responded rather weakly in accommodation; there was a small fibrillar
tremor of the face, eyes, and tongue. The skin reflexes were
diminished and there was a general hypalgesia; considerable mechanical
overexcitability of muscles; no other neurological disorders. The
mental state was one of confusion. Although he was in one of the corps
hospitals, he said he was in a dug-out; the doctors were lieutenants;
the attendants were privates in his company. Answers to questions
were irrelevant or incoherent; there were a number of delusional
expressions. He was to be shot because he had not himself shot enough
Germans. If he were not to be shot, anyhow the soldiers would poison
him. Rather than this he should be allowed to go into an attack. He
would take a German fort and the Czar would name him a colonel. His
regimental commander was saying to him, “You will be a hero, you will
soon get a company.” His hallucinations sometimes included the voices
of Germans saying, in broken Russian, “We will hang you and cut your
belly open!” There was considerable amnesia for dates and even his last
battle.
Numerous attacks and counter attacks in one day: Sudden incoherence
with disorientation and the rapid development of war hallucinations of
a scenic type. Suggestion of catatonic phenomena.
=Case 352.= (GERVER, 1915.)
A Russian lieutenant, 28 (no mental disease, non-alcoholic), was in
battle August 14, 1914, on which day his company attacked and was
itself attacked several times. An officer who observed the lieutenant
said that he came to him and informed him that the Germans must first
be burned and then fought with. Thereafter the lieutenant began to
speak loudly and incoherently, sometimes yelling incoherent orders.
He was accordingly removed from the battle-field to the hospital back
of the line. Upon examination, he was found to be of middle height,
with dilated pupils, responding weakly to light and not at all to
accommodation; twitchings of face, eyelids, and tongue, digital tremor,
marked dermatographia, general analgesia, tendon reflexes somewhat
exaggerated, cataleptic tendency in feet and hands.
Mentally, the patient was in a stupor, sitting or standing in one
place, without initiative; uncomplaining but occasionally uttering deep
sighs or occasional isolated phrases. He answered no questions or only
after a long pause. He was disoriented for time and place, but gave
evidence of delusions and hallucinations. He thought, for example,
that he was the chief of staff and had brought with him a squad of
captured Germans who were standing nearby. Some wanted to be fed and
let go; others were yelling and saying they would burn down the house.
Sometimes the patient would hear shots and shells bursting, at which
he would shudder and turn away. Apparently he would see his comrades
falling under the shrapnel hail. However, he stood his ground and
commanded the rest of the soldiers to go forward to the attack. Now
and then he was negativistic, flexing the hands upon request to extend
them, refusing food and drink. He was still apathetic on evacuation to
the interior.
Shell-shock after two days in trenches: Hysterical STUPOR seven days.
Cure in three weeks, barring amnesia for stuporous period.
=Case 353.= (GAUPP, March, 1915.)
F. S., in civil life a wreath-binder in a flower shop, and from
childhood very nervous and excited, subject to frequent nosebleeds and
fainting spells (_e.g._, at sight of blood), enlisted at 22, November
3, 1914, as a reservist. January 18 he went into the field.
The wreath-binder was only two days in the trenches before going
unconscious under the whistling and exploding shells. Physically
uninjured, he was received in reserve hospital C in a deep stupor,
January 22. He was unresponsive at first, once however saying, lost in
a dream, “When will mother come?” His gait was unsteady and he had to
be led and held. He slept a good deal in the daytime.
He became somewhat more active mentally, January 24 (remarking that
he had slept well), and made his toilet, but he did not yet have
bearings and wanted to go to his place of business. The next day his
condition was similar. Asked what troop he was with, he said, “In
the flower business.” January 26 he was much better, telling of the
army training and a little about the war, and wrote a postcard to his
parents. The stupor disappeared after January 27 and the patient became
mentally normal. Amnesia persisted for the time, January 20 to 26.
Headaches. February 9 he was well, except for the limited amnesia still
persisting. He was eventually sent back to garrison duty, cured.
_Re_ stupor, Grandclaude remarks that stupor is probably the most
frequent of the mental symptoms of Shell-shock, and that it may
last from a few moments to a week. During the stupor the patient is
asthenic, stertorous, and staring. Upon recovery from the stupor, a
condition of dulness with amnesia and disorientation ensues. There may
be a third phase of a more hyperkinetic character, with hallucinations
and delusions concerning the war. These stuporous cases are among
the most serious of the conditions found, as some of the victims may
even suggest dementia praecox from the persistence of childishness
and silliness. As in Gaupp’s case, Grandclaude finds that headaches
and amnesia persist. Relapses are frequent on the basis of a kind of
sensitization.
_Re_ amnesia and Shell-shock, Roussy and Lhermitte speak of amnesia
as ordinarily a phenomenon of confusion. Amongst the mental disorders
of the Shell-shock psychoses, these authors describe a group due
to inhibition or diminution of mental activity, including the rare
narcolepsy, or pathological sleep, and the confusional states proper.
Simple confusion involves slowness in thinking, and amnesia often
anterograde from the moment of the shock. Simple confusion ought to be
distinguished from so-called “obtusion” or torpor, in which there is a
disorientation for time and space, such as was shown in Mallet’s case.
Chavigny has described an aprosexic form (with “birdlike” movements).
More common is the amnestic form of torpor. The amnesia may not merely
be anterograde from the moment of shock, but may extend to a prolonged
period prior to the accident. Sometimes the amnesias are selective,
producing phenomena of pseudo aphasia.
Amnesia, monosymptomatic. Progressive recovery.
=Case 354.= (MALLET, January, 1917.)
An infantryman, 36, arrived without information at a psychiatric
center, March 15, 1916, looking confused and knowing little more than
his name, believing himself in a distant town. The disorientation
lasted to March 21, on which day the man recognized the doctor as such,
knew that he was at a hospital, but felt that he had just left home
and wife. From this time on, he began to pick up his surroundings,
evidently not knowing that there was a war or that he was a soldier.
He did not recognize one of his own company. It was not until March 31
that the first memory of the war reappeared, namely, a memory of the
call to the colors, drums, bells, and crowds. April 11 he recollected
that he was a soldier and that his wife was in the country, where he
had left her on the eleventh day of the mobilization. In the next few
days, memories came back bit by bit. He had been at first a little thin
and showed a slight fever, oliguria, and poor digestion. All these
symptoms now lapsed, and the man became apparently perfectly well.
Such states, according to Mallet, are relatively frequent in soldiers,
both in epilepsy, and in infectious deliria,--more than in the deliria
of exhaustion.
Aviator shot down: Organic mental symptoms.
=Case 355.= (MACCURDY, July, 1917.)
A Canadian, 20, of normal makeup, in 1915 lost part of his left foot in
a railway accident, but, notwithstanding, was finally commissioned in
the Royal Flying Corps. He enjoyed the nine months of English training
greatly. In France he made several successful flights over the lines,
but was shot down and crashed to the ground within the British lines
after two weeks of service. He got black eyes and bruises and lost
consciousness for about four days, though a week later he was still
hazy about recent events and was not quite sure in what hospital he
lay. After another week he arrived in a London hospital.
Here he would not answer questions, but stared at the examiner, finally
shouting: “I want to get up.” He said he was in a certain suburb of
Toronto, which, however, he insisted was a part of London not far away.
He wanted a taxicab to go thither. He pondered, but seemed content
when told that Rosedale was across the ocean. A superficial machine
gun wound of the hip the patient said must be the mark of a hospital
in France; it was a secret mark, meaning that he could return to the
line and fight whenever he wanted to and that he could use the lavatory
whenever he wanted to. He sometimes uttered brief phrases after
questioning. Asked if he dreamed, he looked up cunningly and said,
_e.g._, “I down the Boche. I am a live wire.”
Next day it was clear that he had gained a good deal of information
from the nurses, and the day after he had become oriented for time and
able to recognize the physician, though still confused about hospital
names and his recent movements. The 7 from 100 test he did slowly
and made several bad unrecognized mistakes. He was over-fatigueable,
complained of foggy eyesight, showed haziness and redness and obscure
margins in the optic discs, with the remains of one hemorrhage, and
presented nystagmus on looking to the extreme left. Two weeks later
he complained less of his memory and said that he was beginning to
remember what had happened during the last day of his fighting; the
chase by the German airplane and the maneuvers. He worried about being
sent back to France by a medical board, which would not realize that he
was incompetent to fly again. The left pupil was slightly larger than
the right.
In this case there were no neurotic symptoms and according to MacCurdy
the difficulties here are strictly those of organic type.
_Re_ organic cases of traumatic psychosis, Lépine sums up the
subjective phenomena as follows: There is (_a_) a cephalea, often
a feeling of weight, varying at different times of the day; often
frontal; often subject to marked alteration on movement. There may be
(_b_) a number of visual phenomena like those mentioned under Case
355, part and parcel of a sort of absence, suggesting an epileptoid
effect. Sometimes (_c_) there is vertigo, but this is rare. There are
also congestive attacks. The patients are unable to work, and have
strange head sensations when they attempt to work. The memory disorder
is not as a rule markedly accentuated. This amnesia is usually a
disordered fixation of current events, but there is also a retrograde
amnesia. Insomnia and impulsiveness are also found, and more rarely
is a depressed and melancholy state suggesting that which Case 355
exhibited. Lépine has tried to define the traumatic psychoses (not
_neuroses_) on the basis of phenomena found in trephined cases. He
remarks upon the extreme analogy, not to say identity, between the late
sequelae of trephining and the syndrome of _commotio cerebri_.
Daze with relapses; mutism--following shell fire and corpse work.
=Case 356.= (MANN, June, 1915.)
A soldier lost his voice apparently from two factors: shell fire and
the emotional shock of helping to fill the big common graves. The man
could never tell for certain (retrograde amnesia) whether he went from
corpses to shell fire or from shell fire to corpses.
