a pseudospondylitis dolorosa, such as may be sometimes observed in
hospitals near the front. Later, however, the suffering in camptocormia
is due more to the abnormal position of the trunk, with strain upon
vertebral ligaments, than to the persistence of any original pain.
Moreover, these patients recover almost immediately from their pains
when the contraction is relieved.
In differential diagnosis, one has to consider, according to Roussy
and Lhermitte, Pott’s disease, traumatic spondylitis, as well
as Bechterew’s vertebral ankylosis, Pierre Marie’s rhizomelic
spondylosis, Kocher’s intervertebral disc contusions, and Schuster’s
myogenic ankylosis of the vertebral column; but in Pott’s disease, the
fixed pain points, rigidity of column, fluid examination, and signs
of myelitis, should suffice for the differential diagnosis. Traumatic
spondylitis follows the contusion after months and after a phase of
neuralgia. Ankyloses do not so much concern the trunk as the vertebral
column itself; disc contusion produces disorders in standing and gait
as well as pains and edema. Schuster’s disease shows paresis, hyper
reflexia, and amyotrophy not shown in camptocormia.
Shell explosion; partial burial; forcible flexion of spine. Paraplegia,
cured by suggestion. Then camptocormia, also cured.
=Case 245.= (JOLTRAIN, March, 1917.)
An infantryman in the Côte du Poivre was sitting on the ground in the
opening of a dugout eating soup, when a shell burst and the roof of the
sap fell in on him. The planks and the stonework fell heavily on the
dorsolumbar region. The patient was almost bent in two, head to knees,
legs buried, hardly able to breathe. He did not lose consciousness
and cried out, feeling for a moment very anxious and fearful that his
comrades had left. Only two hours later was it possible to dig him
out. He said he had been absolutely unable to make any movement, had
kept his body bent, and felt violent pains in the back. He was carried
back twelve hours later and reached the dressing station in eight
more hours, eventually reaching the neurological service two days and
a half after the accident. On entrance he was prostrated, complained
of lumbar pains and of inability to move, and was able to make only a
few contractions on the left side when asked to try. The right leg was
flaccid. The left knee-jerk was stronger than the right. Other reflexes
normal. Hyperesthesia to pin prick on the right side. Slight saddle
hypesthesia, reaching to the iliac crests above and perineum below with
preservation of touch sensation. Slight forward posture of vertebral
column. The patient complained of pain on pressure of the spinal
processes and the lumbar spine. There was slight ecchymosis about the
left iliac crest.
Lumbar puncture showed clear fluid without hypertension, in which were
a few lymphocytes. There was a large amount of albumin. The blood
pressure was normal. There had been a slight diarrhea following the
accident which disappeared on entrance to the hospital. The question
was raised whether the case was one of slight hematomyelia or was
pithiatic.
Suggestive therapy was tried, and liquid was injected into the muscles
of the lumbar region and the posterior surfaces of the thighs. In
a quarter of an hour the patient found himself able to raise the
foot above the bed. There remained an extensor paralysis of the
right leg. When the patient was made to raise the foot he began to
show the phenomenon of Souques, called camptocormia. He could walk,
nevertheless, and took a few steps sustaining the weight of his body
by placing his arms on his thighs. Though he complained of lumbar
pain, it was finally possible for him to pick up an object from the
ground and lean sidewise. He could not, however, stand up. Yet when the
patient was made to lie down, his back was spontaneously straightened.
Treatment of the camptocormia was also successful.
Astasia-abasia: Two cases from (a) thigh wound, and (b) shell-shock and
wound of thorax. Cures by faradism.
=Case 246.= (ROUSSY and LHERMITTE, 1917.)
An infantryman was wounded September 23, 1914, by a bullet in the
anterior and middle part of the left thigh. From the moment of the
trauma, he had not been able to walk, but gradually regained his
ability to stand, and then to walk. He was returned to the front
(January, 1915).
Slightly wounded again in the neck, January 6, 1915, he was evacuated
and operated on. After the operation he could neither walk nor stand.
His reflexes were normal; he could perform all movements when lying
down, although the movements were executed very slowly. As soon as he
could sit upright, he was taken with tremors and could not hold himself
in a vertical standing position, nor take a single step. If he was
given crutches, he dragged the two legs.
Under the influence of electric treatment--a mild faradic current--he
was cured at a sitting so that he could both stand and walk (March,
1916).
=Case 247.= (ROUSSY and LHERMITTE, 1917.)
Astasia-abasia after shell explosion occurred in an infantryman
observed by Roussy and Lhermitte at Villejuif, July 8, 1915.
The patient had been wounded September, 1914. The wound was a
superficial one in the thoracic wall, under the right nipple. He had
been cast into a very deep shell hole, but had been able to get back to
the aid station alone, taking very short steps only.
As soon as he reached the station, his gait became spastic, trembling
and hesitant. Given two canes, he could walk painfully, trembling.
At each step, he would balance his body back and forth. He gave the
impression of a man drawing some sort of vehicle, who had to make a
considerable effort at each step.
The faradic treatment cured this patient at one sitting.
War strain; fall into water-filled trench: Dysbasia, tremors, vasomotor
disorders. Cure by hypnosis. Case to demonstrate “traumatic” hysteria
WITHOUT somatic TRAUMA.
=Case 248.= (NONNE, December, 1915.)
An artilleryman (without hereditary or acquired neuropathic taint)
underwent much stress and strain in the war in Belgium, Lorraine and
Flanders. One night, on leaving his observation post, he fell into a
trench filled with water. He felt pricks in the groin and gradually
developed a pseudospastic tremor of the lower extremity, paraparesis
inferior, depression, irritability, pressure sensations in the head,
and sleeplessness. He passed through three hospitals before arriving at
Hamburg and received the diagnosis of concussion of the brain and cord.
Nonne found an emotional state of depression with hypochondriacal
fear, disturbance of sleep, deficient appetite, constipation and
pollakisuria. He walked upon two crutches, dragging his legs inertly
after him. There was marked cyanosis, lowered temperature and
hyperidrosis of the feet and lower legs; exaggeration of tendon and
skin reflexes and pseudoclonus; no Babinski or Oppenheim reaction.
There was anesthesia of the lower extremities and of trunk as high as
the ribs. Pulse 130. Visual fields normal. Sensory disorders absent.
After the first hypnotic treatment the patient was able to stand and
take a number of steps, and the tremor gradually diminished. After two
treatments standing became normal and walking was much improved, the
tremor ceased, cyanosis and hyperidrosis disappeared, and the movements
of the bowels and urination became normal. Thereafter the patient had
no attention paid to him deliberately and in a week’s time became well.
Here is a case in which, as Nonne states, the somatic trauma required
by Oppenheim as the basis of every traumatic neurosis did not occur.
Moreover, the sudden cures by hypnotism, or by any other method in
these cases, warrant us in supposing that there are no such fine
molecular changes as Oppenheim and von Sarbo assert. Such experience
as the cures in this group of cases confirms, according to Nonne,
the surprising result first achieved in this war (Bonhoeffer, Wagner
von Jauregg, Karplus, Wollenberg, Westphal) that the most severe
neuroses produced by somatic and psychic traumata can be cured in an
astoundingly rapid manner without residuals.
_Re_ the controversy over Oppenheim’s traumatic neurosis, Nonne holds
with the Charcot school that traumatic neurosis is clinically identical
with hysteria. Oppenheim admits the part played by psychogenesis,
but has always laid a greater emphasis upon the actual injury of
the neuronic apparatus in which he believes. He thinks that small
hemorrhages, inflammatory processes, and degenerative processes affect
the neurones unfavorably, and permit the psychogenic effects to occur
more readily. Of course the insurance-company attitude and the attitude
of railway corporations saw malingering in all cases, and to this day,
neurologists are inclined to see a great deal of “indemnity neurosis”
in these cases. Opposed to the corporation men and the neurologists
were the psychiatrists, who chiefly upheld an emotional theory of
genesis--whence we began to hear of the neuroses of fright and of
accident.
Oppenheim claims to have established with war cases the fact that
an entirely normal person without heredity and without antebellum
acquired soil, may develop a neurosis through war stress. Oppenheim
concedes that there may be purely psychic cases, but holds that there
are nevertheless, numerous purely physical cases and a great number
of cases of a compound nature, which are both physical and psychical
in their etiology. Oppenheim’s point is not that every single symptom
described _may_ not be upon occasion psychogenic, but that the data
of this war prove that neuronic injury, particularly injury of the
peripheral neurones, can also produce these effects. Nonne, Forster,
Lewandowsky, and others, opposed Oppenheim’s views vehemently. See
especially comments by Zeehandelaar.
Shell-shock; BURIAL HEAD DOWN: Brachial monoplegia, head-shaking,
speech disorder, corneal and conjunctival reflexes absent.
Determination of hysterical phenomena to parts buried.
=Case 249.= (ARINSTEIN, 1916.)
A Russian private was buried after a shell explosion, September 13,
1915, head down, so that only his legs stuck out of the débris.
Afterward his right hand refused to move, and there was edema of the
right wrist, with pain referred to the shoulder joint. The head shook
and made jerky movements during the day, but ceased them in sleep.
Speech was retarded; words were uttered clearly enough but in a
sing-song fashion; sometimes the man stammered. Hearing was diminished
in the right ear. Pupillary responses were lively, but the swallowing
reflexes were diminished, and the corneal and conjunctival reflexes
were absent. The tendon reflexes were lively on both sides. There were
no pathological reflexes.
At the end of October--six weeks later--the patient was sent home on
convalescence for three months, and improved rapidly after a short
time in family surroundings. He was examined again, two months after
discharge, and found normal in all respects. He returned to the ranks.
_Re_ Shell-shock in Russians, Arinstein concludes that concussion
hysteria may occur in a perfectly normal person, yet be innocent of
all organic signs indicating destruction of peripheral or central
neurones. Rifle or machine-gun fire had not in his experience brought
about concussion hysteria, which was invariably due to the bursting of
a large projectile. With reference to Schuster’s remark that a sleeping
man never acquires hysteria from the bursting of a shell near by,
Arinstein confirms Schuster, finding amongst 2000 cases no instance in
a soldier sleeping at the time the shell burst.
_Re_ effects of cannonading, Gerver reports Russian instances of a kind
of hysterical _clavus_, or sensation of a nail being driven into the
back of the head, in men who have been a number of days under stiff
shelling.
Multiple wounds and bullet wound of palm: ACROPARALYSIS. Cure, five
months.
=Case 250.= (ROUSSY AND LHERMITTE, 1917.)
A patient was observed at Villejuif, February 5, 1915. He had been
wounded, January 2, 1915, and showed scars of a bayonet wound on the
anterior surface of the right thigh, of a lance wound on the dorsal
surface of the right foot, and of a bullet wound in the palm of the
left hand.
There was left wrist drop with fingers extended. On the sensory side,
there was a glove anesthesia and analgesia up to the bend of the elbow.
The right leg showed a paresis and contracture, but there were no
sensory disorders in the legs. Reflexes were normal. The patient was
discharged cured, in May, 1915 (psychoelectric method).
This is an example of the so-called acroparalyses, paralyses limited
to the hand or foot, many of which have developed in this war, after
grazing wounds or more severe injury. More rarely they appear as if
spontaneously. Sometimes they are preceded by slight arthralgia or
vague pains.
The condition in the hand suggests a radial paralysis. The patient
is unable to flex his fingers, though he probably is able to make
some movements with his thumb. Sometimes, on request to move the
hand, a series of coarse oscillations follows, somewhat like a
tremor. These oscillations are, according to Roussy and Lhermitte,
apparently pathognomonic, and depend upon the contraction of the
muscles antagonistic to those whose movement has been requested. These
antagonistic muscles, themselves entirely incapable of voluntary
movement, are seen to be contracting effectively and jerkily to meet
the action of the agonists, also seen making jerky movements. If the
forearm is moved passively and rapidly, the hand flops about inert,
like the hand of a marionette, although not to the degree of hypotonia
in organic paralysis. The hand is often cold, moist, and cyanotic, and
even possibly analgesic and hypesthetic.
Bullet wound of arm: Apparent radial paralysis, not resolved by
self-preservative swimming movements. Paralysis actually hysterical.
=Case 251.= (CHARTIER, October, 1915.)
A professional acrobat, 22, Corporal in an African Chasseur regiment,
was rather instructively tattooed and had apparently performed some
of his service in disciplinary companies. In short, one might have
a legitimate suspicion of the objective value of any manifestations
he might present. However, one of his chiefs had written a favorable
letter concerning his services. He had had various crises of a
hysterical character since adolescence, and there was alcoholism in the
family.
He was wounded May 4, 1915, by a bullet which passed through the outer
and lower part of the right upper arm, and thereafter the forearm and
hand became completely inert, both for flexion and extension. There
was a considerable hyperesthesia. The wound healed quickly, without
complications.
August 5, about 10 o’clock at night, the man--then at his dépôt--tried
to commit suicide (motive not related with the war). He threw himself
into the Rhône from a height, where the water was deep and the current
rapid. His brother and a comrade, who knew that he was going to make
the attempt, saved him. Chartier himself happened to see the whole
scene, and noted that throughout the affair the forearm and hand of the
patient remained inert. It seemed as if there was a radial paralysis.
