine. He spat

blood for several days; but the skin wounds quickly healed.

When he got up, his trunk and thighs were found to be in a state of

moderate flexion upon the pelvis, the trunk being bent almost at a

right angle; the legs were flexed somewhat upon the thighs. The man

could not voluntarily extend his trunk, but he could extend his thighs

to a moderate degree. He could bend his trunk still further forward

than its habitual contractured position, being able to pick up an

object from the ground. If the man was put in the ventral position,

the trunk could be straightened to a considerable degree. Curiously

enough, the man felt no pain, nor had there been any pain since the

healing of the wound. No motor, sensory, reflex, trophic, vasomotor,

electrical, visceral, or X-ray disorders could be found. It was evident

that there was a contraction of the muscles of the abdominal wall and

of the iliopsoas, yet it was also clear that these muscles were not

contractured on account of the subject’s ability to flex his trunk and

to extend his thighs.

Here, then, is a vicious attitude crystallized (in the phrase of

Souques) in the form of a pseudocontracture.

Blown up by shell; unconsciousness: Camptocormia (bent-back,

“cintrage”). Cure by corsets.

=Case 243.= (ROUSSY and LHERMITTE, 1917.)

Camptocormia with antero lateral bending is described by Roussy and

Lhermitte in an infantryman observed at Villejuif, February, 1915,

after having been wounded September 3, 1914. The infantryman had been

thrown into the air by the bursting of a shell, had lost consciousness,

and came to with violent pains in the back. The trunk was found to

be bent strongly forward and to the right side, and remained in this

position thereafter. There was no evidence of wound.

In February, 1916, a plaster corset was applied by Souques, which

brought the patient partly to normal station in three weeks. The trunk

was now no longer bent forward, but was still bent to the right. A

second corset was applied for three more weeks, with which the patient

became absolutely straightened out again. He was discharged cured and

sent to the Grand-Palais for the reëducation course.

This condition is a form of trunk contracture in the nature of a

kyphosis (scoliotic and lordotic forms of contracture are also found

in the hysterical group), for which the terms _plicature_ of trunk,

traumatic kyphosis, pseudo-spondylitis, and camptocormia have been

in use. The term camptocormia has been proposed by Souques and

Rosanoff-Saloff. The _poilus_ speak of the condition as _cintrage_

(arching). In these cases the trunk is held almost horizontally,

with the head in hypertension and neck muscles and thyroid cartilage

jutting. The patient looks fixedly straight forward, with eyes wide

open, and carries his legs extended or half flexed. The normal folds

of the abdominal wall are very deeply marked, and at the level of the

groins, the epigastrium and the pubis, there are deep folds. Viewed

from behind, the median lumbar fold has disappeared or is faintly

marked, as are the sacro-lumbar and other masses of spinal muscles.

The whole lumbar region is elongated and flattened. The dorsal spines

of the back are accentuated; the buttocks are flattened and broadened

transversely. The back of the neck is marked by deep transverse

folds, and the seventh spine does not stand out. The patient can walk

perfectly, though sometimes there is a pseudocoxalgia and lameness.

Attempts to straighten the body lead to visible forcible contractions

of various muscles, but the kyphosis remains persistent. There is a

sense of active resistance on the part of the patient, which can be

demonstrated by palpation. If an active attempt at straightening is

made, lumbar or sacral pain develops, followed by a very lively and

emotional state of anxiety on the part of the patient, with interrupted

and accelerated breathing, an expression of terror in the face, and a

rapid pulse. The patient then subsides into his earlier attitude, and

his anxiety disappears in a few seconds. It is much easier in many

subjects to reduce the camptocormia in the position of dorsal decubitus

than upright.

Burial after shell explosion; lumbar ecchymoses; regionary pains;

camptocormia, 5½ months. Cure by three months’ plaster cast about trunk.

=Case 244.= (ROUSSY and LHERMITTE, 1917.)

An infantryman was buried after shell explosion August 25, 1914, but

he sustained no wound or bone injury. There was, however, a large

ecchymosis of the lumbar region, and he had felt violent lumbar pains.

The trunk was carried flexed, symmetrically bent over and quite

incapable of being straightened completely. A plaster corset was

applied March 16 by Souques. Three months of this was followed by a

complete straightening, which lasted after the corset was removed. The

patient was discharged well.

As to these cases of camptocormia, some authors regard them as due to

anatomical changes in the vertebral column itself, or in the ligaments

and muscles, and accordingly regard the condition as a form of

spondylitis, syndesmitis, or psoitis. This view is held by Sicard, who

bases the idea upon the local pains and the results of cerebrospinal

fluid examination. According to Roussy and Lhermitte, hyperalbuminosis

of the fluid is extremely rare, and one case of their own _with_

hyperalbuminosis was nevertheless cured with great rapidity. Roussy and

Lhermitte even inquire whether the fluid albumin may not be due in some

way to an interference with venous and lymphatic circulation.