Several weeks of daze followed in which he hardly reacted to outward
stimuli, but occasionally said “It smells!” “Leave me still!”
He recovered gradually from the daze. But merely hinting at his
experiences, especially the smells, sufficed to throw him into another
daze.
The loss of voice lasted for some time after he had wholly stopped
lapsing into the dazed states.
There was some alcohol in the previous history of this case, which is
the only case among twenty-three Shell-shock cases reported by Mann
which had a psychiatric disorder of any lasting nature due to shell
fire.
_Re_ mutism and the two factors of shell fire and emotion spoken of by
Mann, compare the views of Babinski to the effect that emotion alone is
unable to cause such a hysterical manifestation as mutism.
_Re_ the corpse work, see remarks under Case 342.
Mine explosion: Mental confusion. Amnesia effected through Y. M. C. A.
=Case 357.= (WILTSHIRE, June, 1916.)
A sapper, 21, was admitted to a base hospital semi-stuporous, unable
to answer questions and mistaking the identity of persons about him.
At first he slept, but next day found he was in hospital. His mind was
“all of a blur.” He did not remember coming to France; “It all seems a
mist.” He felt he was ill and was afraid of becoming insane. There was
no physical sign of disease except coarse tremor of hands.
At intervals over a period of about half an hour, helped by questions,
he was able to get out the following with much emotion:
“Joe, don’t go--Give me my rifle, Joe--Ten killed. Poor old
Taffy--Dreamed last night--Saw Harry Edmands with all his ribs
broken--when we had the explosion--5000 bombs or two and a half
tons of explosives blew up.--Joe--Clay said he would never
live three weeks,--Glasses blown in.--Taffy killed by shell
in stomach--S-- L-- All privates blown off him--Just after
leaving workshop.”
Between the above statements, the patient might go off into short
trance states, staring and pointing out of the tent.
Next day he was found in a condition of cheerful emotion, saying that
he was ever so much better; an orderly had “saved him!” This orderly
had taken him to the Y. M. C. A. recreation tent, played the piano to
him, and made him play himself. His whole emotional state suddenly
changed over. He now had a good memory for everything previous to
his reaching France, and remembered simply that there had been an
explosion. He remembered two names that he had mentioned, but he could
remember nothing about their fate in France. He did not know where they
were but he was not anxious about them.
Shell-shock: Hallucinations; alternations of personality.
=Case 358.= (GAUPP, March, 1915.)
A soldier, 29, a helper in a wholesale house, came to a hospital by
hospital train, uninjured, directly from the field, having become
completely deranged under shell fire. He arrived at the clinic January
11, 1915, in deep emotion, anxiously excited, and looking tensely
and suspiciously at the bystanders. He seemed to hear very badly and
shouted his statements like a deaf person. Led to the sick section,
he shouted out of the window, “Frenchmen!”; then he went willingly to
the bath and was put to bed, unresisting. He lay in bed on his elbow,
listening in the direction of the window or the wall, answering loud
questions with a quick, yelling voice after a pause. He gave his
name correctly. He seemed to think he was in the trenches and to see
hallucinatory pictures of battle.
In the examining room he immediately sat down, back to the wall, taking
the chair at the desk and leaning it against the wall. Asked why he did
so, he said with a horrified expression, “The shells, they are coming
over! Whew! they are shooting all the time.” He ducked, imitating the
hissing and whistling of the shells. Asked if he had been struck, he
said, “There are two dead and one’s head is off.” He declined to be
told where he was, and when he was told that he was no longer in the
enemy’s country, but in Württemberg, he said, “No, no; they don’t
come so far. No, the Frenchmen don’t come so far.” He was very easily
frightened and started at every touch as if wakened from a dream.
Sometimes his whole body would tremble with anxiety. He would not allow
his pulse to be taken, at first. He would suddenly shout, “That’s the
Krupp now flying by. Now it has struck.” He cast his eyes along the
ceiling as if to follow the course of the shell. Asked what he was
doing, he said he was in the trench on the mountain.
He was able to tell about his family, his marriage in Berlin, and his
child, and he could tell time by the clock. Then he would suddenly
shout: “The shells, they are shooting everything; they are shooting
like another earthquake.” Gaupp stepped up to him, in uniform, and
asked if the patient knew him. He examined Gaupp suspiciously from top
to toe, looked at the shoulder-straps, and then quickly cried loudly,
“Physician.”
At another time he described the shell havoc with evidence of extreme
anxiety. He would take food only when one broke off a piece and ate
of it before him. He would not drink out of ordinary drinking-glasses
but only out of his field cup, examining it carefully. He denied he
was on patrol duty at Soupis. His comrade was merely asleep just
now. A civilian physician in his long coat was termed by the patient
“a baker” after careful examination. There seemed to be no pause in
the man’s behavior, which looked absolutely genuine and dominated by
strong emotion. He had the look of a man in immediate danger of death,
exerting himself to escape shell fire.
This dream-like disorder of consciousness with war delirium persisted
for a number of days. There was no marked motor excitement. He would
remain for the most part quietly in bed, absorbed in his thoughts,
watching and listening, sometimes looking about in astonishment but not
getting his bearings. Gradually his emotions declined and he developed
a certain confidence in the nurse. She was able to convince him that he
might be in a hospital, although he objected that there were no wounded
there. (He was in a mental section where there were no bandaged men.)
All the while he was very hard of hearing and shouted loudly in speech.
For twelve days he could not be convinced that he was in Germany. The
fact that the Sister was speaking German was met promptly by the fact
that in France the physicians and Sisters spoke German too.
An extraordinary change came over him January 27 (sixteen days after
admission). He went into the garden, apparently deaf and shouting
his answers, accompanied by Sister Margarethe, whom he always called
“Sister Anna” and whom he thought came from Lichterfelde. While
walking with the Sister, his condition suddenly disappeared. He began
to hear; he spoke in a normal tone, in fact, rather low, and began to
address the Sister by her right name, Margarethe. He was astonished at
the snow in the garden, and asked the Sister whether she noticed that
the artillery had just stopped firing. Gradually getting his bearings,
he wondered whether he had been in the hospital since the day before.
He certainly was not ill, he thought.
This normal state lasted for a half hour. The patient then relapsed
into anxious semi-consciousness, becoming deaf again and shouting his
words. During the next few days and weeks he had frequent changes of
state like the above described. The changes to a normal state would
take place spontaneously in the absence of apparent occasion, but
the relapses into semi-consciousness took place when there was some
outer irritation, especially some noise. Every fright would cause a
relapse. Once a small cannon fired at a great distance off caused such
a relapse; again, a sudden shouting at the patient.
During the clear state there was a complete amnesia for the period of
illness. He did not want to believe that he had been in the hospital
for weeks, declaring that he must have been in the trenches two days
before.
Gradually the semi-conscious states decreased in length; the deafness
and loud speech returned with the semi-consciousness. With the return
of orientation, the man looked entirely normal, speaking in a low voice
somewhat shyly. He was rather suspicious and could find his way about
with difficulty. His memory broke off with the last days of December,
1914, at which time he was in the trenches under intense shell fire.
His wife had received no word from him since December 26. Even at the
beginning of February he grew anxiously tense when the word _shell_ was
mentioned.
February 4, Gaupp presented him in clinic as entirely clear. He
mentioned that his relapses to semi-consciousness occurred on the
occasion of a loud noise or word spoken. His face was contorted at
Gaupp’s remark but there was no other change in him. The next day,
however, he told the Sister that Gaupp had shouted out once to “get
him away.” He said he had then heard artillery fire for a moment,
but pulled himself together though he had almost gone off, and had a
violent headache afterward.
These states of alternating normality and semi-consciousness continued
until about February 10. During a clear spell, the patient was quiet,
reserved, taciturn, a little ill-tempered and seclusive, occasionally
writing his wife a rather empty letter. In the semi-conscious state
he was emotional and restless, seeking cover from the enemy. These
states stopped altogether about the middle of February. He then
became somewhat more open, though he had no idea of the gravity of
his condition. He was angered by the window-bars, and offended by the
opening of a letter to his wife, declaring that he would never write
a word again, as it was just like a prison. These outbursts passed
quickly by. He wanted to go home and believed he would soon be able to
go to his comrades in the field.
At the time of the report, Gaupp felt that he could not be discharged
for a number of weeks. He was pallid, gave the impression of being
exhausted mentally, complained of restlessness and internal irritation.
His memory gap covered at the end of March a period of about five
weeks: from the end of December, 1914, to the beginning of February,
1915.
Frostbite; thrown into water by horse; horse shot under its rider who
becomes: A HORSE IN THE UNCONSCIOUS.
=Case 359.= (EDER, March, 1916.)
A private in the Royal Engineers, 25, went through Gallipoli without
injury and without fears. He was sent to the hospital in Malta,
December 18. When observed by Eder, February 7, the frostbitten finger
of the right hand was well although there was some loss of grip. He
was suffering from insomnia, terrifying dreams, shaky hands. It seems
that December 6, a horse started and he was thrown into the water from
a bridge. The next day his horse was shot under him. A few days later,
a finger was frostbitten. Then his hands began to tremble and the
insomnia set in, with severe headaches.
This patient was a jovial, thickset, farmer’s son, with a diffuse
enlargement of the thyroid gland, a high blood pressure, lymphocytosis,
a fine tremor of the hands, irregular and rapid pulse, and anginal
attacks. Extremities were cold and blue; the palms perspired markedly;
there was hypersensitiveness to sound; there were occasional attacks of
dizziness, with a feeling of suffocation; there was frequent desire to
micturate.