This was the more likely as the man had been wounded in the arm. First
care was given. The man had not known of Chartier’s presence. He had
been under water about two minutes.
From hospital he was evacuated three weeks later with a diagnosis of
radial paralysis, coming on service September 11. Examination showed
a slight paralysis of the extensors and flexors of hand and fingers,
and of the hand muscles. There was also a slight contracture of these
muscles, more marked in the flexors. There was pain upon reduction,
with some jerking of the muscles. Electrical reactions proved normal
in nerves and muscles. There was a segmentary anesthesia to pin prick,
reaching to the level of the elbow; deep hyperesthesia of the finger
joints. There was no trophic or vasomotor disorder.
In short, here was a case of functional paralysis with contracture of
the right hand, to be regarded as hysterical in the classical sense
of the term, both by reason of the anesthesia and absence of trophic
disorder, and on account of the hysterical history of the patient.
Functional reëducative treatment quickly improved the paralysis, so
that two weeks later the patient was able to extend fingers and hand.
His total recovery was hoped for, when, September 26, wishing to get
out of the hospital without leave, the patient jumped from a window and
broke his right leg. The functional paralysis of the hand persisted and
even grew more marked.
The interesting point in this case is that despite the powerful nature
of instinctive efforts with drowning persons, this patient, subject
to an hysterical arm paralysis, did _not_ make defensive movements
with the paralyzed arm; yet this paralysis was such as to be greatly
improved by psychotherapy.
Bullet wound in brachial plexus region: SUPINATOR LONGUS CONTRACTURE,
hysterical-looking. Callus of fractured rib probably at fault:
Treatment surgical.
=Case 252.= (LÉRI and ROGER, October, 1915.)
A man was wounded, December 21, 1914, by a bullet which entered about
the middle of the spinous process of the left scapula and was extracted
a few days later from the posterior border of the sternocleidomastoid
muscle, two finger-breadths from the left clavicle, that is, at about
Erb’s point. The left upper extremity was inert for ten days, but then
began to move again, although extension and flexion of the fingers did
not begin at once.
October, 1915, movements were normal, except those of extension of
the forearm, due to contracture of the supinator longus muscle, a
contracture that had developed about three weeks after the wound and
stood out along the external border of the forearm, almost suggesting
a musculotendinous retraction. There was a palpable, hard callus of a
fractured rib, presumably a cause of the permanent irritation of the
supinator longus, being precisely at the point where lesions usually
produce superior brachial plexus palsy.
Why should the supinator longus alone of the Duchenne-Erb group
be affected? Perhaps a single root was involved in the irritative
lesion. The biceps showed also a partial R. D. The deltoid was normal
electrically and in contraction.
The treatment planned for this case of isolated contracture of the
supinator longus was surgical operation of the irritative focus.
According to Léri and Roger, it is sometimes dangerous to use such
measures as massage and electric baths for a paralyzed limb, since the
massage or electricity excite not only the affected muscles, but also
the other sound muscles,--muscles that are already more powerful than
the paralyzed muscles and may go into antagonistic contracture. Even in
limited galvanization, it is desirable to work with weak currents, so
as not to diffuse the current into non-paralyzed muscles. In case of
radial or sciatic paralysis, apparatus permitting the extremities to
rest without over-action of the muscles antagonistic to the paralyzed
ones may well be applied.
We here deal with a case, therefore, which looked purely functional,
but in which careful examination and X-ray served to show an organic
focus of irritation.
_Re_ nerve concussion, Tubby offers the following definition: Nerve
concussion is damage to a nerve trunk without actual destruction of the
axis cylinders. The damage may consist of an effusion of blood between
the nerve fibres following compression of a nerve against the bone by
rapid passage of a foreign body near the nerve. Sometimes, however,
the lesion which causes damage to the nerve trunk without actual
destruction to the axis cylinders is nothing more than a temporary
anemia or hyperemia. In most instances, both motor and sensory function
are together interfered with, but in the case of large nerve trunks,
_e.g._, the popliteal, there may be a separate concussion of motor or
sensory bundles.
Contusion may effect a sort of STUPEFACTION OF MUSCLE and paralyze it
by a non-psychic process: The SYNERGY in contraction of biceps and
supinator longus is thus SPLIT. Biceps restored to synergy with the
supinator by massage and faradism.
=Case 253.= (TINEL, June, 1917.)
A man was wounded at about the middle of his biceps and three weeks
later was found to be able to flex the forearm only by means of the
supinator longus. The biceps remained absolutely flaccid and soft, so
that the diagnosis of a lesion of the musculocutaneous nerve (unlikely
as this seemed on account of the low site of the wound) was entertained.
However, the biceps and the musculocutaneous nerve proved electrically
normal. In short, this paralysis of biceps was functional in nature.
But, according to Tinel, there could be no voluntary suggestive or
hysterical element in such a paralysis, since flexion of the forearm
is normally produced by a synergic contraction of biceps and supinator
longus that cannot be separated voluntarily.
Treatment by massage and rhythmic faradization caused the biceps
function to return to normal, so that voluntary synergic contractions
of the biceps took place along with those of the supinator longus.
We here deal, according to Tinel, with a genuine functional paralysis,
nonhysterical--a paralysis due to a kind of stupor of the muscle. Such
paralyses due to muscular stupor ought to get well in a few days or
weeks. Should they persist, it is clear that a stuporous paralysis
might be transformed into a hysterical paralysis. In short, the direct
contusion of a muscle or group of muscles may be the point of departure
for various persistent paralyses.
Wound of arm: Blocking of impulses to certain hand movements. Recovery
with splint.
=Case 254.= (TUBBY, January, 1915.)
A private was wounded by a shell fragment, September 16, 1914, and
admitted to the London General Hospital, September 27. A high-velocity
shell fragment had passed through the soft parts of the left arm at a
spot exactly corresponding to the musculospiral groove. He could extend
the middle finger of the left hand, but the other fingers were held in
flexion. The last two phalanges of index finger could not be moved, it
was found, on account of severance of the extensor tendon some years
previously. Accordingly, the loss of function due to the shell injury
was that of thumb, ring, and little fingers. Supination could not be
executed completely to the extent of 15 degrees; there was no R. D.
upon electrical test, October 2. The sensation of affected fingers was
woolly. November 3, the little finger had recovered, but supination
could not be completely executed.
The treatment consisted in a bent malleable iron splint, with the wrist
and affected fingers hyperextended. November 20 all power had returned
with full supination, except for the two phalanges of index finger
previously injured.
Major Tubby thinks this a case of physiological blocking, as from a
small hemorrhage amongst the fibers or around the nerve.
_Re_ inhibition, Myers thinks it is the functional cause of the effects
of shell-shock. He thinks it is not a fixation of the _idea_ of the
paralysis of volition, but that it is a fixation of the _process of
inhibition_ itself that produces the effects we see in Shell-shock.
It is a block of ascending paths that produces the anaesthesia so
characteristic of Shell-shock. It is a blocking of sensory paths
that produces mutism or aphonia. But according to Myers, there is
also a block in certain cases of _descending paths_ that control and
coördinate various mechanisms. The result of a block in the descending
paths is shown in spastic, clonic, or ataxic phenomena of, _e.g._,
functional dysarthria. See also Case 253 (Tinel).
Eight months of war experience (often under heavy fire) without
reaction; then, shell-shock; unconsciousness: Right hemiparesis; pain
in the left side of head; heat sensations of right half of body;
diminution of hearing in left ear; a variety of asymmetrical bilateral
phenomena.
=Case 255.= (GERVER, 1915.)
A Russian private, 24, sustained shell-shock April 14, 1915. He was
observed, when the shell burst, to crouch down, and then to fall to
the ground, unconscious. The unconsciousness lasted about two days,
after which he was found to be oriented, though slow and stammering of
speech, hardly able to concentrate attention or sustain a conversation,
and giving the impression of a man stunned. There was difficulty in
the expression of thoughts, and a marked over-fatigueability. After
adding and subtracting accurately two-digit figures for a time, the man
quickly grew confused and said that trying to solve such a problem made
him dizzy.
His imagination was filled with gunshots, shell-bursts, and the
killing of comrades, and during any conversation the man frequently
shuddered. Concerning the shell-shock, he remembered only that a number
of shells had burst near him and that he came to in the hospital. He
kept looking to one side and to a distance, as if listening, sometimes
bending his head downwards. He would cry and sigh during conversation,
and then be quite unable to explain why. He said there were loud
noises in his ears, and that his head and the whole right side of his
body felt hot. Pain was felt in the left side of the head. The right
hand and the right foot were weak (on distraction, this hemiparesis
remained unaltered). Tremors affected all the extremities. He had a
sensation, possibly hallucinatory, of the creeping of insects on his
skin. The hearing of the left ear was objectively diminished. There
was palpitation of the heart and difficulty of breathing. Tendency to
Romberg. There was a general hypalgesia, more marked on the left side
of the body. Both conjunctival reflexes were diminished. Knee-jerks
and Achilles jerks were exaggerated. All the reflexes on the right
side were livelier than on the left. There was a moderate Babinski
reaction on the right side. Mechanical over-excitability of muscles.
Dermatographia. Both sides of the skull were sensitive on tapping, but
especially the left side. Mannkopf sign on pressure of the left side of
the cranium.
Hemorrhagic points without injury to the skin were noted on the skin
of the left hand and foot. Speech was stammering. There was a marked
digital tremor, sometimes spreading to the rest of the body during
examination. The muscles of the face, eyelids, and tongue showed sharp
fibrillary twitching. The pulse stood at 100 and frequently missed
beats. Battle hallucinations, visual and auditory, sometimes occurred,
the commands of superiors and the noise of guns, rifles, yelling, and
groans; the man would see trenches or redoubts, or a field full of
wounded soldiers or attacking columns of the enemy. He recognized the
hallucinations as such. His sleep was troubled by nightmares of the
same general description.
For eight months the man had been in action at the front, under heavy
gun and rifle fire. He was a courageous man, who had never felt fear,
regarding himself as used to battle and the bursting of shells. He had
not been wounded. The entire situation seems to have developed after
the single shell burst of April 14, 1915.
LOCALIZATION OF SHELL-SHOCK SYMPTOMS: Hemiparesis and hemianalgesia on
side of body exposed to explosion; contralateral irritative symptoms of
face and tongue.
=Case 256.= (OPPENHEIM, January, 1915.)
A soldier had a shell explode to his right, October 23, 1914. He
declared that the concussion launched him through the air. When he
recovered consciousness three hours later, he lay in a bog and was
unable to move either leg. Gradual improvement followed. The symptoms
were sensations of formication in the legs, pain in the back, blurred
sight, hardness of hearing, disturbance of speech, headache, vertigo,
weak memory. After a fortnight weakness in right arm.
He was admitted to hospital a week after the injury, unable to walk,
restless, given to palpitation and attacks of anxiety. On attempts to
walk, leg spasms and tachycardia.
Transferred to nerve hospital, December 2. Sleep poor, uneasy with
dreams. Tic on left side of face. On opening the mouth, left-sided
faciolingual spasm. Paresis of right arm. At first, right-sided
ankle-clonus and paresis of leg. Knee-jerks increased. Speech
hesitating. Right hemianalgesia. Concentric contraction of visual
fields. Tachycardia (120). In walking the right arm failed to swing
normally. Attacks of vertigo, with falling. Patient got up at night and
pushed against objects in his room.
There was only slight improvement while under observation. He became
psychically more frank and even talkative, and was moving more readily
when transferred.
_Re_ Oppenheim’s conception of the strongly peripheral element in
traumatic neurosis, he sums up by saying that a traumatism attacking
the organism at its periphery is in line to produce a neurosis without
any psychic mediation whatever. The rôle of the psychic process, in
Oppenheim’s view, is contributory to the fixation of neuroses. Even
when there is a free interval betwixt shell burst and neurosis, still
there are physical effects of trauma upon neurones.
Shell-shock; unconsciousness; after improvement in symptoms (4 months)
return to trenches; more symptoms after 5 days: Sensory disorders,
especially on left side (the side more exposed to explosion);
exaggerated reflexes on right side with slight clonus and with Babinski
sign. Improvement.
=Case 257.= (GERVER, 1915.)
A Russian Captain, 45 (heredity good; non-alcoholic, non-syphilitic;
always in good health) sustained shell-shock in a battle in
southeastern Prussia, August 13, 1914, and was unconscious for two
days. He was carried to one of the provisional field hospitals, and
then evacuated to Petrograd, where during a period of four months, he
was given electricity, suggestion, and baths. He was feeling so much
better in December, 1914, that he went back to the front and headed his
company in the trenches. He stood only five days of trench work, and
was sent for mental examination December 29, 1914.
The captain was of middle height, well developed but poorly nourished,
of a dejected and preoccupied appearance, looking to one side in
conversation, and finding difficulty in the expression of his thoughts.