The patient’s dream was always the same: He saw a Frenchman digging
a knife into his horse, getting off a cart to do this somewhere in
Serbia. Occasionally he had this dream in the form of a vision in the
daytime. It seems that he had actually seen a French soldier plunge a
knife into a mule to make it go. He had been busy with horses since
childhood: as stableboy and groom. He thought that the sufferings of
the mules in Gallipoli were worse than those of human beings. According
to Eder, this farmer’s son was the horse of his dreams; instinctive
fear had to emerge; he was pitying himself. According to Eder, “That
the person should become a horse in the unconscious would not startle
one who has dipped into the totems and taboos of the lower races.”
Shell-shock; gassing; fatigue: Anesthesias.
=Case 360.= (MYERS, March, 1916.)
A stretcher-bearer, 44, eleven years in the service and two months on
French service, was seen by Lt. Col. Myers eight days after reporting
sick and admission to a base hospital.
While he was under cover in a cellar, three days before reporting sick,
a shell had jammed the door and the fumes came in. Later in the day,
in another cellar, he had been blown off his seat by a shell and six
other men had been laid out. The shelling continued that day and two
following days. He had worked on the wounded without any rest.
On lying down he found his left arm numb and cold. The numbness then
spread to the legs, especially to the left leg. There was continual
tingling in terminal joints of fingers of left hand; hypalgesia over
both forearms and hands, especially on left side; total analgesia over
left dorsum.
Two days later, the patient could feel articles and reported that the
numbness occurred only in the early morning and was followed by a
tingling as the numbness passed off. On the same day, the hands and
forearms showed a total loss of sensibility to pain, except for a small
area on the flexor surface below the elbow joint.
_Re_ spread of anesthesia and alternation of sensory symptoms in
this case. Babinski, of course, believes, that the majority of these
conditions are the product of medical suggestion, but Babinski meets
any critique by pointing out that any other sort of suggestion may
produce such results. The heterosuggestion need not be medical.
Thus, the sight of a comrade with paralysis or anesthesia, organic
or hysterical, may suggest such to the soldier. Léri remarks that
these may also be produced by autosuggestion alone. “From a tired
feeling in a limb to a loss of power in it, there is but a small
step. Another step leads to paralysis and anesthesia. The neuropathic
temperament takes these small steps in perfectly good faith.” Léri
has found no case in which he could exclude the influence of auto- or
heterosuggestion.
Shell-shock; burial; somnambulistic state: Amnesia. Recovery of memory
in hypnosis.
=Case 361.= (MYERS, February, 1915.)
A healthy-looking man, with flushed face and large dark eyes with
wide pupils, complained of pains in abdomen, back, and limbs, chiefly
in knees and ankles, and of visual impairment. This corporal said
that his sight had been very indistinct since he was buried, and that
if he looked at an electric light, he could see nothing for five
minutes afterwards. He was admitted to the Duchess of Westminster’s
War Hospital at Touquet, December 11, 1914, having been buried for 48
hours, December 8, when a shell blew in the trench where he lay. He
said he could remember nothing until he found himself in a dressing
station, lying on straw, in a barn. He was at that time unable to see
and fell over something when he tried to walk.
He had gone out August 13, and had been in the last two days at Mons
and then at La Bassée. He had slept badly and had taken a good deal of
whiskey. He had led a fast life and had had domestic worries recently.
It appeared that his vision had improved since the day of the
explosion; though he could read for a short time only when things
became blurred, and only with the type close to the eyes. Bowels had
not opened for five days. Vision in right eye was 5/60; left eye, 2/60.
Tested for smell, he failed to smell peppermint, ether, iodin tincture,
and carbolic acid 1-40. Sugar was tasted only after tongue movements
were permitted, as was also a strong solution of salt. Acid tasted
salty like alum. The patient complained that he did not sleep, though
in point of fact he slept well.
The patient was treated by suggestion, both in hypnosis and without,
when he was transferred on the 31st of December, to the London
Temperance Hospital, whence he was discharged. The treatment by
suggestion occurred daily. At the second trial and thereafter,
light hypnosis was easily induced, but the deeper stages, with
hallucinations, anesthesia, and post-hypnotic anesthesia, could not be
reached. The lighter stages brought about sleep, a gradual restoration
of memory, and later an improvement in visual and olfactory acuity; in
near vision, in visual fields, and in color sensibility.
The stages in the restoration of memory are as follows: December 22,
he was able to describe how he was buried, how Sergeant L. dug him
out, how men of another regiment than his own took him to a dressing
station, whence he was packed off by the M. O. to the dressing station
of his own regiment. Capt. S. had spoken to him and given him a drink.
Post-hypnotic suggestion caused him to remember this latter fact after
he had come out from hypnosis.
December 23, even before hypnosis, he could remember a big hospital
with a stove in the center of a big square room, and gave a fragmentary
account of struggling in the trench after being buried, and of going to
sleep and enjoying himself at home, when somebody started messing him
about. In hypnosis, he gave further details of his dreams after falling
asleep in the buried state.
December 26, further details were remembered before hypnosis, such
as a ride in the motor ambulance, offers of tea, cocoa, sweets, and
cigarettes, a bad headache, and the like.
December 27, in hypnosis, he was able to describe with apparent
accuracy the position of the trenches and their appearance. He said:
“The explosion lifted us up and dropped us again. It seemed as
if the ground underneath had been taken away. I was lying on
my right side, resting on my right hand, when the shell came.
I got my right hand loose but my wrist was fixed behind a
piece of fallen timber. At last I dropped off to sleep and had
funny dreams of things at home. One thing in particular I have
thought of many times since, I have not been able to make out
why I should dream of the young lady playing the piano. I don’t
know her name and I don’t think I have seen her above twice.”
According to Myers, it is questionable how far the patient’s memory
can be trusted; and there is considerable doubt whether the man had
remained in the trench for more than an hour after the shell had burst.
A comrade said that the doctors at the barn thought the man off his
head. Another soldier, familiar with the positions of the regiments in
question, gave information suggesting that the patient had wandered in
a somnambulistic state from the trench, past his own dressing station
to that of another regiment.
_Re_ Shell-shock and burial cases, compare remarks of Grasset and of
Foucault concerning the feeling as if dead on the part of certain
buried persons. Somnambulism is a natural sequel to such feelings. For
somnambulism, compare cases of Milian (364, 365, and 366).
Shell-shock; minor injuries: Somnambulistic “carrying on”;
fatigueability, physical and mental.
=Case 362.= (DONATH, July, 1915.)
A lieutenant of infantry, 31, threw himself down on the earth September
9, 1914, as a shell was passing over him. The shell exploded and
seriously injured a soldier one meter away. The lieutenant got up and
ran for cover about twenty meters distant. Only six and a half hours
later did he perceive that there was a small skin lesion between his
thumb and index finger, caused by a shell fragment, as well as a
superficial burn on his right temple. Neither wound bled or had to be
dressed. He carried on, aware that they were marching toward the River
D.; but only two or three days later did he find they had already
marched to the other side of K., had rested there and spent the night
in various places in between. During this whole period the lieutenant
led his battalion and held a piece of woods without anyone’s noticing
anything striking about him. These dazed states were twice repeated,
for periods of ten and twenty-four hours respectively, and finally he
was brought behind the firing lines unconscious.
The physician found him to be in a state of exhaustion, pulse 108, and
had him brought to the nearest station. There Donath found increased
tendon reflexes, some dermatographia and increased fatigueability of
mind and body. He was especially fatigued by walking, though he had
always been a good mountain climber. He was now unable to concentrate
on reading, writing or calculating, though he had been accustomed to
dictate letters and calculations in his official work in peace times.
He had seizures of crying and trembling on September 10 and October 27,
both quieted by bromides. There was diminution of sexual power.
Rest, lukewarm baths, cold compresses to the head, and psychotherapy
improved his status rapidly.
This patient had never been epileptic or hysterical, subject to dazed
states of any sort, was weak, delicate and anemic (three sisters
leukemic), but had before the war been well.
Emotion of captain who saw men burned by bomb: Stupor “as if dead”;
awakening “as if a German prisoner.” Recovery.
=Case 363.= (RÉGIS, May, 1915.)
A captain, one day seeing some of his men hit by incendiary bombs,
felt the deepest kind of emotion. He threw his coat over one of his
men and succeeded in smothering the fire. Of a sudden, he completely
lost consciousness, only regaining contact with the outer world two
days later, in the sanitary train. He did not know where he was, but
thought himself a prisoner surrounded by Germans. The disorder of
consciousness lasted three days, and the memory of what happened during
those days never returned. In fact, the captain declared that he felt
as if he had been dead during that time. His dreamlike state lasted for
some time, and for several weeks he did not sleep without disturbing
nightmares. It was always the same night attack, with the burned men
and the anguish of feeling that his men were not about him and that
he was alone in the skirmish. He later recovered entirely and made
preparations to start for the front.
_Re_ feelings “as if dead,” see remarks of Régis under Case 293.
Emotions over battle scenes: Spontaneous hypnosis or SOMNAMBULISM
lasting twenty-four days.
=Case 364.= (MILIAN, January, 1915.)
Upon recovery from a state of apparent hypnosis described below, the
victim wrote, in part, as follows:
“After marching two days we reached a Breton village near
Virtou. Next day we were in a battle that lasted from seven in
the morning to eight in the evening. I was somewhat troubled by
the first balls and bullets that whistled by, but felt I had to
get used to them and we marched on, under our brave captain’s
orders. Then we really got under fire. It was sad to see my
comrades falling under the murderous bullets, and the captain
was soon mortally wounded; but we had reinforcements and went
on and chased the enemy from his positions. During the battle
I kept thinking of my old mother and father and I felt that
I should die without seeing them again. Little things about
the family came to my mind. I saw my father’s roof, and his
favorite garden seat, and I saw my mother weeping over her only
son, her only ambition in old age. The return from the battle
was very sad for me. Night began to fall on the frightful
field. I saw on the bare earth the bodies of poor comrades
whose joys and sorrows I had shared. There they were, cut down
in all the strength of youth, leaving their parents in trouble,
their widows in despair, and their poor orphans. I wanted to
carry them off and I could not. We had to march over their
glorious remains. I was able to give a word of encouragement
to one of my comrades who now probably is no more. We then
retired. Although I was very weary, I was unable to get any
rest. My mind was occupied with the frightful things I had
seen. I thought of the comrades over there and that no one
could help them. I remember I drank coffee the next morning and
talked with my relative. Then that is all. From that time I do
not know what happened.”
The writer was an infantryman, 20, who had been employed in civil life
in the Crédit Lyonnais, and was brought August 24, 1914, to the Saint
Nicolas Hospital in a state of hypnosis.
Once placed in the standing position he kept balancing back and forth,
with head motionless, eyes fixed and directed to the left side. He
did not speak in reply to a request for his name or facts about his
life, but as soon as the battle was talked of he began an expressive
pantomime, speaking in a very low voice a few words interrupted by
sighs. “What were you doing in the fight?” He extended his arms,
described a half circle with his hand, as if to show the extent of the
field, thrust his hands forward with a finger outstretched, saying,
“Zi, zi,” as if to indicate whistling bullets; plunged forward with
hands in front of his chest, as if holding a gun in charge bayonet
position, saying “Prussians, Prussians,” and threw himself down in a
kneeling posture, saying, “Trenches, trenches.” “Do you remember the
battle?” “Belgium, Belgium. Germans pushed back,” making a sign as if
chasing them. “Captain dead. Two hundred men dead.” With a suitable
gesture he sighed, and tears ran down his face.
August 28 the mutism was still almost complete, but he could say his
name and lay stretched out on the bed.
September 4 the hypnosis was less, but the delirious state was more
active. He got up in the night and tried to escape to help the wounded.
In the daytime, if he saw a man lying down resting he went to him and
unbuttoned his coat to see whether he was wounded. Upon seeing the
physician he would cry, “Major! Wounded! wounded!” and then pull the
physician by his coat. He could hardly be stopped from these maneuvers.
He had to be fed like a child, but went alone to stool.
He began to be employed about the hospital a little September 14,
in sweeping the room and in guarding another patient in complete
somnambulism, over whom he watched as over a child, leading him by the
hand and keeping him from bumping into objects.
September 16 he awoke suddenly. Some one had talked to him about his
own village and his relatives. He was astonished to find himself
in a hospital. He wrote out, on request, the above account of his
recollections. The man was 177 cm. tall, well proportioned; showed a
slight facial asymmetry and a few other facial features of a dystrophic
nature, such as an adenoid appearance. There was no stigma of hysteria.
Putative loss of brother nearby in battle: Spontaneous hypnosis or
somnambulism; mutism, except “Mamma, Mamma.” Sudden awakening after
twenty-seven days.
=Case 365.= (MILIAN, January, 1915.)
A man, 22, was brought to the Saint Nicolas Hospital in a sort of
coma August 24, 1914. He lay on the bed, eyes closed as if asleep,
insensible to excitation, irresponsive. Flies crawled upon him with
impunity. He did not wink. The arms raised fell back inert. The corneal
reflex was absent on the left side, diminished on the right. The
knee-jerks and the skin reflexes were normal.
Next day he had to be fed like a child and looked after. Lifted from
bed, once on the ground he stood up with flexed legs, as if to crouch.
It seemed as if he was about to fall, but he did not.
The next day he was in the same immobile state. Upon removal from bed
he again made as if to fall, but got his balance. He kept his legs
flexed, his head lowered in a fixed posture, with his eyes on the
ground. He would walk quickly without falling, if taken by the hand,
feet dragging, and even holding back with a certain amount of force.
His walk suggested that of a somnambulist. He was left in a standing
posture by his bed throughout the medical visit. After a few minutes
he began to flex his legs progressively and slowly. The attendant
cried out, “He is going to fall.” Instead of falling, he sat down upon
the floor near the bed. He was in the same immobile, somnolent state
September 1, eyes half open, hidden under long lashes. Flies walked
over his eyes and lids, but he did not wink. He would rise only when
pushed and walk only when pulled, but had begun to eat a little better.
To all questions he replied, from between his teeth, “Mamma. Mamma.”
The next day there was a bit more spontaneity in his walking.
Lumbar puncture showed a slight hypertension. There were traces of
albumin and very few lymphocytes.
September 6, he was able to eat soup alone, but kept the same immobile
posture, with eyes fixed on the ground, eyelids not winking, in a
posture suggesting Parkinson’s disease, but without rigidity. He still
replied only, “Mamma. Mamma.”
September 19 the patient suddenly waked up completely. Douches and
external irritations had not served to wake him up, but a soldier told
him upon this day that his brother was not dead, as he believed, but
was alive and he then began to speak, opened his eyes, and began to
talk. He told how he had been by the side of his brother in battle.
Germans had taken them in the flank and opened machine guns upon them.
Two men had fallen by his side, and, catching at his garments, kept
him from retiring when the order was given. He got loose, looked for
his brother among the corpses, could not find him, thought him dead,
and from that point forward had been without memory. He shortly became
perfectly normal.
Shell-shock; slight trauma; windage felt; fall; loss of consciousness;
wandering, conscious, over night; shrapnel burst: Spontaneous hypnosis
or somnambulism, lasting four days. Return to the corps.
=Case 366.= (MILIAN, January, 1915.)
An infantryman, 20, boxer by profession, was brought with other
wounded, in the night, to Saint Nicolas Hospital and was seen next
morning, August 24, in bed, lying motionless on his back, eyes open,
fixed, eyelids not winking. No reply was got to questions. The arm
lifted fell back upon the bed, although slowly and not heavily as in
apoplexy. There was no catalepsy. The patient was taken from his bed
and put upright. In this position he remained immobile, hands at side,
head bent forward, eyes fixed on the ground. The eyelids did not move
upon approach of the finger or a lighted candle, unless there was a
fine beginning of movement. If he was pushed, he made two or three
steps forward, with eyes fixed on the ground and head bent forward. The
only spontaneous movement was carrying the left hand back to the side
as if to take the bayonet. He got into bed alone.
Next day the patient could walk better and began to talk, but preserved
the same absorbed attitude. He told, in monotonous voice, of the shells
that his squad had received and of the dead that he saw about him.
August 27 he woke up and was unable to tell how he had come to the
hospital. He told how the regiment had been bombarded for a time and
how a shell burst near him; how he got a splinter in the buttock (of
which the contusion was still visible); and how he had been thrown down
by the windage of the shell. His sack had been torn from his shoulders.
He had lost consciousness, he thought, for a short time, anyhow he
could not find his regiment. He passed the night near Longuyon and
next day looked for his regiment again. Shrapnel burst near him, and
from that time forward he had lost memory. August 27, at his express
request, he started back for his corps. There was no stigma of
degeneration or hysteria.
Burial; struck in head by beam; overcome by gas: Tremors, convulsive
movements, confusion, flight toward enemy.
=Case 367.= (CONSIGLIO, 1916.)
An Italian private, 28, of meager build (infantile eclampsia; brother
epileptic) was buried by a shell explosion and overcome by gas. After a
month’s leave he went back to the trenches.
But now, whenever a shell burst, he fell into irresistible terror and
made convulsive movements which he forgot afterwards. He could not
sleep. The mere memory of the scene would throw him into terror. He
was tremulous, developed asymmetrical innervation of his face, was
generally hypesthetic and mentally blocked.
In the midst of convulsive tremors he fled towards the enemy. He was
stopped and brought back, and remained for two days confused and
hallucinated.
In the original accident he had been struck in the head by a beam.
_Re_ this Italian’s flight toward the enemy, see various cases of
fugue. Clinically and medico-legally, Roussy and Lhermitte remark that
these confusional escapades are of great interest, and that many cases
are encountered near the front line, put under trial by court-martial,
and handed over to specialists. The dream is being lived through. Such
a case as this of Consiglio recalls the hystero-emotional psychoses
of Claude, Dide, and Lejonne. The relation of oniric delirium to
mental confusion is still a matter of polemic. According to Régis,
however, the common oniric delirium of toxic or infectious origin
is nothing more than a sort of somnambulism. The retrograde amnesia
which follows toxic delirium is the same in principle as that which
follows hysterical delirium. Régis pointed out that suggestive hypnosis
could bring back the memories in both types of disease, as well as
from the toxic delirium as from the hysterical somnambulism. However,
the differential diagnosis between onirism and hysteria is not easy.
Alcoholism and actual brain trauma need to be excluded.
Shell-shock; windage; unconsciousness: Carried on with fugue
tendencies. Variety of hysterical symptoms. Fit for garrison duty four
months from explosion.
=Case 368.= (BINSWANGER, July, 1915.)
A non-commissioned officer, 22, entered service at 20, went into the
artillery and had been advanced repeatedly. There was no heredity; the
man had been a moderately good scholar. It appears that he had had at
17 a febrile angina with delirium.
September 25, 1914, a big shell load for a cannon was exploded by
the enemy. All the men about the cannon were thrown to the ground by
air pressure, and the officer became unconscious. On awaking, he had
headache, dizziness, and vomiting. There were many corpses lying about
him.
He resumed work at once, but in the evening his headache and dizziness
increased and there was “a feeling inside as if he had to run away.”
This feeling appeared to come from the heart; it was an oppressive
feeling, running to the head. On the next day he did gun duty,
noticing, however, that every shot he fired caused him a sharp pain.
He was relieved from work at 11 A.M., and was declared ill by the
physician. His comrades told him that he had often been noticed trying
to run away, but about this he himself declared he knew nothing.