He talked almost exclusively of his illness. He found difficulty in
adding or subtracting 2-digit figures. He seemed to have amentia,
frequently being mistaken as to the most important dates in his life.
He complained of general weakness and inability to work. Any endeavor
to concentrate caused vertigo, irritation, and pains in the head.
Day and night he was troubled about his health, his future, and his
family’s future. He was going to become an invalid and a burden. He
was tormented with the idea that people thought him a simulator. He
complained of lumbar pains. It seems that the explosion had affected
the left side of the body more than the right and he complained more
of pains upon that side. In the dark his gait was unsteady, and he
often had marked tremors of feet and hands. In excitement the tremor
would increase uncontrollably. The patient thought that his hearing
was diminished, especially upon the left side, and that his left ear
was weaker than the right. He slept poorly and had many nightmares;
his appetite was poor, and he was constipated. There was difficulty in
respiration; the pupils were slightly dilated and sluggish in their
responses. There was a marked tendency to Rombergism; dermatographia
marked; the skull and especially the lumbar spine was painful on
tapping; hyperesthesia of the lumbar skin; paresis of left hand and
left foot. The tendon reflexes were more marked on the right side than
on the left, and there was even a slight ankle and patellar clonus.
The Babinski sign was present on the right side. There were frequent
fibrillary contractions of the muscles of the trunk and back.
Objectively the hearing was somewhat decreased in the left ear, and the
vision of the left eye appeared to be somewhat impaired also. If the
eyes had been held closed for a time, there was difficulty in opening
them quickly. Aside from a somewhat elevated pulse and slight cardiac
arrhythmia, there was no disorder of the internal organs.
This patient remarkably improved but was not absolutely well at the
date of the report.
_Re_ organic signs in Shell-shock cases, Oppenheim warns practitioners
and experts against undervaluing war neuroses. He does not like to have
them set down in too offhand a way, as hysteria, wish-fulfilment, and
simulation. Hysteria is not likely, according to Oppenheim, in cases
with permanent cyanosis, disappearance of the radial pulse, trophic
disturbances, hyperidrosis, alopecia, fibrillary tremors, myokymia,
cramps, dilated and sluggish pupils, and weakening of tendon reflexes.
Hyperthyroidism also has been found by Oppenheim.
Shell-shock, explosion on left side: Sensory disorders especially on
left side; ecchymosis of right (uninjured) leg, possibly conditioned
upon shock of left hemisphere.
=Case 258.= (GERVER, 1915.)
An artillery officer had had a shell burst to the left side of his
horse, which veered to the right but did not fall. The officer’s left
hand immediately became so numb and weak that he could not hold his
reins with it; it shortly became more painful. The left foot showed a
tendency to the same anesthesia and paresis.
Curiously enough, a number of punctate hemorrhages appeared on the
right thigh and lower leg, upon the outer aspect. According to Gerver,
these hemorrhages into the skin of the _right_ leg may have something
to do with a disturbance of circulation related with effects wrought
upon the _left_ hemisphere. During the course of the disease, pains
occurred not only in the left arm and leg but also in the right leg.
_Re_ brain injuries produced by shell explosions without external
wound, Roussy and Boisseau have not found a single clinical instance
amongst 133 cases observed, which suggested cerebral softening, or
even hemorrhage into the brain substance, the cord substance, or the
meninges. These 133 cases were observed in army neurological centres
and contained instances of (_a_) mental disease (confusion, delirium,
amnesia), (_b_) nervous disease (astasia-abasia, tremors, paralyses,
contracture), and (_c_) an intermediary group (either mental confusion
with stupor, or hysterical deafmutism).
Shell-shock; unconsciousness: Hysterical deafness, speech-disorder,
gait. Recovery by reëducation. Brief relapse to deaf-mutism at noise of
drums. Improvement. Relapse to numerous and severe hysterical symptoms
at small guns fired on King’s birthday. Improvement. Speech wholly
regained in a quarrel. Recovery.
=Case 259.= (GAUPP, March, 1915.)
A musketeer, 22, had been blind for a time at 11 on account of some
spinal cord disease.
He was a soldier up to Christmas eve, 1914, when he was hurled backward
in a trench in the Argonne by an exploding hand grenade. He lay
unconscious for several hours, though without sign of physical injury.
Coming to his senses, he worked himself out of the trench and crawled
to another, but again fell unconscious. When he awoke he was in a
physician’s care in quarters, to which he had been taken by ambulance
men. Thence to the field hospital, and then to a private hospital at B.
Upon admission, January 17, he was hard of hearing on both sides, and
his speech was peculiar: choked off and retarded. His gait was heavy,
on a broad base. He was subject to headaches.
Exercises gradually improved the speech and the walking disorder was
quickly overcome. February 5 came a relapse through fright at the
rolling of drums near by. Speech was completely lost, deafness set in,
and the patient ran restlessly to and fro in tears. After a few hours
speech returned with still some minor difficulty.
From time to time came fainting spells and attacks of disorder of
consciousness, with loss of orientation and the idea of being in the
trench or under cover. He would ask whether it were raining through.
His mood herein was at times cheerful and excited. Speech further
improved from the middle of February, as well as did the other
symptoms.
On the King s birthday, February 25, occurred another relapse due to
his hearing small guns fired: Apathetic stupor, clonic spasm, aphonia,
abasia, severe deafness, poor sleep, refusal of food. The next day
he was still mute, but the spasms had ceased. He lay apathetically
in bed, taking a little liquid food. February 27 he was still mute,
though more active, not deaf, getting up alone, walking unsteadily on
a broad base, and playing cards at the table. March 2 the word _yes_
was again enunciated. March 3 he talked more freely and took a short
walk. March 4 speech of a sudden came completely back on the occasion
of getting excited in a quarrel among some other patients. The patient
thereafter began to talk a great deal, was bright and cheerful, but
still complained of a variety of nervous troubles. Speech was somewhat
difficult, but he was free from any definite aphasia or paraphasia.
_Re_ Shell-shock deafness, Jones Phillipson states that concussion
deafness is due to three contributory factors: (_a_) cerebral
concussion, (_b_) fatigue (violent oscillation of the perilymph,
continued noises, strain of organ of Corti), and (_c_) temporary or
permanent disorganization of the conductive apparatus.
_Re_ concussion deafness, J. S. and S. Fraser found in four cases
of actual explosion injury, a ruptured drumhead and hemorrhage into
the fundus of the internal meatus in three cases. They did not find
evidence of neuro-epithelial changes. Possibly the fundus hemorrhages,
besides giving rise to deafness, may start up the tinnitus and
giddiness that are sometimes found. In one case, there were changes in
the delicate nerve endings of the auditory ampullae.
Shell-shock: Deafness
=Case 260.= (MARRIAGE, February, 1917.)
A shell burst behind an English lieutenant in 1914 without causing
any wound but making him unconscious for an hour. During the hour
the Germans passed by and stripped him of all articles of value. He
came to and felt himself markedly deaf in both ears with an intense
headache. There was no hemorrhage, no discharge, no tinnitus, no
vertigo. Four days after the shell burst he could hear spoken words on
each side at two feet, but could not hear a watch that could usually
be heard from 3½ to 4 feet. With tuning fork C air and bone conduction
proved much subnormal, though air conduction was better than bone
conduction. With tuning fork C-5 air conduction was subnormal. Drums
healthy. Improvement followed; hearing became normal eighteen days
after explosion. The treatment was rest in bed with bromides early and
strychnine later.
Marriage states that the psychical deafness due to shell-shock is
usually bilateral and absolute. It is accompanied also, as a rule, by
other nervous signs and symptoms, such as aphonia, tubular vision,
paralyses, and anesthesias. Milligan and Westmacott state that the
deafness is due to a functional suspension of neuronic impulses. They
regard the brain as in a state of physical fatigue, and the mind as in
a state of strain. There is no organic lesion. The neuronic impulses
which are temporarily suspended are those which run from the higher
cortical cells to the periphery.
Mine-explosion: Unconsciousness: Deaf-mutism. Recovery of speech after
epistaxis and fever.
=Case 261.= (LIÉBAULT, October, 1916.)
A soldier, 24, teacher in civil life, was in a mine explosion November
27, 1914, at Vienne-le-Château. He was unconscious six weeks and
remembered nothing of what had passed. They had told him that he
had been blind for a month. After regaining consciousness he was a
deaf-mute and for seven months he did not speak. His mutism did not
bother him, as he thought he had always been mute. He had always been
able to write. He could not remember what had interfered with his
speech or tell whether he could think the words which he could not
utter.
May 22, 1915, there was considerable nasal hemorrhage, with fever. Upon
this day he began to speak, at first a few words, telegram style, and
with aphonia. A week later his voice returned. He was very irritable
during the period of mutism and had ideas of persecution and of suicide
and complained of becoming easily fatigued and exhausted.
His voice, however, became completely normal again and his respiration
better. On the spirometer he breathed four liters, but still got out of
breath easily. His diaphragmatic respiration was still imperfect. His
deafness remained at the time of report about as before, though he had
now been hearing for some time a slight resonance of his own voice and
could hear sounds emitted a few centimeters from his ear. At time of
report there was still general fatigue with insomnia.
_Re_ war deafness, Castex states that not merely shell bursts and
explosions are able to cause deafness, but the din of battle alone.
There are two big groups of war deafness: one due to drum rupture,
and the other due to labyrinthine shock. Labyrinthine shock--a much
more serious matter--is produced when a big shell bursts. In these
cases, the labyrinthine disorder is simply of the same general nature
as _commotio cerebri_. The labyrinthine shock cases often need to be
retired permanently from the front.
Shell-shock: Deaf-mutism.
=Case 262.= (MOTT, January, 1916.)
A deaf-mute, 24, not of a neurotic temperament or of a neuropathic
predisposition, was admitted to the Fourth London General Hospital
November 16, 1915.
He wrote, “I left England the 8th of March, and went to Gallipoli on
the 26th of May, and about the middle of August, one of our monitors
fired short. I felt something go in my head; then I went to the Canada
Hospital. They said it was concussion.” He had seen the monitors
firing. He came to in a dug-out about an hour afterward. He was quite
deaf and his head felt as if it would burst.
He could see and speak a little but lost his speech completely when
Barany’s tests were applied. The headache then passed away, leaving the
deaf-mutism. The ears, on examination, proved normal. The patient was
able to cough and whistle. He wrote his wife a letter, telling her how
he killed a Turkish woman sniper, but he did not remember that he had
written the letter. Although he said he did not dream, while asleep he
would assume the attitude of shooting with a rifle, as if pulling a
trigger, and then the attitude of using the bayonet: the right parry,
the left parry, and the thrust. Sometimes while asleep he would jump as
if a shell were coming, and he would catch his right elbow as if hit
there. He would then open his eyes wide and look under the bed. Then he
would wake up and begin to cry, but without sound. Just such habitual
attitudes occur in soldiers under anesthesia. In hypnotic sleep,
although he trembled at his trench experiences, he did not assume these
defensive attitudes.
Mott states in his Lettsomian lectures that hearing is often absolutely
lost, but that sometimes a man is absolutely deaf on one side alone,
either from the ruptured drum or from the violence with which wax has
been driven against the drum. Mott speaks of the frequency of auditory
hallucinations, and of hyperacusis--part of the patient’s general
hypersensitivity--which may increase the violence of the neurosis and
especially aggravate the headache.
Shell-shock: Deaf-mutism; convulsions and dream.
=Case 263.= (MYERS, September, 1916.)
A private, 28, was seen by Lt. Col. Myers at a base hospital. This
deaf-mute wrote, “I was standing and a shell bursted and that is all
I can remember.” This might have happened six days previously. The
patient wrote vaguely about a walk to “windy corner”; about being
billeted in a dug-out, a train journey, and another hospital. He was
deaf, deficient in sensibility throughout, especially in the left arm
and left side of the face, and had severe headache. Two days later he
started distinctly when hands were clapped while he was writing, but at
the next hand-clapping there was no response.
After Lt. Col. Myers wrote down, “Imitate me,” and made consonant
sounds, the patient succeeded imitating them. “You hear me a little
now,” Lt. Col. Myers wrote. “Is this the first time you have spoken?”
Patient replied, “I hope the Lord I can get my speech.” “But you did
speak just now. Read this word. Say it.” Whereupon he was got to say
his name and number.
The therapy was proceeding properly when suddenly he was seized with
convulsions, limb movements chiefly clonic, back arched, eyes starting,
later upturned. The patient pulled out a crucifix from a locker near
the bed and regarded it ecstatically (pulse 85, corneal reflexes
preserved). Three minutes later there was quieting down, and the
patient was induced to talk. He began to talk about his wife. He had
just been “seeing a farm and all the fighting.” A shell must have come
in there. He had “seen the Lord Who saved him.” Intense headache and
thirst followed. According to the patient the excitement was due to
recovery of speech.
He later said, “It was just like a dream when I came to. I was sweating
awful. I was seeing the Lord while I was in the farm by the Captain. I
dreamed that I had the cross in my hand to meet him coming. I saw the
trenches and the dug-outs and the wife.” In point of fact, the Captain
at the farm had had his arm blown off, and he had found him lying on
the straw unconscious. Under hypnosis it appeared that he had gone to
a dugout from the farm and that at the clearing station he had been
“raving, seeing things, shells, trenches, and things like that, sir.” A
slow recovery was made after evacuation to England. Seven months later
he returned to the front.