He was received at the Jena Hospital, October 9, 1914, a very strongly
built and well-nourished man. Neurologically, he showed a marked
dermatographia; knee-jerks were obtainable only on reinforcement;
Achilles jerks somewhat more marked; there was a weakly positive
Oppenheim reflex. The abdominal reflex on the left side was greater
than that on the right; and this was also true of the cremaster reflex.
Percussion of the head was extremely painful; and there were painful
points on pressure of the spine and head.
Touch was poor on the entire left side of the body; but there was no
diminution of sensibility to pain. There was a fine static tremor
of the hands. The strength of both hands appeared to be decreased
(dynamometer). Gait was unsteady and stiff; Romberg sign was positive;
the patient fell over backward. Hearing was greatly diminished,
ordinary speech being heard only close to the ear.
Toward evening of the second day after admission, there was a marked
attack of dizziness while the patient was lying on his back in bed.
During this attack the face was very red. It lasted two or three
minutes. Hearing was remarkably improved on the left side for some
time after the attack. The ear clinic examination, October 19, showed
much disturbance of hearing on the right side (direct injury of the
vestibular apparatus in both ears).
Headaches continued, radiating from the orbit to the top of the head,
and sensitiveness to pressure at the exit point of the upper branch of
the right trigeminal. The whole of the forehead was somewhat red and
swollen (neuralgia of the frontalis). The patient wore dark goggles on
account of his marked photophobia.
Improvement was gradual; there was a transient slight swelling and
a venous hyperemia of the nasal mucosa, which was treated in the
nose clinic. The impairment of hearing was quite gone in two months’
time, though buzzing was now and then heard in the right ear. The
supersensitiveness in the right upper trigeminal region vanished also.
The patient was discharged January 21, 1915, fit for garrison duty.
Later he went into the field again.
Burial: Dissociation of personality.
=Case 369.= (FEILING, July, 1915.)
The following are some stories told by a “lost personality” under
hypnosis.
The patient, aged 24, was a bandsman in the Second Battalion Wiltshire
Regiment, who sometime near the end of October 1914, was buried in a
trench near Ypres. This is his account:
“I was dug out at night and taken to a dressing station; it was cold
and dark. Then I went on to a hospital at Ypres; it was really a
convent, and there were a lot of nuns about, dressed in dark robes with
white hats; some of them spoke English. I stopped there for a night and
a day. There were a lot of wounded there. Then I was sent on by train;
I lay down all the way on a seat in the carriage; we took the whole day
to get to ----, and kept on stopping at stations. I was at ---- about
ten days; I don’t know what hospital it was, but there were English
doctors and nurses. It was near the harbor. We came over to England in
a hospital ship, the _Arethusa_; I went straight on to Manchester by
train. The hospital there was really a school turned into a hospital.”
Here is a brief account of a scrap with some Uhlans.
Q. Did you see any Uhlans? Yes.
Q. What are they like? They’ve got no guts. One time 30 of them were
against 8 of us infantry, and they “done a bunk.” Their horses were not
bad. They wore helmets with a double eagle on the front.
He was asked to describe the country round the trenches and to give
some account of the fighting there:
“It’s agricultural land, ploughed fields. There were two farms in front
of us. One day we saw an old cow between our trenches and the Germans,
and we all had pot shots at it. Once the Germans rushed our trenches;
we killed hundreds, bayoneted them mostly, and hit them over the heads
with the butts of our rifles. It was hellish. The British were all
shouting. I saw a German officer behind with a sword and a revolver.
I saw a lot of French soldiers, too; they wore long coats with the
corners turned back; some had blue and some had red trousers. The
French dragoons are like Life Guards, with big steel breastplates and
brass helmets with a long plume; they carried swords and rifles and a
few had lances.”
He was asked to mention some of his impressions in Belgium and what he
thought of the manners and customs of the French and Belgians.
“We cut off all our buttons and gave them to the French girls. The
French cigarettes are muck; you buy them in little blue packets; the
tobacco is rather dark and strong. When we bivouacked on the march at
night we were not allowed any lights, but you could smoke by digging a
hole in the ground with your bayonet and smoking into that.”
The following are some of his remarks about his stay at Gibraltar.
“Gibraltar’s like a great big rock; the steep side looks toward Spain.
I was in barracks there, and used to spend a lot of time in the
band-room practicing. Sometimes we bathed in the sea. I went to Spain
two or three times and saw some bull-fights; they were very exciting,
but rather too cruel for my taste. They used to kill six or seven bulls
a day. The horses got fearfully cut about.”
This bandsman showed what Feiling calls dissociation of personality.
There was an amnesia of such degree that all conscious memories of the
patient’s life, as well as all memory of letters, objects, and life in
general, were suppressed. The patient was brought, after the burial
above noted, to the hospital for epilepsy and paralysis at Maida Vale,
January 21, 1915. After his experience, he had been transferred to the
Second Western General Hospital, Manchester, where he spoke sensibly,
understood and was able to remember things since the burial. His mind
was a complete blank for all previous experience. He was unable to
recognize his own father or relatives. He was slightly deaf for a time
but this defect disappeared.
At Maida Vale he showed a nervous twitching of eyelids and facial
muscles; otherwise he was neurologically and physically normal,
dreamless, without complaints, and straightforward about all
experiences since coming to himself in the hospital at Manchester. He
took his parents on trust. “I don’t know if I ever went to school.” “A
bayonet is like a knife; you see soldiers with them on their rifles. I
have never seen a bullet.” His memory for recent events was also not
good. He once recognized a single tune played at a concert.
Suspected of malingering, he was tried out in various ways. He was told
that an elephant was a little furry animal and shown a little 6 inch
toy sample. On going to the zoo he was greatly astonished at seeing a
real elephant. He did not know what the war was about and he had no
interest therein.
March 10 he was hypnotized and proved an easy subject. Powerful
suggestions that lost memories would return were unavailing. The next
day, during hypnosis, it was found that his previous experience could
be readily tapped, and a history of his family, schooling, running
away, and eventual enlistment was told. He had been at Gibraltar when
war broke out. He was at the first battle at Ypres, and was for ten
days in severe trench fighting, and was finally buried in the mud and
débris of a trench blown in by a high explosive shell. He had been
buried for about 12 hours, was dug out at night, and (according to his
father) remained unconscious 24 hours, and deaf and dumb three days. He
was transferred to another hospital and then to Manchester, where he
came to himself.
Only during the first few sittings did the patient lie with eyes
closed. Later, during hypnosis, he behaved exactly like a normal
person. The fact came to light that when hypnotized the patient
returned to the personality that possessed him just before awakening
in Manchester, and accordingly during hypnosis, he had to become
acquainted again with his hypnotizer. Maida Vale astonished him, as it
should have been Manchester. Thus there were two personalities: No. 1:
The personality since the date of the Manchester awakening; No. 2: The
personality containing all the memories of the past life as well as the
more recent Flanders memories. In State No. 1, the manner was jaunty
and cocksure. In State No. 2, the man was more modest and less loud.
Moreover, though in State No. 1 he spoke with a Lancashire accent,
in State No. 2 his speech was in the West Country dialect--a strange
observation, confirmed by several observers. He was asked to write down
the answers to questions, and on awakening from hypnosis was shown the
things written; whereupon he laughed and said, “Why, that’s not my
writing.” On writing out the same sentences again, various minor points
of difference were apparent. Hypnotized in the presence of his father,
in whom in State No. 1 he took no great interest, he showed every sign
of joy, causing his father to think that in State No. 2, his son had
“come all right again.” In State No. 2 he could play a euphonium better
than in State No. 1; but after practicing in State No. 1 he rapidly
became as expert as in the hypnotic state.
If the patient were left for some time before being awaked by a
previously-arranged method of counting three, he would experience
disturbed dreams, with clenched hands, snarling lips, and muttered
phrases, “Give it them,” etc.
Twenty-five hypnotic sittings were given but no improvement took place
and the patient was discharged May 5. May 25 there had been no further
change and he remained in State No. 1, in which state he was invalided
from the service by a medical board, May 28.
Ear complications and hysteria.
=Case 370.= (BUSCAINO AND COPPOLA, 1916.)
An infantryman, 22 (father and mother quite normal; patient showed
slight convulsions, attributed to worms, from which he actually
suffered; was malarial from 9 to 15; had otitis media and lost hearing
completely at 11; had suffered from 9 onwards with joint pains; as an
adult had no convulsions), was called to arms August, 1914, and sent
to the front May 2, 1915. About the end of August, in a water-filled
trench by Monte San Michele, he was covered with mud from a shell
explosion, lost consciousness, and in some way got back to the second
line. He was told that blood had flowed from the right ear, and on
recovery he found himself unable to hear with that ear, although it was
the left in which he had had otitis. There were continual noises in
the ear. He was, however, sent back to the front line. By mistake, one
day, he got with companions in the midst of the enemy’s barbed wire,
saw sparks from the guns, heard no shots, saw comrades fall, and threw
himself instinctively into the wire network. Leaving the food kettles,
he finally got back to the trenches. He was sent to the hospital at
Legnano for his ear pains, and was treated by leeches, which he could
not feel. He began to hear a little more. Flies walked on the left
cheek without being felt. This anesthesia had begun a few days after
the shell explosion. He was transferred to a military hospital at
Florence.
One day he wedged a toothpick in cotton into his left ear and was
charged with simulation, though he had been absolutely deaf in his left
ear since childhood. From the moment the military surgeon told him he
would be denounced for simulation, he lost his memory. Reports indicate
that he had headache and delirious dreams (October 30), and suddenly he
became furious (October 31), about three hours later going into severe
collapse, for which camphor injections were given.
November 1 he had battle dreams and lumbar puncture had to be given
up as he was in the midst of an attack. A hypodermic injection was
interpreted by the patient as a wound, and he cried as if he were
being abandoned on the battle-field. At one point he woke up from
his hallucination and asked where he was and shortly relapsed into
stupor. November 2, the patient was slightly bewildered and felt pains
where the lumbar puncture needle had been tried the previous day.