This case appears to belong to the B group of mutism cases,
according to the classification of Myers, namely, to the group
in which the effects are psychical rather than physical.
According to Myers, whether mutism occurs as an apparent result
of physicochemical or of mental causes--that is, as an A or a
B case--it is _actually_ always the result of mental--that is,
psycho-physiological shock. Mutism in the A cases of physical
nature, where the shock must have been grosser and more
profound, generally proves more severe than in the B cases.
As to the appearance of unconsciousness, apparently confirmed
by the patients’ statements that they “lost consciousness,”
it is a question whether these cases are not really cases
of deep stupor. According to Myers, the mutism is in nearly
every instance closely dependent on some form of stupor, being
generally the relic of such stupor after it has passed off.
Let the loss of consciousness be a profound stupor due to
the lifting or burial of the patient, then from this stage
there will be a transition to a state of ordinary stupor in
which intelligence is active but the patient is unresponsive
to stimuli. The patient is in a condition called by Myers
_excommunication_, in which the inhibitory process may be
regarded as protecting the individual against further shock. As
the stupor now passes away, it is natural that the inhibition
should appear lost in the case of hearing and speech, which are
two main channels of intercourse with others.
Dumbness is, by far, the commonest disorder of speech,
occurring in about ten per cent of shock cases in the first
thousand cases of shell-shock seen by Lt. Col. Myers.
Stuttering and jerky speech have occurred in about three per
cent. Loss of voice is rarer.
As against the view of Babinski, that mutism, being curable by
suggestion, must have been produced by suggestion, Lt. Col.
Myers argues that the stupor preceding mutism is the antithesis
of suggestibility and is, in fact, a condition of extreme
_autofixity_.
Naval gun-fire effects on seaman: Aphonia. Two recurrences.
=Case 264.= (BLÄSSIG, June, 1915.)
A seaman from the _Derfflinger_ was brought into a naval hospital with
loss of voice, December 22, 1914, able to speak only in a whisper. As
a child he had had diphtheria, but recovered without complication. He
had always had a very well-controlled voice. Early in December he had
had a cold owing to sentry deck duty in bad weather. Two days after
the shelling of Scarboro,--December 16,--while in the munition chamber
of the big guns, he suddenly lost his voice. He had been greatly upset
during the firing of the guns. In two weeks he recovered speech.
February 12, 1915, he returned to the hospital with a complete aphonia.
This was immediately after the naval engagement in the North Sea.
Three days later he was treated with electricity directly applied to
the vocal cords. March 20 he was discharged with speech completely
recovered. As soon as he went on leave, however, his voice was lost for
the third time, and he was still aphonic at time of report.
Shell-shock MUTES observed, then DREAMED OF: MUTISM developed the
SECOND NIGHT after shell explosion.
=Case 265.= (MANN, June, 1915.)
A volunteer of 20 was made unconscious for a short time by a shell
explosion, but was still fully able to speak when brought to the field
hospital.
In the second night after the explosion, however, he dreamed that
he had lost his speech. In the ward, meantime, he had seen a number
of shell-shock mutes. Following this dream of aphasia, came several
weeks of mutism, which then cleared up. According to Mann, this is
experimental proof of the psychogenic origin of a mutism.
Mortar explosion: Hysterical deafness.
=Case 266.= (LATTES and GORIA, March, 1917.)
A young soldier, a peasant, fell down unconscious when a mortar
exploded killing several men. He regained consciousness a few hours
later but was deaf on both sides. He looked dazed and did not
spontaneously move, having to be called for meals. Communicating by
writing, he could tell all the details of the accident.
The laryngeal and corneal reflexes were absent and there was a
hyperesthesia and hypalgesia of the right side of the body. No
anatomical basis for the deafness could be determined.
Shell explosion: Onomatopoeic noises in ears.
=Case 267.= (BALLET, 1914.)
A Zouave was with his squad at Tracy-les-Val Church, October, 1914,
when the roof was burst in by a shell which wounded four men. The
Zouave felt a strange emotion with trembling, and whistling in his
ears. However, he helped his comrades into a neighboring car. From
that time forward, he was very emotional, and felt noises in his ear,
sometimes humming, sometimes whistling. At Compiègne Hospital a lumbar
puncture was made, perhaps with a therapeutic purpose, but this gave
no results. The noises were heard as a whistling _pseeee_ followed by
a _boom_,--an onomatopoeia recalling the whistling and bursting of
the bomb. There was, in short, no labyrinthine lesion, but merely an
obsessive mental phenomenon. There were no ear lesions objectively. The
man developed a stuttering some time after the humming and whistling in
the ear.
Injury of eyes by gravel from shell-burst: Photophobia, blepharospasm,
facial anesthesia, pains.
=Case 268.= (GINESTOUS, January, 1916.)
A soldier of the Ninth Engineers, 28, a Beaux-Arts student, was
wounded, December 19, 1915, by stones and gravel thrown in his eyes
by a shell-burst. The eyelids swelled and the eyes filled with tears.
He was treated at the relief station and then evacuated to Verdun.
The edema disappeared in five weeks, but it was impossible for him to
look at light. February 2 he was evacuated to Nice, where he received
the diagnosis of traumatic keratalgia, blepharospasm, and photophobia.
After eight days’ leave he went back to his corps; but the eye troubles
persisted and he was sent to the ophthalmological center at Angers, May
18, 1915.
Both his father, 67, and his mother, 58, were irritable and odd. Three
brothers and three sisters were also more or less neuropathic, and one
of the sisters had been in a hospital for the insane with a persecutory
mania. The patient had a daughter, fourteen months, well.
The man was a nervous, impressionable person, who wept at the slightest
emotion. With an effort of will he could open his eyes, but if one
tried to open them passively there was stout resistance. In the dark
the occlusion was not so complete. Both eyelids were wrinkled and
folded and made jerky, fibrillary movements. The conjunctiva and cornea
were normal (fluorescein test), but the palpebral conjunctiva was red
and injected. The patient said he had subcutaneous pains recurring at
irregular intervals above and below the left orbit, brought out or
exaggerated by pressure; but such pressure had no effect upon the lid
movements. Visual acuity was normal, but the use of ophthalmometer
was impossible, as was measurement of the visual field. There seemed
to be no disorder of chromatic sense. The reflexes could not be fully
examined; knee-jerks preserved. There was a zone of anesthesia to pin
prick, less marked to heat, on the whole left side of the face. W. R.
negative.
Shell-shock; burial; blow on occiput: Blindness.
=Case 269.= (GREENLEES, February, 1916.)
A man in the third Wiltshire regiment was buried in a shell explosion
and struck by a large mass of earth on the back of the head. When dug
out, he was found blind. It was thought at the time that the severe
blow at the back of the head had “concussed” the occipital cells for
sight.
Some months later the man was sent to Mr. Pearson’s home for blind
soldiers in London; but two months later was returned to Weymouth,
under Greenlees’ charge. He thought himself worse, since now he could
not see light at all. He had trained himself to take care of himself
and steered confidently aside from obstacles in walking about. He was
able even to learn the various colors by the sense of touch, according
to Greenlees; thus, blue was diagnosticated against red: according to
the patient, a piece of colored card always had a rougher feel if it
was blue than if it was red. In fact, his work consisted of making
colored net bags.
As to the possible interpretation of such a case, see Case No. 433 (man
who could see large letters sometimes).
_Re_ blindness, H. Campbell states that the number of cases of
hysterical blindness appears to be decreasing as the war continues. The
blindness he finds to be rarely an absolute one. As a rule, the vision
is merely blurred or there is a contraction of the visual fields. The
condition is much less frequent than that of deafmutism.
_Re_ hysterical blindness, Dieufaloy is cited by Crouzon as describing
a triad of conditions characteristic of hysterical blindness, namely,
(_a_) sudden onset, (_b_) preservation of pupillary reflexes, and (_c_)
normal fundus.
Shell-shock amblyopia (composite data).
=Case 270.= (PARSONS, May, 1915.)
Parsons describes a typical case of shell explosion amblyopia. After
more or less prolonged fatigue from marching and trench exposure,
the soldier is knocked down or blown into the air, and more or less
severely injured or wounded by concussion, fracture, bullets, or shell
splinters, losing consciousness, but perhaps not enough to prevent
automatic walking in a dazed state to the dressing station. Memory of
this phase is lost. The man is instantaneously stricken blind, possibly
also deaf; and possibly smell and taste are also lost. Blepharospasm is
intense; there is lacrimation; the lids are opened with such difficulty
that examination of the eyes is almost impossible (nor, according to
Parsons, have the pupils yet been examined at this stage).
In a week or two the blepharospasm diminishes, and the fundi, which
are found to be absolutely normal, can be examined. The eyes may be
found to be quite normal, the pupils reactive to light though perhaps
sluggishly and perhaps unequally. Sight is now somewhat restored, light
can be perceived, and large objects distinguished. The patient can
grope about and usually does not stumble against obstacles. The fields
of vision are markedly contracted, and more so than the avoidance of
obstacles in walking would suggest.
Vision is eventually recovered completely. The right eye (the shooting
eye) is often more deeply affected and recovers more slowly. Perhaps a
central scotoma may persist. Sometimes on manipulation of lenses the
full vision can be produced for the types. Parsons seeks to explain the
psychology of traumatic amblyopia in the light of deductions of Lloyd
Morgan, Mark Baldwin and McDougall.
Shell-shock amblyopia (excitement, blinding flashes, fear, disgust,
fatigue).
=Case 271.= (PEMBERTON, May, 1915.)
Pemberton calls attention to the following factors in a case of
amblyopia: First, excitement during a prolonged and somewhat critical
attack; second, overstimulation of eyes and ears due to brilliant
flashes, night firing from many batteries close together (the gunners
are always subject to temporary deafness from this firing); third,
natural fear from close bursting of shells; fourth, disgust at
decapitated and disemboweled soldiers; fifth, fatigue from twelve
hours’ work.
The artillery sergeant worked under heavy shell fire at Gun No. 1. A
direct hit killed three men serving No. 2 gun. The sergeant became
somewhat excited but worked his gun until the following dawn, when he
collapsed across one of the disemboweled corpses. He thus had been at
work for about twelve hours. The battery had fired 400 or 500 rounds.
A few hours later, the man was conscious but very feeble and much
shaken. There was amblyopia and contraction of the fields of vision to
rough tests, but no change in color vision. Taste sense was blunted,
and salt could hardly be told from powdered quinin tablets. Smell
also was practically absent, although he had never been able to smell
accurately. Hearing was not more affected than that of other men in the
battery, and there were no tympanic fractures. Both thighs, from about
the apex of Scarpa’s triangle to the knee, showed partial anesthesia,
such that a pin prick that should have been painful was felt only as
a tactile sensation, whereas lighter stimulation caused no sensation
whatever. The patient himself complained of numbness in these areas.
The gait was slow and spastic. The knee-jerks were brisk. Sent back to
the wagon lines for a week, the patient lost his sensory disturbance,
but the symptoms of mental distress increased. He walked weakly and
stiffly; he continually thought of the dead men at the next gun, one of
whom was a friend. He was finally sent to a hospital in England.
Shell-shock amblyopia.
=Case 272.= (MYERS, February, 1915.)
A private, 20, lay in the booking-hall of a station, October 28-29, not
securing much sleep; motored in a bus next day to another place at 7.30
p.m.; went into billets at 8 p.m.; mounted guard 10-11.30 p.m. and 1.45
to 3.45 a.m.; and went to the firing-line for the first time at 11 a.m.
October 31. The platoon advanced through two sets of trenches, which
were full, and had to retire. About 1.30 p.m. they were found by the
German artillery.
This man had been rather enjoying it and was in the best of spirits
until the shells began to burst. The platoon was retiring over open
ground. He was kneeling on both knees, trying to creep under wire
entanglements, when two or three shells burst near by. Three more
shells burst behind and one in front. The escape was described
by an eye-witness as a miracle. He managed to get back under the
entanglements and into the trench, and shortly, as the fire slackened,
rejoined his company.
His sight had become blurred immediately after the shell burst. Opening
his eyes hurt him, and the eyes burned when closed. The right eye
“caught it” more than the left. At the same time, he was seized with
shivering, and cold sweat broke out, especially about the loins. He
thought the shell behind caused the greater shock, like a punch on the
head without pain. The shell that burst in front had cut his haversack
away, bruised his side, and burned his little finger. This shell he
thought caused his blindness.
He was led to the dressing station by two comrades, opening his eyes
to see where he was going but finding everything blurred except
immediately after opening his eyes. There was no diplopia. Objects
seemed to dissolve. He was weeping and worrying about becoming blind.
The horse ambulance took him to a hospital and thence to another
hospital, and thence he went by motor ambulance at night to the
starting point, where he arrived five days after he had entered the
field. He could remember nothing about the ambulance trips. There
was a slight deafness which soon passed off. In hospital he shivered
almost incessantly in bed, and he kept thinking about his experience
and the shell bursting. The shivering ceased November 3. No micturition
from the afternoon of October 30 until the afternoon of November 2. No
movements of bowels from October 30 to November 5.