November 5, he was disoriented, thinking himself still at Legnano.
The pupils were throughout dilated. November 6, confused and dreamy;
November 7, he soiled his bed, was somewhat disoriented, immediately
corrected himself; oculo-cardiac reflex 64 full compression, 62 during
compression. November 11, headache; November 12, a slight bewilderment
reappeared; November 13, remembered for the first time having been
stunned by shell explosion, and this day got up and wrote home.
November 14, complained of pains in muscles and weariness. Pupils still
dilated. November 16, pulse 86; a gradual increase from 50 to 60 during
previous days. November 17, patient had begun to remember facts that
preceded the dream syndrome. November 18, pulse standing 88; November
20, pulse standing 120. This day cried when he remembered having been
suspected of simulation. November 22 and 23, aches in joints and
intense otalgia; pulse 86. November 24, diarrhea; deafness somewhat
diminished; 26, diarrhea; looked as if he were about to have a new
hallucinatory episode. This, however, did not come about until December
1, when he heard cannonading and knew the regiment was near. Next day
he had forgotten the cannonading. December 14, the patient had become
entirely tranquil and lucid and was able to give his entire history.
December 16 and 17 he was given a systematic neurological examination,
which showed on the left side complete anesthesia, hyperesthesia to
pressure, thermanesthesia, analgesia, loss of bone, tendon, and muscle
sensation. Vision was diminished more on the right side than on the
left, and the visual fields on this side were more contracted. During
examination, the fields became still more tubular. There was complete
deafness, anosmia, and ageusia on the left side. On the right side
there was a slight diminution of hearing. The pharyngeal reflex
was abolished; the cremasteric reflex was somewhat less on the left
than the right; and the defensor reflexes of the left leg were less
marked than those of the right. There was no clonus or Babinski. The
dynamometer grasp on the right was 37; on the left 18; and on this side
there was a limitation of voluntary movements.
CHART 10
ETIOLOGY OF SHELL-SHOCK
WOUNDS 14 of 150
PHYSICAL
EXHAUSTION FROM EXPOSURE, HARDSHIP (all neuropaths) 3 of 142
CONCUSSION 52 of 142
CHEMICAL--SHELL GAS 3 of 150
PSYCHIC
GRADUAL EXHAUSTION, PREDISPOSING (43 neuropaths) 51 of 132
SAME, ACTING PER SE (patients chiefly neuropaths)
SUDDEN SHOCK
HORRIBLE SIGHTS 51 of 142
LOSSES OF COMPANIONS
FRIGHT NEAR EXPLOSION (one neuropath)
SOUNDS (a few neuropaths)
RELAPSES (41 of 150 observed, three-quarters neuropaths)
After Wiltshire
C. THE DIAGNOSIS OF SHELL-SHOCK
Chè non è impresa da pigliare a gabbo
descriver fondo a tutto l’universo,
nè da lingua che chiami mamma e babbo.
For to describe the bottom of all the universe
is not an enterprise for being taken up in sport,
nor for a tongue that cries mamma and papa.
Inferno, Canto XXXII, 7-9.
In the course of our study of psychoses incidental in the war (Section
A) and especially of Shell-shock’s nature and causes (Section B),
we have naturally met most if not all of the major diagnostic
difficulties. In the present Section we shall study cases for the light
they may throw on the more technical troubles of the diagnostician.
Who would _à priori_ have felt that such diseases as tetanus, rabies,
malaria, would produce practical difficulties in clinical diagnosis in
the field of Shell-shock?
Mayhap there was no need to emphasize further the values of lumbar
puncture fluid examination. Yet the admixture of “functional”
and “organic” symptoms in numerous puzzling cases can hardly be
over-emphasized.
But the interpolation, through the ingenious inquiries of Babinski,
of a new or but vaguely suspected series of “reflex” (“physiopathic”)
troubles between the organic neuropathic disorders on the one hand and
the hysterical psychopathic disorders on the other--the result of these
observations, sampled only in Section B, is given more in detail in the
present Section. What a split in therapeutic method a recognition of
this new group of “physiopathic” disorders might entail is seen also in
further cases in the Section that follows this (Section D on Treatment
and Results).
A number of simulation cases has been added.
CHART 11
ETIOLOGICAL GROUPING OF WAR PSYCHONEUROSES
I. NEUROSO-ORGANIC ASSOCIATION (NO CAUSAL NEXUS)
II. REFLEX NEUROSES (LESION DISPROPORTIONATELY SLIGHT BY
COMPARISON WITH PSYCHONEUROSIS)
III. NEUROSO-SOMATIC ASSOCIATION (TRENCH FOOT, NEURITIS,
RADICULITIS)
IV. FATIGUE OR EMOTIONAL PSYCHONEUROSES (CONSIDER EFFECTS OF
PSYCHIC CONTAGION, EDUCATION)
V. PSYCHONEUROSES ON ANTEBELLUM BASIS
After Grasset
CHART 12
WAR PSYCHONEUROSES
SYMPTOMATIC GROUPS
I. EMOTIONAL (HYPER- HYPO- PARA-)
II. CONFUSIONAL (ATTENTION AND MEMORY DISORDER, DREAM STATES;
DELIRIA)
III. CONVULSIVE AND PITHIATIC (HYSTERICAL)
IV. NEURASTHENIC AND PSYCHASTHENIC
V. SENSITIVOMOTOR AND SENSORIMOTOR--_e.g._, LIMITED PARALYSES,
CONTRACTURES, DEAF-MUTISM
VI. COMPLEX
VII. PHYSIOPATHIC (BABINSKI)
After Grasset
Value of lumbar puncture.
=Case 371.= (SOUQUES and DONNET, October, 1915.)
A colonial soldier arrived at Paul-Brousse Hospital with a hospital
ticket showing that ten days before he had had _commotio cerebri_.
He was dull, had a fixed stare, held his head in his hands, was
disoriented for time and place, and had lost memory for everything that
had happened for eighteen months. There was no sign of wound. There
was no motor disorder save that walking was a bit slow and uncertain.
Perhaps the right knee-jerk was stronger than the left. Percussion
of the right Achilles tendon produced tremor. The plantar reflexes
were flexor on both sides; flexion lasted longer right than left. The
cremasteric and abdominal reflexes were a little weaker on the right.
Arm reflexes were lively. Sensations proved normal. Complaint of
headache, frontal and vertical.
Lumbar puncture October 7, that is, on the thirteenth day after the
shell-shock, yielded a transparent, slightly greenish fluid, with 92
cells per cm. (lymphocytes with one or two large mononuclear cells and
a few sometimes degenerated endothelial cells) and hyperalbuminosis.
October 9, the clouding of consciousness was less marked. The headaches
and amnesia were constantly complained of; the reflexes were normal.
October 12, there was less headache. October 25, another lumbar
puncture showed but 14 or 15 lymphocytes per cm. and hyperalbuminosis.
There was now no longer any clouding of consciousness. The amnesia,
retrograde and anterograde back to May 9, 1914 (date of his daughter’s
birth), and up to September 25, 1915, persisted. The man did not
remember the declaration of war, or the mobilization, or his regiment,
and the like. Meantime, the man’s judgment and reasoning powers were
normal.
If there had been no early spinal fluid examination of this patient, he
might well have been considered an hysteric or even a simulator.
Meningeal and intraspinal hemorrhage: Lumbar puncture.
=Case 372.= (GUILLAIN, May, 1915.)
A gunner from Morocco, who lost consciousness for an hour March 28,
1915, upon the explosion of a large-calibre shell in his trench, was
carried to the ambulance. He complained of headache and generalized
pains. His status was scarcely modified during five weeks, and a
generalized contracture of the body developed whenever movements were
attempted. In horizontal decubitus, the muscles of the limbs and neck
were of a normal tonicity, but the head went into hyperflexion if
the patient was asked to sit. The eyes turned upward, and Kernig’s
sign developed. The patient could walk only with short steps, with
legs apart and arms held away from the body, the head in a sort of
tetanoid dorsal hyperflexion. There was a right-sided hemiparesis with
trepidation and the Babinski sign.
Lumbar puncture assured the diagnosis of something organic. The
fluid contained blood cells and a marked lymphocytosis. The symptoms
evidently depended upon hemorrhages in the meninges and the nervous
system, affecting particularly the right pyramidal tract.
_Re_ hypothesis of organic changes in hysterical cases, Roussy and
Lhermitte remark in comment upon albuminosis in the cerebrospinal fluid
that the albumin is perhaps due (in cases of camptocormia) to the
effect upon venous and lymphatic circulation of the spinal curvature.
It was Sicard’s claim that camptocormia, or bent back, was due possibly
to anatomical changes in the spinal column, that is, that camptocormia
was in one sense a spondylitis. In other cases the camptocormia might
be due to a ligamentous or muscular change; that is, to a syndesmitis
or a psoitis. His idea was that the curvature was in a sense antalgic;
that is, a response having the purpose of avoiding pain.
Slight hyperalbuminosis.
=Case 373.= (RAVAUT, August, 1915.)
A farmer, 32, in the 66th Infantry, was lying in a dug-out March 5,
1915, when a bomb threw him on the ground and covered him with earth.
He was picked up unconscious, and remained so for an hour. In the
ambulance it was found that he could hardly stand, could not speak,
and appeared to be completely confused. There was no sign of wound.
The next day he recovered consciousness and complained of a violent
headache. He was completely deaf in the left ear, and vision was also a
little impaired on that side. The puncture fluid was clear, and there
was a very slight excess of albumin by the heat test. The next day the
headache had entirely disappeared, the left ear was absolutely deaf,
but the patient complained of buzzing. Lumbar puncture the following
day showed a normal amount of albumin.
March 16 the patient was evacuated to the rear presenting no abnormal
symptom except deafness.