It seems that this soldier had been for two months in the Aisne
district, sleeping badly on account of lumbar pains and toothache.
There had been albuminuria, and the patient said he had failed to pass
a medical examination. The fields of vision were found to be distinctly
contracted. There was difficulty in taste and smell, which the patient
said he had lost since the shell-burst.
Hypnosis was tried but the patient “insisted on resisting.” The
suggestions were offered during the concentration period. November 13
taste and smell began to return and the fields of vision were less
contracted. He was transferred to England for further treatment, and by
November 27 had become much improved and not so “nervy.” February 1 he
had begun to attend hospital as an out-patient.
SHELL WINDAGE (NO EXPLOSION): Multiple affection of cranial nerves.
=Case 273.= (PACHANTONI, April, 1917.)
August 22, 1914, a French officer was leading his company to an attack
and carried on, though wounded in the side by a bullet. Suddenly he
felt as if he had received a terrible blow with a hammer on the left
cheek and eye and as if his arm had been torn off. He fell to his knees
without losing consciousness. _There had been no explosion_, and none
of his soldiers had been hit. He felt of his arm and carried his hand
to his head to make sure of the wounds. There were none, but he was
bleeding from the nose and the mouth. His left eye was closed and his
left cheek drawn “by an invisible hand.” His tongue had swollen until
it had to be pushed out of his mouth. He was breathing hard. He fell
upon his side without losing consciousness and he was carried by his
men to shelter in a trench. Placed on his back he felt that he could
not lift his head as “it had become too heavy.” His voice was lost.
He could neither cough nor spit. In order to get air he had to remove
bloody saliva from his mouth with his finger. The left side of the
head was swollen. On opening his eyes he could no longer see with the
left eye. His cheek was covered with ecchymoses but without wound. A
few hours later he was made prisoner by the Germans. For two months he
had an increase of temperature every evening and for three months he
lost his voice. Six months later there was still visual impairment.
He was anesthetic in the left cheek, unable to chew, paralyzed in the
left facialis region. There was alteration of taste, with atrophy of
the left side of the tongue deviating to the paralyzed side, and nasal
regurgitation. There was continual drooling and convulsive coughing. In
dorsal decubitus the head could be lifted with difficulty. There was
a kind of paresis of the esophagus, as he felt the bolus stop at the
level of the third ribs so that with each mouthful he had to swallow
a little water. Apparently he had a paralytic state of the following
nerves: optic, oculomotor, trigeminal, glossopharyngeal, pneumogastric,
spinal accessory and hypoglossal. There was evidence of a slight old
tuberculosis at apices. The man was slightly pale. There was an atrophy
of the optic nerve and some retinal swelling. No pupillary reactions
to light on the left side; but the accommodation reflex and sensory
reaction were preserved. Divergent strabismus of the left eye. The
taste on the left side and on the anterior part of the tongue was
slightly diminished. Diminution of galvanic and faradic excitability on
the left side of the face. No reaction of degeneration. Bitter, salt
and sweet tastes altered. Left-sided atrophy of the tongue. No reaction
of degeneration in the tongue and thyroid muscles although there was a
marked diminution in faradic excitability.
The author records this case of multiple lesions of cranial nerves
as due to shell windage. Thirty-one months after the onset of the
paralysis the cranial nerves, although manifestly regenerated, had
not regained conductivity. The officer was examined by Pachantoni at
Louèche-les-Bains in Switzerland.
_Re_ windage, see remarks under Case 201.
Wound of thigh: Claudication, vasomotor disorder, hypothermia, but
no exaggeration of tendon reflexes. Under CHLOROFORM, ELECTIVE
EXAGGERATION OF REFLEXES, _i.e._, in this case, hyperreflexia of
affected thigh, including patellar clonus, after other reflexes
(including conjunctival) had become extinct. The case described led to
the new formula of THE PHYSIOPATHIC SYNDROME (BABINSKI).
=Case 274.= (BABINSKI AND FROMENT, 1917.)
Babinski examined in August, 1915, at the Pitié, a soldier who had
been wounded in the upper and outer part of the thigh. He showed a
most marked claudication with outward rotation of the foot. There was
a muscular atrophy of the thigh but no appreciable disorder of the
electrical reactions. There was a slight limitation in the movements of
the hip, namely, the movements of flexion and internal rotation of the
thigh upon the pelvis; yet this limitation of movements did not seem to
be in proportion to the rest of the motor disorder. The X-ray showed
no joint lesion. The right knee-jerk was a bit stronger than the left,
though this was controversial. Achilles reflexes were normal and equal;
epileptoid trepidation of the foot, and clonus of the patella absent;
the limb showed marked and permanent vasomotor disorders and local
hypothermia; both phenomena were of a sharp and definite nature.
On the basis of the intensity of these vasomotor disorders, Babinski
felt that, in accordance with his general ideas, he was not dealing
with hysteria, and that he was in fact dealing with the so-called
physiopathic syndrome. Lacking for this syndrome was the exaggeration
of the tendon reflexes of the affected limb. Might it not be that the
improper attitude and muscular stiffness of the limb were based simply
on retractions of tendons? The patient was chloroformed. This procedure
was the more warrantable as a number of physicians had thought of the
patient as an exaggerator or even as a simulator. Under chloroform
there was in fact a slight tendon retraction; yet on the whole it
was clear that the attitude and stiffness of the limb were largely
dependent upon a contracture. When during narcosis all the other tendon
reflexes and skin reflexes had become extinct, there was still to be
observed on the affected side a hyperreflexia, and even a clonus of
the patella; and the clonus lasted an hour after recovery from the
anesthetic. This curious phenomenon of elective exaggeration of tendon
reflexes in narcosis, Babinski has observed to be not infrequent.
It is a valuable diagnostic sign for a sure proof of excess tendon
reflexes in cases where doubt prevails under ordinary circumstances.
Sometimes the contracture will yield, but only in the deepest sleep,
outlasting even the conjunctival reflex and the reactions to pricking
of the normal extremities. Moreover, the contracture would return from
20 to 25 minutes before any manifestation of consciousness. If an
endeavor was made to reduce the contracture under full anesthesia and
in complete unconsciousness, a spasmodic movement was provoked which
exaggerated the abnormal attitude of the limb. Sometimes even the leg
would be thrown into flexor contracture.
The case above described was the one which led Babinski to his new
formula of the PHYSIOPATHIC SYNDROME. This he describes in general
terms as follows:
These disorders consist in post-traumatic contractures, paralyses
or paretic states, but are not attended by any of the signs of the
so-called organic diseases, either of lesions of the central nervous
system, or of the peripheral nervous system, or of the great arterial
systems. In fact, these disorders somewhat resemble hysterical
manifestations. The underlying lesions appear to be sometimes
extremely small; in fact, so minimal as to be out of proportion with
the functional disorders that they produce. These disorders do not
correspond with any known anatomical regions, but they are singularly
tenacious, and, unlike truly hysterical (pithiatic) phenomena, they
are completely resistant to suggestion. Yet it is not merely in
resistance to suggestive therapy that these reflex disorders differ
from hysteria; for besides the contracture and the paralysis or
paresis found in the different segments of the extremity concerned,
the complete Babinski syndrome includes also muscular atrophy,
exaggeration of tendon reflexes, alterations of skin reflexes (even
amounting to areflexia), hypotonia, mechanical over-excitability of
the muscles with retardation of the muscular contraction; quantitative
changes in electrical excitability of muscles (excess or diminution
without R. D.), mechanical over-excitability, and occasionally
electrical over-excitability of the nerves, disturbances in objective
and subjective sensibilities (anesthesia and pains), heat regulation
disorders (especially hyperthermia), and disorder of the vasomotors
(cyanosis, skin redness, oscillometric lowering at the periphery of the
extremity in the presence of low temperature), secretory disorders, and
various trophic disorders of the bony system, the skin, and the nails.
Despite the permutations and combinations of these symptoms, according
to Babinski they amount to a new group of disorders and represent a
nosological species: a species of disease phenomena that lies midway
between the organic affections and hysterical disorders. Babinski
proposes the term _physiopathic_ for these phenomena, a term which
excludes the connotation of hysteria and all forms of psychopathia, on
the one hand, and seems, on the other, to express the fact of their
correspondence to a physical material perturbation in the nervous
system of a novel sort.
Bullet wound of ankle: Contracture effect of chloroform.
=Case 275.= (BABINSKI AND FROMENT, 1917.)
A man was wounded, September 1, 1914, by a bullet in the left ankle.
Contracture of the foot and of the four outer toes in extension
followed, with a flaccid paralysis of the great toe. The left knee-jerk
was a little stronger than the right; the left Achilles jerk also
appeared weaker but observation was difficult on account of contracture
of the foot.
Chloroformed, October 22, 1915: There was no sharply defined
asymmetry of the tendon reflexes. The left Achilles reflex appeared a
little weaker. In the phase of muscular resolution, the contracture
disappeared entirely, but it reappeared a little after the return of
the tendon reflexes. The reappearance of the _contracture preceded_ the
reappearance of _consciousness_ from twenty to twenty-five minutes.
Post-typhoidal reflex or physiopathic disorder of right leg. Elective
exaggeration under chloroform.
=Case 276.= (BABINSKI AND FROMENT, 1917.)
A typhoid patient, October 20, 1914, showed phlebitis and abscess of
the right buttock with contracture of pelvic trochanteric muscles. He
was sent to the Pitié on medicolegal grounds.
September 22 there was found a slight laxity of the patella tendon, as
well marked on the left side as on the right. The right side was more
cyanotic, due to the inactivity of the limb. There was no edema. Tendon
and skin reflexes were normal. The lack of power was diagnosticated as
purely functional, and the report was rendered that the soldier could
begin to walk as soon as he desired. The two knee-jerks were noted to
be stronger and polykinetic, and the right knee-jerk appeared a little
stronger.
The patient was chloroformed, October 25, 1915. Almost immediately,
the knee-jerks, Achilles jerks, plantar, and cremasteric reflexes
disappeared. During the first period of anesthesia, there was no
accentuation of the reflexes, but at the beginning of recovery the
anticipated reappearance of the _right_ knee-jerk was observed. This
knee-jerk was already sharply defined at a moment when the left
knee-jerk was still abolished. In a later phase of recovery, the
right knee-jerk was very markedly exaggerated and a patellar clonus
was demonstrable on the right side. Even percussion of the _left_
patellar tendon brought about a contraction of the _right_ adductors.
There was a true clonic and tonic spasm of these muscles. On the other
hand, percussion of the right patellar tendon was able to provoke no
contraction of either right or left adductors. Nor was there at any
time any ankle clonus.
Hysterical lameness (bullet wound of calf) cured, but the associated
“reflex” disorder (in the sense of Babinski and Froment) NOT cured.
=Case 277.= (VINCENT, April, 1916.)
A corporal was wounded by a bullet in the calf, September 8, 1914. At
the end of July, 1915, his lameness continued and he disliked to lean
on his left leg which bent under him. There was a slight atrophy of
the left calf. The lower leg could not be extended upon the thigh if
the foot was in dorsal flexion, and the dorsal flexion of the foot
was itself limited. There were no reflex, vasomotor or electrical
disorders. The man was given the usual treatment by Vincent and soon
learned to carry his body on either foot, and, being well disposed,
speedily abandoned his lameness, acquiring such skill in movements that
he became monitor over the other soldiers, watching over them in his
capacity as corporal.
For about a year he thus served as monitor, and when fully dressed
did not seem abnormal or look as if he were walking lame. However,
after walking, say 6 kilometers, rapidly, he dragged his leg; nor
was extension of the lower leg upon the thigh absolutely complete in
habitual walking, though he was able to extend perfectly if requested.
Dorsal flexion of the foot was also still somewhat limited, and the
measurements of the two lower extremities at both calf and thigh showed
a persistent slight atrophy on the left side. He was then sent into the
auxiliary service and did good work as draughtsman. In the winter the
left foot got cold rather easily.
This case is instanced by Vincent to support the contentions of
Babinski and Froment that the truly “physiopathic” or “reflex”
disorders do not completely clear up in the recovery from the
associated hysterical disorders. That limb, which is the seat of
physiopathic disorder, is not in a state of meiopragia.
Foot trauma: Pains and dysbasia, hysterical; slight atrophy of calf,
physiopathic. Differential disappearance of hysterical symptoms;
increase of physiopathic symptoms.
=Case 278.= (VINCENT, April, 1917.)
Clovis Vincent examined a man who had been wounded in the foot but
without injury to the bones. He was first examined in July, 1915, when
he complained of foot pains and was walking with crutches. The left
calf was smaller than the right (4 cm.). The tendon reflexes were
normal. There was no abnormality of electrical reaction. There was
no proportionality between the trouble with walking and the organic
status. A large part of the trouble appeared to be hysterical. In fact,
upon treatment, the man was soon able to abandon the crutches and to
walk, though lamely. He was put into the auxiliary military service.
However, the pains grew more marked and the lameness increased.
Incapable of working, the patient was sent to the neurological center
at Montpellier, whence he came to the neurological center at Tours
in September, 1916. He had never been confined to bed, and had never
ceased his daily walking, aided by a cane. The walking disorder was
very pronounced. The patient said he was still suffering much. The
difference between the two calves was now 8 cm. and the thigh was
atrophied, though the atrophy had been absent in July, 1915. There was
hyperexcitability of leg muscles. The right foot was colder than the
left. The hysterical phenomena, so pronounced in July, 1915, were now
absent, yet the reflex phenomena were sufficient to invalid the man.
Shell-shock paraplegia may AFTER TWENTY MONTHS develop vasomotor and
secretory disorders: The whole to vanish on treatment.
=Case 279.= (ROUSSY, April, 1917.)
A foot chasseur, 22, a farmer in civil life, sustained shell-shock _à
distance_, June 2, 1915. He had no wound, but lost consciousness. He
was evacuated for “contusion of back” to a hospital June 4 to 12; for
“contusion of back and _commotio cerebri_” to Portarlier, to July 21;
for “internal contusions and _commotio cerebri_” to Besançon, where he
was in three hospitals up to May 31, 1916, and the diagnosis “hysteria,
old _commotio cerebri_ and trepidant astasia-abasia” was rendered and
psychotherapy tried. The man was then evacuated to Saint Ferréol and
the diagnosis “hysterical paraplegia” rendered. He finally reached
Veil-Picard in February, 1917, still victim of paraplegia.
Up to this point there had been no signs suggestive of organic lesion
of the spinal cord or any hysteroörganic intimation whatever. But in
February, 1917, besides the motor disorder there was a hypothermia of
several degrees, with cyanosis and hyperidrosis of both feet, with a
marked diminution (and absence on one side) of the plantar cutaneous
reflexes. The man was also victim of “hysterical pregnancy.” The
cyanosis, hypothermia and hyperidrosis lasted six weeks.
March 23 the man was given treatment and for the first time in 21
months was able to stand and walk. The foot now turned from blue to
red, and instead of cold became warm, even hot. In about a week the
hyperthermia diminished, and, with the other troubles, disappeared.
There remained only a slight swelling of the foot and ankle joints, due
to the painful exercises given the patient.
It would seem, then, that a hysterical paraplegia of long duration may
finally associate itself with marked vasomotor and secretory disorders
and that these may be altered with extreme rapidity on the very day in
which the hysterical phenomena are removed, and quite disappear in a
fortnight.
Tetanus clinically cured: Phenomena in part reproduced UNDER CHLOROFORM
ANESTHESIA five weeks afterward.
=Case 280.= (MONIER-VINARD, July, 1917.)
An infantryman, wounded at Notre Dame de Lorette, May 9, 1915, by a
shell fragment in the right popliteal space, was given a preventive
injection of 5 c.c. of antitetanic serum, evacuated to a hospital, May
12, and developed signs of tetanus August 1, with trismus and pains and
spasms in the right leg.
The disease progressed with dysphagia, stiffness and paroxysmal
hypertonia of the legs, especially of the right leg, fixed orthotonus
of the trunk, neck hyperextended, arms stiff but able to move.
Antitetanic serum was given daily. At the end of eight days there was a
marked improvement and the whole course ran to approximate recovery in
25 days from the onset of tetanic symptoms, at which time the man was
able to get up and walk on a crutch. The external popliteal nerve had
been sectioned, and the foot was in a marked equinovarus.
Chloroform was administered for the purpose of straightening the foot,
September 2, that is, about five weeks after the apparent end of the
tetanus. The first stage of the anesthesia lasted about two minutes,
but at this point the trunk and leg muscles passed into a state of
diffuse contracture. In fact, a _tetanic syndrome_ took place _in
the midst of the anesthesia_. At a time when the corneal reflex was
completely abolished, it was still impossible, with the exertion of
the greatest strength, to flex the segments of the lower extremities.
Moreover, the trunk was stiffly extended and the jaws were in trismus.
Tonic and clonic contractions were produced by the efforts made to
straighten the foot, and these contractions passed from the right
side to the left. The chloroform was now increased and a transient
resolution of the muscles was obtained, lasting hardly more than a half
minute. As all efforts to reduce the pedal deformity failed, anesthesia
was stopped. The contractures and paroxysms lasted a few minutes. The
knee-jerks were extremely exaggerated and there was a bilateral ankle
clonus. After a brief phase of excitement, the patient emerged from
anesthesia, began to talk with his comrades, and ate his usual meal
without inconvenience. The chloroform anesthesia had lasted twenty
minutes, and 60 grams had been administered.
It was now determined to section the tendo Achilles and the tibialis
posticus. September 8 the man was chloroformed again and the same
phenomena were exactly reproduced. Sixty grams of chloroform was again
administered. The tendon resections permitted placing the foot in the
proper attitude. Next day the patient was examined neurologically.
The skin reflexes were found normal. The Achilles and knee-jerks
were somewhat exaggerated, but equal on the two sides. There was
no ankle clonus. Sensations proved normal. There was a mechanical
hyperexcitability of the muscles of the anterior aspect of the thighs
and of the calf.
In another case chloroformed 17 months after recovery from tetanus
no such phenomena appeared. It would seem that the impregnation with
tetanic virus or toxin must last in the nervous system a good deal
longer than the apparent disease clinically lasts, but that this
belated and concealed intoxication eventually passes.
The phenomena are perhaps _analogous to_ those of _Babinski and
Froment’s_ so-called post-traumatic physiopathic or _reflex phenomena_.
It was following the special work of Babinski and Froment upon the use
of chloroform anesthesia in detecting physiopathic conditions that
Monier-Vinard made his observations in cases of tetanus.
Shell-shock from falling of shell at a distance: Hysterical hemiplegia,
terminating in brachial monoplegia. Case to show that the reflex or
physiopathic disorders of Babinski and Froment may occur without
mechanical injury in the region involved.
=Case 281.= (FERRAND, June, 1917.)
A soldier of the class of 1917 who never went to the front, while
in training at Belfort, felt violent emotion on the occasion of
the falling of a big shell in the town of Belfort. The explosion
was a good distance from him. He lost consciousness a few moments,
February 23, 1917, and almost at once found himself unable to move
his left side. He was hemiplegic three months, but his leg shortly
regained power. December 23 he entered a neurological center with his
arm flaccid and a paralysis affecting the shoulder also. There was
an almost complete anesthesia of the arm terminating in segmentary
fashion about the shoulder, and the whole of the left side was slightly
hypesthetic, although there was no disorder of motion except in the
arm. The tendon reflexes of the left arm were exaggerated, and there
was even contracture upon percussion of the muscles themselves.
Percussion of the thenar and hypothenar eminences produced movements
of the hand. There were several vasomotor disorders. Percussion
led to large vasomotor plaques, and rubbing of the skin produced a
reddening which passed away slowly. The hand was red and cold. Slight
electrical hyperexcitability of flexors with feeble galvanic current;
excitation of the extensors not associated with any contractions of the
antagonist muscles. Threshold lower for flexors on the affected side
in the forearm. Half centimeter atrophy of the biceps. The forearm and
hand were possibly slightly increased in volume from a blue edema of
the dorsal surfaces. The man was very timid, complained little, and
accepted all treatment, which, however, was not very effective. This is
presented by Ferrand as a case with physiopathic disorder in the sense
of Babinski and Froment, though it does not present any sign of organic
lesion whatever.
Shell fire: Delayed shell-shock symptoms, sub-lethal, appearing in
England.
=Case 282.= (MCWALTER, April, 1916.)
A soldier was picked up insensible in the public street and brought
to hospital by ambulance, unconscious, breathing stertorously, pupils
dilated, lips parched, unresponsive to stimuli, but without signs of
injury or alcoholism.
The pulse grew slower, the respirations more sighing, the heart-beat
more diffused and labored; but towards evening, about eight hours
after admission, he began to move the eyelids and lips, and muttered a
response to the request for his name. After ten more hours, respiration
grew better, and Croton oil led to a movement of the bowels. Natural
sleep intervened, and 18 hours after the onset of unconsciousness, the
man woke up, and in the course of a few days became fairly well though
still dazed and confused.
This soldier had never received any definite injury in his war service,
but McWalter attributes his break-down to the effects of the constant
shocks from the bursting of shells, and the scattering of shrapnel.
McWalter generalizes that a soldier, in the course of some civil
occupation _after_ the war, might develop symptoms, even fatal
symptoms, and still the death in the case would be a direct consequence
of the war.
Shell-shock symptoms, some initial, with recovery--others late and
gradual, with deterioration.
=Case 283.= (SMYLY, April, 1917.)
A soldier became blind, deaf and dumb, as well as paralyzed, as a
result of shell explosion. When he arrived at the hospital, he was
able to see but had visual hallucinations. In a few days he recovered
his hearing. There was a fine tremor of the hands, controllable by
suggestion. There was an almost complete amnesia, but the patient
remained able to read and write.
The pain persisted several months. The patient was physically well
and seemed perfectly intelligent despite his aphasia and amnesia.
One night, he sprang out of bed, shouting, “The guns are coming over
us!” and from that time forward was able to speak. Amnesia, however,
supervened for the months in the Dublin Hospital, and the patient
believed that he was still in France. He also became unable to read or
write, and was unable to recognize any letters except those he had been
taught to speak during his period of dumbness. Still later he got a
flaccid paralysis of the legs. From seeming perfectly intelligent, he
began to seem markedly deteriorated. Hypnosis with waking suggestions
had no power upon him. After a time, intelligence reappeared, but there
had not been any recovery of locomotion at the time of report.
Wounds, gas, burial: Collapse on home leave.
=Case 284.= (E. SMITH, June, 1916.)
A non-commissioned officer went through the first eleven months of the
war in France and Flanders and was subjected to every kind of strain
therein. He was wounded twice, gassed twice, and buried under a house,
in each instance being treated in the field ambulance and returning to
the trenches. Some time thereafter he was granted five days’ leave.
On reaching home, while waiting for a train, the officer suddenly
collapsed and became unconscious. For months thereafter, he was the
subject of a severe neurasthenia; “the whole of his trouble seemed
to be due to the dread, lest on his return to the front, the added
responsibilities which would fall upon his shoulders might be too
much for him.” He thought his intelligence had been numbed by his
experience. He thought his memory was unreliable, and that he could
understand neither complex orders nor even the newspapers.
As to the reason for his maintenance of composure at the front, this
may be laid to the excitement, the officer’s sense of responsibility,
and the example he felt he should set his men. This kind of case
“demands a great deal of patient and sympathetic attention before the
real cause is elicited, and then months of daily reëducation to build
up anew the man’s confidence in himself.”
Bullet wound of neck: Late sympathetic nerve effect.
=Case 285.= (TUBBY, January, 1915.)
A Belgian was wounded, October 21, 1914, at Dixmude. The bullet
wound was just below the right mastoid process. He was admitted to
the London General Hospital, October 29. He said that the bullet had
passed into the tonsil, lodging there, but that on the third day, while
vomiting, he brought up the tonsil with the bullet in it. There was in
fact a large ragged wound at the site of the right tonsil. He could
swallow fluids only, but articulated clearly. There was a question
of injury to the following nerves: facial, glossopharyngeal, vagus,
hypoglossal, spinal accessory, and sympathetic. None of these nerves,
however, appeared actually to have been injured. The difficulty in
swallowing was due probably to the faucial wound, and it is hard to
see how the pharynx could have been involved on account of the perfect
articulation. November 3 the right sympathetic nerve was slightly
affected; the right pupil was smaller than the left although it reacted
to light. November 12 the patient left the hospital and nothing
further is known of his history. Thus there was a late effect upon the
sympathetic nerve thirteen days after the wound.
_Re_ peripheral nerve disorders, see remarks under Case 252 (Tubby).
Fall from horse under shell fire: Crural monoplegia, hysterical.
Reminiscence? Autosuggestion?
=Case 286.= (FORSYTH, December, 1915.)
A patient of Forsyth had been exercising a high-spirited horse.
Artillery fire close by made the horse leap sidewise, and the rider
fell, his back striking the ground. He seemed to be curiously shaken
out of proportion to the gravity of the fall. In a day or so, he lost
the use of one leg.
He recalled a rather similar incident: He had taken a hand in a local
uprising in a distant quarter of the world. While he was escaping up
a mountain track, a rifle-shot from the enemy brought down his horse,
which rolled over and threw him violently against a boulder, where the
small of the back met the force of the impact. He felt intense pain and
lost consciousness. Upon recovery he found he was paralyzed. At the
end of several days, in a hiding-place in the rocks, he found himself
still unable to move his legs. The friend who had carried him to the
hiding-place refused to leave him. He thought of suicide, but then
discovered that he could move: at first, the big toes, then the ankles,
then the knees, and finally the hips. He was finally able to get into
the saddle.
Moreover, years before, he had heard that a man who broke his back was
paralyzed in the legs.