_Re_ the spinal fluid, Armstrong-Jones considers that a shock directly
sustained by the spinal apparatus through sudden impact to the
surrounding cerebrospinal fluid, ought to be felt more by the anterior
horn cells than by the spinal root ganglia, since the latter are
shielded by the sheath in the intervertebral spaces. Motor symptoms
would, naturally, then be more frequent than sensory symptoms. He also
believes that the controlling neurones in the intermedio-lateral tracts
that have to do with the sympathetic system, would be affected just as
anterior horn cells are. Accordingly, the dilated pupils, rapid heart,
dyspnoea, and a variety of precordial pains and disorder of the viscera
would ensue. The jar would thus be communicated to the neuronic cells
of origin of two types: spinomuscular and preganglionic, leaving the
gangliospinal neurones relatively intact.
Paraplegia, organic: Lumbar puncture.
=Case 374.= (JOUBERT, October, 1915.)
A gunner, 23, was thrown to the ground, according to his story, by the
explosion of a large-calibre shell, at eight o’clock in the morning of
September 10, 1914. He could not get up but thought he had not lost
consciousness. September 13, he arrived at hospital, looking like a man
with dorsolumbar fracture of the spine. There was, however, no external
injury. There was a marked paresis of the right upper extremity, with
diminished sensibility, weakened reflexes, numbness, formication. The
right lower extremity was subject to complete flaccid paralysis, with
lost reflexes, and anesthesia in all respects reached to the belt
level, and stopped sharply at the median line of the abdomen. The left
leg, also, was paretic but the muscles could be contracted weakly;
the knee-jerk was exaggerated; there was a tendency to epileptoid
trepidation, and the sensations were only slightly diminished. There
was a Babinski reflex on the right side; the abdominal reflex was
absent on the left side; both cremasteric reflexes were present.
The feet at times gave formication. Rectal, bladder, and sphincter
paralysis. Dark albuminous urine, with a few blood cells, was obtained
on catheterization. There was an early sacral decubitus; consciousness
was somewhat clouded. The man made no requests except for something to
drink, and seemed apathetic.
Lumbar puncture, September 14, yielded hemorrhagic fluid. Three days
later, the upper extremity regained its powers and sensations, but the
paraplegia had become complete, with abolition of reflexes on both
sides, and absolute anesthesia. The feet yielded formication at times,
however. Sacral decubitus increased and healed not. The temperature
varied between 38 and 39. The patient died September 24, in coma, with
anuria and Cheyne-Stokes breathing.
Gunshot wound of spinal column; no penetration or injury of dura mater:
At first quadriplegia; later cerebellospasmodic type of disorder.
=Case 375.= (CLAUDE and LHERMITTE, July, 1917.)
A soldier, 22, sustained a gunshot wound in the neck about the level
of the fourth cervical vertebra. He immediately became quadriplegic.
He recovered arm motion in two months and some weeks later ability to
stand and walk.
Three months after the injury, station was difficult, better on a broad
base. Rombergism, even with eyes open. Cerebellospasmodic gait. There
was no weakness of leg muscles, but there was a certain degree of
weakness of the upper extremities, especially in finger flexion. There
was hypertonia of the muscles of all the extremities and the hands
showed the signs of Raimiste, of Klippel and Weil, and of Dejerine.
Static equilibrium was preserved to the will, but the kinetic balance
was affected, and as much in the upper as in the lower extremities.
Ataxia, tremors, dysmetria, adiadocho-kinesia, and disorder of combined
movements in thigh and trunk flexion were all in evidence. Meantime,
there was no disorder of sensation whatever except that the ulnar
border of the right hand showed a hypobaresthesia, and there was a
disturbance of tactile discrimination and absolute astereognosis in
the hands. The deep reflexes were everywhere increased, and ankle and
patellar clonus were easy to excite, especially on the right side.
Bilateral defense reflexes. Bilateral Babinski sign. The hypertonia and
ataxia ebbed away during the following three months. Walking became
normal, and there was little sign of difficulty except astereognosis of
both hands, combined with slight disturbance of deep sensibility and
poor response to compass test in palm.
We here deal with a case of spinal column injury without injury to the
dura mater. This cerebellospasmodic form of the superior cervical type
of spinal concussion is less frequent than a quadriplegic form with
Brown-Séquard syndrome. It is striking that both types of concussion
may recover.
Spinal column trauma, with local signs: Later, hysterical anesthesia
and contracture of back muscles homolateral with the trauma.
=Case 376.= (OPPENHEIM, July, 1915.)
A musketeer, wounded August 20, 1914, by a shell splinter in right side
of vertebral column, fell unconscious, but was able afterward to crawl
on all-fours out of the firing line. Severe vomiting and epistaxis
followed. August 23, there was pain in the small of the back; the last
two ribs were painful on right side; and the muscles were slightly
swollen up to the iliac crest. August 30, a slight rise of temperature
(at first it had been above 38) still persisted, but the muscular
swelling was diminished. Treatment by aspirin and baths. No further
rise of temperature after early in September.
On October 9, patient was permitted to get up, whereupon he showed a
peculiar curved attitude of the body, reduced almost completely by
passive straightening. Swelling of the longitudinal muscles. Radiograph
negative, except that one picture showed a change in left twelfth rib,
near the transverse process. Pains in left lumbar region.
November 19, on examination, pulse 112. November 23, after massage,
vomiting. Temporary use of plaster corset.
On admission to the nerve hospital December 22, the musketeer was
unable to extend the trunk, and the long muscles of the back were
on the stretch, often as hard as wood, especially those of the
left (longissimus dorsi). Patient lay on right half of pelvis.
Hemianesthesia and hemianalgesia, left side. Tachycardia. Formerly the
patient had done hard work, especially carrying heavy bags. He declined
to be examined under general anesthesia. He seemed to be of unreliable
character, and his trouble did not prevent him from returning from
leave of absence, on one occasion, drunk.
Mine explosion: Combined hysterical and lesional effects.
=Case 377.= (DUPOUY, September, 1915.)
A lieutenant, 23, was in a mine explosion June 23, coming out in
complete torpor, with mutism and retention of urine. He was brought
to hospital June 26, with jactitation, irregular pulse, markedly
exaggerated tendon reflexes, absent skin reflexes, sluggish, dilated
pupils, especially right, and general anesthesia. The spinal fluid
contained an excess of albumin, altered blood cells and many
lymphocytes.
Several hours after puncture he suddenly demanded where he was, thought
it was the year 1911 when he was in the Dragoons, talked about his
camp, and was confused, irritable and stereotyped in questions. There
was no verbal amnesia. Speech was hesitant, explosive and scanning,
suggestive of multiple sclerosis. Next day there was still retrograde
amnesia. He clung to the belief that it was July, 1911, and asked
wearisome, stereotyped questions. The words, “German house” caused a
jactitation, stiffening and relapse into a _second état_, out of which
he came with hiccoughs and sighs, and amnestic for this conversation.
There was general hypesthesia and muscular weakness especially of legs.
The reflexes were as before.
The morning of June 28, he heard the hum of an airplane, whereupon
his memory returned. It seems that he had himself once ascended. The
memory gap was now limited to the time immediately preceding the
mine explosion and the days following, up to the time of hearing the
airplane. He told about his military life and also about incidents
immediately preceding his blowing up. He complained of malaise and of
pains in the vertebral column and limbs.
There was a quadriparesis, more marked, however, on the left; walking
with falls to the left; astasia with left foot; double facial paresis;
inability to whistle and to close eyes completely; intestinal and
bladder paralysis; nocturnal emissions non-pleasurable; partial
anesthesia of right leg, of arm and of hand, with hyperesthesia
of thigh, of forearm and of the posterior aspect of the upper arm;
anesthesia of the left side, including thorax and abdomen, excepting
that the arm was hypesthetic only. Face hyperesthetic. Complete
anesthesia of nipple and testis; hypesthesia of neck; anesthesia of
tongue, nose and vertex; plantar, cremasteric, abdominal reflexes
absent; exaggerated tendon reflexes; pupil reflexes normal; painful
heat flashes and profuse sweating on the slightest movement; vertigo
and tendencies to syncope after effort; explosive, scanning speech;
intermittent convulsive movements of the arms. Palpation and X-ray show
separation of the spinous processes of the third cervical vertebra.
Improvement was marked and progressive in motor, sensory and reflex
fields. At the time of report three months later, there was a definite
paresis of the left leg, with anesthesia and absent plantar reflexes,
and slight paresis of the orbicularis palpebrarum, scanning speech
and syncopal tendencies. Here, then, due to diffuse, non-systematic
lesions, with superadded hysterical manifestations, were probably some
effects of a permanent nature due to destructive processes.
_Re_ combination of functional and lesional effects, Sollier and
Chartier state that in Shell-shock hysteria, physical causes
and conditions are the chief factors; that in the so-called
hystero-traumatism of Charcot, the psychic and physical factors are of
virtually equal importance, and that in ordinary cases of hysteria, the
psychic is the chief genetic factor.
Shell explosion: Hysterical and organic symptoms.
=Case 378.= (HURST, 1917.)
A champion heavy-weight boxer, 29, was unconscious for two days after
being knocked over by the explosion of a shell in December, 1914. He
found at first that he could not move the right arm or left leg; and
after power had returned to the limbs, he had forcible involuntary
movements in the left leg whenever he tried to stand. Examined, April
1, 1915, he answered questions slowly and with slow words; the right
arm was weak. When the left hand was clenched, an associated movement
took place in the right hand, but not vice versa. There was, however,
no diminution in the girth of the muscles. The man was unable to
localize light tactile stimuli accurately. Movements of the left leg
were somewhat weak, the left knee-jerk was slightly brisker than the
right; ankle clonus could be obtained on the left side and Babinski
second sign (paralyzed leg rising higher than the normal leg in
combined flexion of thigh and pelvis). When the man tried to walk, the
left leg moved rapidly from side to side round the point of contact of
the toes. When the right leg moved forward, the left dragged behind in
irregular movement.