_Re_ autosuggestion, Babinski remarks that suggestion may work
in hystero-organic cases not precisely as in hysterical cases.
Autosuggestion may here replace or accompany the ordinary
heterosuggestion. Some temporary disturbance--a slight pain, a
trivial injury, or a mere bruise--may start up a complex process of
autosuggestion in which it may be difficult to unravel the part played
by the patient’s own reflexes, his previous experience and beliefs (in
this case, the reminiscences of a similar accident), the solicitude of
his friends, and the medical examination itself. Babinski believes that
hysterical paraplegia or monoplegia never appears automatically under
the influence of emotion; never appears after the manner of sweating,
diarrhea, or blushing.
Shell explosion; struck in cave-in: Symptoms in right leg (antebellum
experience).
=Case 287.= (MYERS, March, 1916.)
A private, 26 years old, had 11 months’ service and one month’s service
in France. He arrived at a base hospital the day after his shock.
Concussion had caused the dug-out in which he was standing to collapse.
A beam struck him on the left side of the face, and pinned him to the
ground on his right side. A piece of iron fell on the left side of
his back, and his right leg was pinned by a cross beam on the back of
his thigh. He was dazed by the shock; was released and was able to
walk, but complained of a pain in the right groin and a giving-way
of the right knee. The medical officer arrived about an hour later.
A numbness, or state of no feeling, in the right thigh appeared, and
increased to the point of total analgesia to the level of the upper
margin of the patella save for a narrow strip in the mid-line on the
posterior aspect of the leg. The only area of complete anesthesia and
algesia was on the outside of the lower half of the leg.
According to the patient, it seems that about three years before, he
had been buried four feet deep in a brick yard, beneath a heap of
clay. He had felt it most in the right leg, but the thigh had been
merely stiff and sore, and not numb. The patient admitted that the
present accident immediately reminded him of his previous experience.
There were no tremors or sensory disorders in the face, arms, chest,
back, or abdomen. There was diminished sensibility to cotton wool of
the left buttock (across which a plank had fallen), and there was a
degree of hypalgesia of the buttock. The right thigh showed a degree
of thermanalgesia and slight loss of vibratory sense. The corneal
and conjunctival reflexes were diminished, and the knee-jerk was
unobtainable on the right side. Three days later, there was a marked
improvement with almost complete return to normal, whereupon the
patient was sent to a convalescent camp.
Emotional subject, ALWAYS WEAK IN LEGS; shell explosion; wound of back:
PARAPARESIS.
=Case 288.= (DEJERINE, February, 1915.)
A Lieutenant, 25, was wounded at Arras about 10 a.m. October 20, 1914,
just as he was leaning on another officer’s shoulder looking at a card
in a chateau room. A shell burst in the court yard. A fragment came in
the window, struck him in the back and pushed him forward, whereupon
he felt pain in the back and a severe dyspnea, due to the gas from the
shell. He lost consciousness several times and the dyspnea lasted for
about two hours. When he was picked up he could not walk.
He was carried on a stretcher to the ambulance at Avin-le-Compte.
During the fortnight there, he was also several times dyspneic.
Strength left his legs and he could only get about on crutches. There
was now a suppurating wound in the interscapular region where he had
been struck by the shell fragment. Evacuated to Paris, he was operated
upon on account of a tremendous abscess in the back, and the shell
fragment and some bits of cloth were removed. The wound healed; but
vague pains in the left thorax remained, especially when the man walked.
On examination, July 28, 1915, he would in the standing position hold
his legs together with the feet resting on their external borders,
especially on the left side. The toes were in plantar flexion, and
the soles were arched upward more on the left side than on the right.
In walking, the legs were always held in extension, the feet twisting
outward. If an attempt was made to walk quickly, the man walked more
and more upon the external borders of his feet, in such wise that the
plantar surface and the heel turned up and became visible from above.
He would get tired after five minutes’ walking even if he spread his
legs out for a broader base of action. He could lift his legs only
about 10 cm. from the bed, but could flex and slowly extend his lower
leg on the thigh. He could not adduct or abduct the feet. Movements
of extension and flexion of leg on thigh were jerky and abruptly
terminated, as also movements of thigh on hip. The patient could not
sit, and when leaning forward he could not straighten up against
resistance. The reflexes were normal. There was no sensory disorder.
The electric reactions were normal. Pupils normal. There was slight
hypertension of the spinal fluid and a slight excess of albumin. There
were no lymphocytes.
In accordance with Dejerine’s idea that these neuropaths always have
antecedents looking in the same direction, it was found that he had
always been an emotional person, easily affected, sympathetic with
other people’s troubles, given to weeping. As Lieutenant, he had not
had the courage to harangue his soldiers. He had often during his life
felt his legs weaken during times of emotion and had sometimes been
unable to walk, though nothing of the sort had happened during the
campaign. He was sure he could get well, and wanted two months’ leave
in order to get back to the front. There were no hereditary features
in the case. A physician had told him that he had had meningitis. This
possibly followed whooping cough. He had had orchitis after mumps at
16. He had not had children, nor had there been miscarriages since
marriage at 21.
Wound near heart; delayed medical care; fear of having been shot
through heart: Paraparesis (antebellum always “hit in the legs.”)
=Case 289.= (DEJERINE, February, 1915.)
An infantryman, 20, was sent as a Colonel’s bicyclist about 1 p.m.
September 30, 1914, with a message to one of the battalions. He was
exposed on the way to shell and rifle fire, and was wounded by a bullet
which entered 8 cm. below and internal to the left mammillary line and
came out in the region of the left hypochondrium. He crawled to some
village houses 20 or 25 meters away. Another cyclist came to transfer
the order, but could not help him. A friend came to his aid but was
struck by a bullet 10 meters off and remained on the ground for an
hour while the young cyclist lay behind a tree on the roadside. At 3
o’clock it was possible to take him to a house around which shells were
raining. Shortly afterward the house caught fire. The man was evacuated
6 kilometers to an ambulance in the night, and that night six of his
wounded comrades died in the same room. The man had lost much blood
and began to think that his heart had been hit. He choked, had violent
palpitations, and intense thirst. By automobile next day he was taken
to the railway station at Maison and was there for a day practically
without food.
That evening, 36 hours after the wound, he was evacuated to Juivisez
and stayed there one night in the temporary hospital. The hemorrhage
had now practically ceased. When he arrived next morning at Vincennes
he could hardly move, was unable to walk, had violent palpitation,
precordial pain, and two nervous seizures, with outcries and weeping.
Several days later he could not walk at all or raise himself in bed. He
was operated on May 29; he afterward felt the same leg weakness and was
still unable to walk. Early in December, when observed by Dejerine, he
was able to stand on crutches with legs flexed, toes on the ground, and
heels up. In walking he would scrape the ground with the dorsum of the
foot. The wound was now healed. Suppuration had been intense and the
scars were extensive. Lying down, the man could move, though slowly,
his lower extremities in every way, nor was there any diminution in the
strength of his flexors and extensors. The patient in making movements
against resistance would let go quickly and jerkily. The plantar
reflexes were flexor but weak. There was no other reflex disorder, no
evidence of sensory disorder, nor any sign of neuritis or arthritis.
Lumbar puncture gave a normal fluid without tension.
There were no hereditary features in the case. The man had been in
childhood nervous and irascible, rolling on the ground, crying and
weeping when crossed. He had had three attacks of appendicitis--one at
15 years and two at 19 years. After each attack he had felt weakness in
the legs. He remembered, too, that after his nervous crises on being
crossed, he had always felt this same weakness.
According to Dejerine, these paraplegic neuropaths, like functional
gastropaths, cardiopaths, and victims of urinary disorder, have had
earlier spells of the same kind, though milder than the attack which
brings them to medical notice.
Wounds: Tic on attempts to walk; tremors. Recovery except for frontalis
tic (ANTEBELLUM HABIT emphasized).
=Case 290.= (WESTPHAL AND HÜBNER, April, 1915.)
A substitute officer (mother nervous; always slightly excitable, easily
fatiguable; had had a habit of wrinkling his forehead) sustained wounds
September 8, 1914, in the foot and thigh. The wounds healed well, but
in the hospital he slept badly and had battle dreams. When he essayed
to walk, he had contractions of face muscles. There was a lively tic
involving both face and neck muscles, with the head pulled to one side
and backward. This grimacing was but slightly influencible by the will.
There was a marked tremor of the arms. Gait was _trippelnd_. There were
tremors of the whole body. There was also a slight hemi-hyperesthesia.
The tendon reflexes were very lively; vasomotor disorders (feelings of
cold and perspiration).
Seven months later the phenomena had all disappeared except for slight
tic-like frontalis contractions.
_Re_ heredity and soil, Mairet investigated 22 cases of Shell-shock,
and found a hereditary taint in eight, and an acquired predisposition
in nine. He found hereditary taint definitely absent in seven, and
acquired soil definitely absent in six; whereas the rest of the cases
were doubtful. He found both the taint and the soil in five cases; two
cases with hereditary taint alone; no case acquired, non-hereditary.
In eight cases with head trauma, Mairet found three with hereditary
taint, four without such; against one with an acquired predisposition,
four without such, others doubtful.
_Re_ cases of somatic trauma (not affecting the head), among five
examined, there were none with hereditary taint, three definitely
without taint, and five definitely without predisposition. According
to Babinski, neither hereditary taint nor prepared _terrain_ needs be
found in hysterics.
A predisposition is not thought important by Oppenheim, especially as
so many normal persons are predisposed.
War strain (fatigue, emotion): Hysterical hemiplegia. Precisely similar
hemiplegia ANTEBELLUM.
=Case 291.= (ROUSSY AND LHERMITTE, 1917.)
A sergeant in a regiment of cuirassiers was observed at Villejuif,
January 25, 1915. He had lost power on the left side as a result of
fatigue and emotion, November, 1914. He had a complete paralysis of
the left arm and a paresis of the left leg. There was an anesthesia
of hysterical type in the left arm, and also of the left leg as far
as the middle of the thigh. He dragged his leg in walking (_démarche
en draguant_: the toe is dragged along the ground, the trunk is bent
forward, and at every step plunges somewhat toward the paralyzed side.
The patient is able to walk, however, by means of a cane or crutches.
This walk is characteristic of hysterical hemiplegia. According to
Roussy and Lhermitte, the number of cases of hysterical hemiplegia
(better, hemiparesis) is not large). The plantar reflexes on both sides
were those of flexion. Upon treatment (not specified), at the end of
six months he went back to service in the cavalry.
The point of note in this case is that this patient had had a precisely
similar phenomenon on the same side, which lasted a month, at the age
of sixteen years and a half. It is noteworthy that in this case there
was no traumatism and only the factors of fatigue and emotion to serve
as an occasion for the hemiplegia. In fact, hysterical hemiplegia is
said very rarely to follow physical trauma to an extremity. There are,
however, some cases in which hemiparesis follows a slight head wound,
particularly if over the region controlling the paralyzed limbs.
During the six-months’ course of successful treatment, no atrophy of
limbs appeared, and there was never any inequality of the reflexes.
A good soldier (son of a tabetic sometimes hemiplegic), at 17 victim of
hysterical hemiplegia, has AT 24 A RECURRENCE after two months’ field
service. “Functional excommunication” of left arm and leg.
=Case 292.= (DUPRÉS AND RIST, November, 1914.)
A cuirassier, 24, one month in the field, began to feel in September,
1914, crawling sensations in left arm and leg; then fingers, later hand
and forearm, and finally upper arm began to work awkwardly and feel
heavy, and there was a little of the same sort of thing in the leg.
Hand and forearm were by the middle of October completely paralyzed,
whereas the arm and shoulder were only paretic. Anesthesia at this
time reached the elbow. The man had to be evacuated, after two months’
active and skilful field service, in one instance (September 19)
carrying out a clever and useful interception of hostile telephone
messages.
It seems that at the age of 17 also the man had had a left-sided
hemiplegia, with sensory and motor symptoms, lasting two months, cured
by electricity applied with a small electrode in his village. The
war situation was therefore actually a recurrence of the transient
hysterical paraplegia.
Moreover, the patient’s father, 52, an old tabetic, had also several
times shown a hemiplegia (however on the right side), a phenomenon
which had strongly affected his son.
It was curious that the slight residuals of movement which the
cuirassier could perform could be made only while he was looking at the
parts he was requested to move, and were impossible with eyes closed.
The anesthesia was a total one when observed in November, 1914, coming
to a sharp and circular termination at the shoulder and garter-wise
above the knee--tuning fork insensibility in the same areas. The left
patellar reflex was diminished when the eyes of the patient were
leveled at the knee; but a surprise test brought the knee-jerk out
normally. The hand and fingers were a little darker in color, and the
whole left arm a little colder than the right. There was also a slight
amblyopia on the left side.
This hysterical paraplegia proved rather resistant to psychotherapy.
The patient seems to have systematically eliminated from consciousness
and from action the entire function of the left arm and a good deal of
the left leg. Duprés and Rist speak of this as a kind of functional
excommunication of the parts.
_Re_ relapses, Wiltshire remarks that the frequency of relapses and the
ways in which they are produced favor the conception that the original
cause of Shell-shock must be psychic. Sir George Savage remarks that
cases of Shell-shock should not return to the service under a period of
six months on account of the frequency of relapse. Others have recently
argued that such cases should not be sent back to the front at all.
Harris notes that relapse may follow so apparently slight a factor as a
vivid dream. Remarks concerning the true nature of relapses are made by
Russell. Russell, for example, disapproves anesthetics in curing such
a hysterical phenomenon as deafmutism. This sort of treatment does not
get at the real cause of the condition, so that the man is very liable
to relapse with the same symptoms. Ballet and de Fursac note the many
cases of relapse after treatment and after discharge. Sometimes the
relapses were due to some unfortunate happening, but in other instances
no external cause could be made out. Fear of having to return to the
front is a factor in certain cases, so that the true answer to the
relapse question may not come until after the war.
Roussy and Boisseau insist upon the value of rapid cures
(psychotherapy, electricity, cold shower, etc.), in diminishing the
number of relapses. They maintain that these rapid cures abolish any
chance for the man to brood over symptoms and thus to exaggerate and
fixate them. These workers send their hospital return back to the
regiments with a statement relative to diagnosis and the request that
he be immediately returned to hospital if neurotic symptoms appear.
War strain; burial: Deafmutism. ANTEBELLUM speech difficulty.
=Case 293.= (MACCURDY, July, 1917.)
A private 20 (always rather tenderhearted, disliking to see animals
killed; rather self-conscious; a bit seclusive; “rather more virtuous
than his companions”; shy with girls; sore throat a year or more before
the war, with inability to sing or talk; always a lisper) enlisted
in May, 1916, spent five advantageous months in training and became
increasingly sociable. However, on going to the front October, 1916,
he was frightened by the first shell fire and horrorstricken by the
sight of wounds and death. He grew accustomed to the horrors and five
months later was sent to Armentières, where he had to fight for three
days without sleep. He grew very tired and began to hope that he would
receive wounds that might incapacitate him at least temporarily for
service.
He was suddenly buried by a shell, did not lose consciousness, but on
being dug out was found to be deaf and dumb. On the way to the field
dressing station he had a fear of shells. The deafmutism persisted
unchanged for a month and then was completely and permanently cured in
less than five minutes. He was made to face a mirror and observe the
start he gave when hands were clapped behind him. He was assured that
this start was an evidence of hearing; that his hearing was not lost,
nor was his speech. He had no relapses during two months.
According to MacCurdy, this case is a typical one of war neurosis of
the type of a simple conversion hysteria. The man never suffered from
anxiety or nightmares.
_Re_ burial cases, Grasset suggests that some of the patients probably
think that they have actually died; both sensation and motion have been
lost, and it is naturally these that permit a man to believe that he is
still alive. The classical case is recalled, of the almost absolutely
anesthetic boy who, with eyes closed, at once fell asleep. Foucault’s
patient also said he actually thought he was dead after an explosion.
War strain: Shell-shock and psychotic symptoms, with determination to
parts injured ANTEBELLUM.
=Case 294.= (ZANGER, July, 1915.)
Several years before the war, a cavalry officer had a severe concussion
of the brain after a fall from his horse, but got no manifest symptoms
therefrom except a mild transient deafness. There must have been a
vestibular nerve injury, however, since there was a marked bilateral
subexcitability of this apparatus later determined.
In September, 1914, as the result of strains and privation in the
field, he got vertigo and lachrymose spells, with some obsessions as
though he would have to shoot himself in the foot or spring out at the
enemy from the trench.
In hospital at Jena, insomnia, anxiety, excessive perspiration and
salivation, feelings of the death of various parts of the body,
especially the forearms and hands, associated with hypesthesia of the
parts, were determined. He had a feeling of vertigo on walking and
was very sensitive to noise. He now developed a very intense and very
variable degree of deafness on both sides, diagnosticated as nervous
deafness. The caloric test demonstrated vestibular subexcitability
above mentioned. We may suppose that in this already injured organism
fresh disorder had set in on a psychogenic basis in the same region
that had been injured years before.
Mine explosion; emotion at death of comrades: Unconsciousness eight
days with hallucinatory delirium; later, dizziness. History of previous
trauma to head with unconsciousness and dizziness.
=Case 295.= (LATTES AND GORIA, March, 1917.)
Sent at end of May to the front, an Italian soldier (Class 1895,
laundryman) was placed in an advanced post where he at once sustained
great hardships.
Father drunkard, mother healthy, sister nervous. Two brothers healthy,
one brother died of tuberculosis. Patient had scrofula, scarlet fever,
and bronchitis (tendency to rave intensely when in fever). At four,
sustained a trauma on the head (skull depression), dizziness, loss of
consciousness.
June 7, a mine exploded in his vicinity, smashing several of his
comrades. He did not himself fall to the ground, but was overwhelmed by
a violent feeling of anguish. After a while, he lost consciousness. He
woke up at Bologna, June 15, as after a long sleep. During the interval
he had been in a state of intense hallucinatory delirium day and night.
Then his mind began gradually to clear, first with amnesia of the shock
which had caused the trauma. Then he recalled this fact too. Dizziness,
however, grew in intensity so that he fell to ground many times during
the day. There were intermittent tremors in the limbs.
Under observation, August 7, a sturdy, robust man. Somewhat dull in
demeanor. Senses intact. Cranial nerves negative. Tendon and skin
reflexes lively, especially on the right. Memory intact, except for
above-mentioned oniric delirium with restlessness and shouting at
night, especially while falling asleep and waking up. Frequent intense
dizziness.
The condition remained unchanged for a week. Patient transferred to
another department, for acute catarrhal bronchitis with fever.
Sniper stricken blind in shooting eye.
=Case 296.= (EDER, March, 1916.)
An Australian, 19, was admitted to hospital for loss of sight in the
right eye. There had been a _right ptosis_ from childhood. January 7
nothing could be perceived but light.
According to the patient, he was sniping through a loop-hole, November
15, when a bullet knocked a piece from the stock of his rifle. He
continued at his post. There were five more shots, when another bullet
struck the sand around the loop-hole. His right eye began to water.
He shut the loop-hole and retired for an hour. His eye improved, he
returned, opened the loop-hole, braced the rifle, and found he could
not see the sights. He went to the physician. Vision grew rapidly
worse, and in a few hours perception of light failed. He had been
stricken blind in the shooting eye (the seat of a congenital deformity).
Anticipation of warfare: Hysterical blindness.
=Case 297.= (FORSYTH, December, 1915.)
Anticipation of warfare may provoke a neurosis as in a case of
Forsyth’s. The man went blind training in England.
It seems that four months before, while mounting sentry at night,
marauding gypsies had felled him by a blow on the head from behind. He
had returned to duty after a day or two and was now expecting to be
moved to France. He said that while sitting with a friend, he began
to feel giddy, turned a somersault, and fell unconscious; and that on
coming to, his mind was clear but everything was dark. For ten days he
had been blind, although once he could see his parents, who visited him
in hospital, almost clearly. His appearance under examination strongly
recalled that of a blind man. He was induced to read some large print,
then smaller print, and finally very small print. He then lapsed into
blindness.
He remembered that before enlisting, he had trained in a smithy, and
heard that blacksmiths often went blind at the forge.
Bareback riding: Spasmodic neurosis (similar ANTEBELLUM episode).
=Case 298.= (SCHUSTER, December, 1914.)
A soldier, 32, had to do a long stretch of riding bareback. As a
result, he later suffered from tonic muscular spasms whenever he had
to exert himself seriously, especially whenever he had to move his
legs and when sudden movements or sudden strong contacts were made.
The attack appeared to be reflexly dependent on the pain. The case is
regarded as one of the Wernicke _Crampusneurosen_, a disease somewhat
related with hysteria.
A condition somewhat like the one developed in the war had occurred in
this man at the age of seventeen after a drenching, but the attack was
at that time much milder. He had, however, frequently had cramps in his
legs.
ANTEBELLUM spasm of hands, functional.
=Case 299.= (HEWAT, March, 1917.)
A boy, 19, had been passed as fit for laboring work at home. He had
been a farm boy from 14. Once at 17 he had developed whilst working
amongst turnips in wet weather, pain in the hands, which got worse and
was followed by pains in legs, arm, and neck, that kept him in bed a
week, and from work ten days. Even on returning to work, his hands were
swollen, though he was able to drive a horse. The fingers had been
somewhat firmly flexed on the palms ever since this illness at 17.
He was sent to Netley after three weeks of army work, as having a
spasm of both hands. He was found to be mentally below par, nervous,
apprehensive, stuttering in speech and not readily responsive, with
defective vasomotor control, though of good average bodily development
except for asymmetry of chest.
Both hands were found firmly closed; tips of fingers applied to palms;
thumbs freely movable; forearms well developed, especially the flexors.
Counterforce was exerted upon passive extension of fingers. There was
no sensory or reflex disorder, and while the patient was asleep, it was
found that the first and second fingers of both hands could be fully
extended. Yet there was a definite contracture of the palmar fascia
which prevented full extension of the third and fourth fingers. He was
awakened by this test and the fingers became firmly flexed at once.
The man was treated by milk isolation behind screens, without
permission to read, smoke, or talk. Twice a day he was encouraged to
move the fingers and made to perform finger exercises. He became able
to extend the fingers over half their normal excursion in three days,
and was then able to abduct and adduct the fingers. He was allowed up
in two weeks’ time, with full diet and screens removed. The contracture
of the palmar fascia was still in evidence, but the power of movement
in the hands and fingers was so satisfactory that he could be sent back
to duty in three weeks. The interpretation of Fergus Hewat is that the
painful condition of the hands which set in in the illness at the age
of 17, had caused an obsession which had developed into a functional
spasm of the hands.
Quarrel: Hysterical HEMICHOREA, DOUBLY REMINISCENT, of a former
hysterical chorea, itself related with an organic chorea of the
patient’s mother.
=Case 300.= (DUPUOY, October, 1915.)
A nineteen year old soldier, for some months a bit distressed and
irritable, had a dispute with an old man whose jug he unluckily
happened to smash. The old man said something was going to happen to
him for that. That day, in point of fact, he fell and sustained an
injury with water on the right knee. He was upbraided by the captain
and evacuated to the ambulance. The fellow thought the old man with the
broken jug had interfered, dreamed of the old man’s threats, and felt
his hand on his shoulder.
Next day hemichorea developed on the right side, a partial and rhythmic
chorea with jerky, regular contractions, fifty to sixty per minute,
affecting synchronously the muscles of the leg, arm, face and tongue.
Dupuoy speaks of the reason for the hysterical “choice” of this
disease, since his mother had had a probably organic hemichorea, also
on the right side, with which she died at thirty years in a stroke. The
boy was at that time thirteen years old and had had a rhythmic chorea
six weeks, limited to the extensors of the hand on the forearm, treated
in hospital.
This new hemichorea was quickly and completely cured by psychotherapy.
Hallucinations and delusions in a soldier, of antebellum origin.
Treatment by explanation of causes.
=Case 301.= (ROWS, March, 1916.)
A private, 31,--a case of Capt. W. Brown,--was admitted to hospital
suffering from hallucinations of hearing and delusions of supervision
by his family and friends; he heard his relatives telling him what to
do and what not to do. He thought they belonged to a secret police
entrusted with the task of supervising his actions and seeing that
he did not again transgress as he had done. An inquiry into his past
revealed the following facts:
He had been a bank clerk before the war and once because of a nervous
breakdown as a result of drinking and smoking had been given a three
months’ vacation. On this occasion he went with a prostitute--his first
and only offence in sex matters. He later thought the behavior of his
family indicated that they knew of his misdeed. He heard the voices of
members of his family, became rapidly worse and more depressed, and
attempted suicide.
He went to a private asylum. Later, he emigrated to Canada, but he was
still pursued by the voices and he returned to England. He enlisted at
the outbreak of the war and went to France. He was soon invalided and
sent to Maghull.
The cause of his condition, according to Rows, was his affair with the
prostitute and his previous drinking. This was explained to him as the
basis of his strong feeling of self-reproach. The hallucinations and
idea of suicide had developed therefrom. Recovery “to a large extent.”
A poor risk (hereditary and acquired); emotionality: Tremors and
convulsive crises with lowering of pulse.
=Case 302.= (ROGUES DE FURSAC, July, 1915.)
A man, 36 (boat painter to 30 and thereafter a wine seller; paternal
grandmother insane, father alcoholic and suicide; gonorrhea, 20; two
attacks of lead colic, 25 to 30; purulent pleurisy, 31; phlegmon of
mouth, 34; also a chronic alcoholic), at the time of examination showed
arteriosclerosis and slightly hypertrophic liver; unequal pupils,
slightly contracted and sluggish to light. He complained of frequent
headaches, possibly due to a combination of plumbism and alcoholism.
He was not in any respect demented, and had an excellent memory. He
had always been emotional, being unable to go to a funeral without
many tears, or remain in a house where there was a corpse without
threatening to faint. He was always overcome if he saw a fight going
on; and even in his wine shop he would escape when there was a fight
and get a neighbor to bring the police.