Every effort to cure the patient by means of suggestion during
hospital care for a month entirely failed. Although the man was easily
hypnotizable, he could not be made to move his leg under the deepest
hypnosis. The first whiff of ether hypnotized him, so that the method
of etherization could not be used in the endeavor to control the leg
movements. Over a year later, July, 1916, the patient had greatly
improved mentally but was otherwise in precisely the condition that is
above described.
Gunshot wound of buttocks with injury to cauda equina: Urinary
disturbance; decubitus; anesthesia. Superimposed paraplegia, regarded
as functional and cured by psychotherapy.
=Case 379.= (OPPENHEIM, July, 1915.)
A German grenadier, October 11, 1914, was wounded in the left buttock
by a missile that passed out through the right buttock. Pains in the
abdomen and legs followed. The man had to be catheterized on the
battle-field.
October 23, he suddenly fell down with total paralysis of both legs.
November 3, numerous small furuncles appeared on the buttocks, and
bedsores developed. The patient lay helpless in bed, was unable to sit
up without support, or to turn from one side to the other, and had
areas of anesthesia.
During November and December, there was persistent high temperature,
between 38 and 40; but January 3 the temperature stood at 36.6.
January 7 the patient was admitted to a nerve hospital. At this time
he was able to pass urine unaided, though with tenesmus and pain,
sometimes nausea and a tendency to vomit. He complained of pain in
the back and pelvic region; the legs lay as if paralyzed. No active
movement whatever was performed. There was a marked increase of tendon
reflexes (even including the semi-membranosus). The muscles were
relaxed through disuse but there was no atrophy. The patient moved
his legs about with his hands. Sensibility was preserved except in
the region of the pubis. The plantar reflexes were absent. Electrical
reactions normal.
The diagnosis was functional paralysis of the legs (previous gunshot
injury of cauda equina).
Treatment with psychotherapy met with prompt results; within a few
days, the patient learned to move his legs and to walk with support,
though making enormous efforts which threw the pulse up to about 160
and made the face congested. The bladder disturbance and the sacral
anesthesia persisted.
Spinal concussion with spinal cord lesion: Thermanesthesia and
analgesia of right leg and side.
=Case 380.= (BUZZARD, December, 1916.)
An officer was hit in the back by a shrapnel fragment, fell paralyzed,
but after a few minutes was able to walk more than a mile to the
dressing station. Eventually arriving in London, he had nothing to
complain of except the wound, as the foreign body had been removed in
France. The wound healed and the patient went to a convalescent home.
However, when taking a bath he could not feel the temperature of the
water with the right leg. Muscular power was perfect; reflexes normal;
but the heat, cold and pain sense was lacking in the right leg and the
right side of the body from the seventh costal cartilage downwards.
One may make a wrong diagnosis of “Shell-shock.”
=Case 381.= (BUZZARD, December, 1916.)
In August, 1915, an officer was blown many yards by a shell, lay
unconscious a while, could find no bruises, and carried on for
twenty-four hours. Then, finding legs unreliable, he reported sick
and was sent home as “Shell-shock.” He remained “Shell-shock” until
February, 1916, then being able to walk five or six miles on smooth
ground. Going downstairs he took the step with left foot rather than
with right, and the right was apt to turn in. The sense of position and
movement in regard to the right foot proved to be faulty. He could not
balance himself on the right foot, nor could he appreciate tuning fork
vibrations as well on this foot as on the other.
An X-ray examination showed a slight fracture, without deformity, in
the left post-Rolandic region near the median line. His helmet had been
bashed in at this point, and the bruised brain yielded symptoms even
eight months later.
Retention of urine after shell-shock.
=Case 382.= (GUILLAIN and BARRÉ, November, 1917.)
An infantryman underwent shell-shock December 19, 1915, from the
explosion of a torpedo nearby. He arrived at the ambulance, unable
to speak, and next day had a confusional crisis of convulsions with
contractures. He had not urinated since the accident, and two liters of
clear urine were withdrawn by catheter; after which, the patient rested
quietly and gradually regained consciousness. He was catheterized again
in the evening and clear urine withdrawn. He remained unable to urinate
spontaneously until December 25, and was catheterized accordingly.
There was no motor, sensory, or reflex disorder in this patient. Lumbar
puncture yielded a normal fluid; the pupils were normal, and the only
appearance was that of a marked asthenia.
Three months after his shell-shock, in March, 1916, the soldier was
once more examined and still complained of headache, weakness, and
inability to walk more than four or five hundred meters without a
certain trembling of the legs. The reflexes remained normal and no
further bladder trouble had supervened.
_Re_ anuria, Babinski remarks that, in days of yore, hysteria was
supposed to be able to produce anuria as well as albuminuria, and even
such organic changes as vesicles of the skin, ulceration, hemorrhages
in the skin or of the viscera, fever, and even gangrene. He remarks
that of late years no single identifiable case of this sort proved
to be hysterical, has been reported. This is aside, of course, from
such superficial and quickly passing vasomotor disorders as erythema
and dermatographia. Anuria and albuminuria have consequently passed
from the textbooks on hysteria, just as Babinski believes that
hysterical edema and hysterical exaggeration of the reflexes are bound
to pass. Hysteria cannot imitate everything; it cannot reproduce the
characteristic phenomena of organic paralysis.
Retention of urine after shell-shock.
=Case 383.= (GUILLAIN and BARRÉ, November 1917.)
An infantryman, 27, underwent shell-shock August 16, 1916, at
four o’clock, from the nearby explosion of a big shell. He lost
consciousness for a period of ten minutes, was sent to the regimental
aid post, and twelve hours later brought to a hospital center, in a
state of profound muscular weakness. He could not walk although he
could make every movement of the legs. There was a marked diffuse
cutaneous hyperesthesia. The reflexes were normal; the pupils were
unequal, the right myotic. The lumbar puncture yielded a clear fluid
under normal pressure, but with an excess of albumin. For three days,
retention of urine was absolute, requiring the catheter. There was
neither sugar nor albumin in the urine withdrawn. On the fourth day he
was able to urinate spontaneously; the asthenia and other symptoms had
disappeared in two or three weeks.
Incontinence of urine after shell-shock and burial.
=Case 384.= (GUILLAIN and BARRÉ, November, 1917.)
An infantryman was subject to shell explosion and burial May 10, 1917.
He lost consciousness for a few hours and spat blood for two days. He
was carried to an evacuation hospital and thence to the neurological
center at Amiens. Incontinence day and night lasted from the period of
shock up to May 29, when the patient was transferred again, to another
hospital. The man had never, either in childhood or adult life, had
incontinence. He showed a slight tendency to latero-pulsion toward the
left. Puncture fluid normal.
Guillain and Barré report but 12 cases of sphincter disorder following
shell-shock without external wound among hundreds of cases, and
among 12 instances of sphincter disorder there were but three of
incontinence, of which the above is one example. Incontinence lasted
longer in these cases than retention. Guillain and Barré are unable to
assign a cause for the findings.
Struck in back by shell splinter: Crural monoplegia; absence of plantar
reflex.
=Case 385.= (PAULIAN, February, 1915.)
An infantryman, 20, was struck by a shell fragment in the small of the
back while lying in the firing position, about 2 P.M. August 22, 1914,
at Eth in Belgium. He felt as if he had been struck by the butt of a
gun in the lumbar region. He was unable to get back with his comrades.
His sack had been cut. He was without ammunition, and getting to a
bridge he was able to jump a distance of about 8 meters. He fell and
fainted. On coming to himself, his left side felt bad and he could not
move his left leg. He dragged himself to the relief post which was
being bombarded just as he arrived, and he got a bullet in the left
frontal region.
He was evacuated to another ambulance and decided to go back to
France. Supported by his Lieutenant, he walked all night making about
35 kilometers on foot. He arrived at Charancy and got by train to
Mont-Midi. On alighting, he could not walk. He said he was bent in two,
and shuffled on in this position.
The “bent-back” lasted about a month, when he began to stand up
again. He passed through various hospitals and was evacuated to the
Salpêtrière. He then walked with the left leg in extension on the thigh
and the foot in external rotation. He was hardly able to stand on
either foot, and especially fell if he tried to stand on the left foot.
He made no resistance to passive movements of the left lower extremity.
The reflexes were normal except that the left plantar reflex was
abolished. On the right, the plantar reflex was normal, and an attempt
to elicit this reflex was followed by strong defensive movements. There
was a tactile, thermic, and pain anesthesia of the foot and leg as far
up as the lower third of the thigh. Above this anesthesia, there was a
zone of hypesthesia. Position sense was also abolished in this region,
and there was a bony hypesthesia likewise. A slight muscular atrophy (2
cm.) affected the lower leg and thigh.
There were no hereditary or acquired features of importance in the case
except that there had been at 14 a chorea for a year. In particular
this man appears not to have been an emotional person.
The point in the case is the abolition of the plantar reflex on
the left side, in association with a functional paraplegia and
hemianesthesia.
_Re_ plantar reflex modification in hysteria, Babinski believes that
the same law which holds that hysteria is not in line to alter either
the tendon reflexes or the pupil reflexes, is true for the skin
reflexes. Dejerine brought forward three cases which appeared to him,
however, to demonstrate absolutely that functional anesthesia might
abolish or greatly diminish the skin reactions of the sole of the foot,
that is, the plantar reflexes and movements of defense. Case 385 was
alleged in support of Dejerine, as also were cases of Jeanselme and
Huet, and of Sollier. Babinski’s critique of Dejerine’s cases ran to
the effect that two of them showed contractures, and accordingly were
not pure cases in which to demonstrate plantar reflexes or movements of
defense. In the third case, Babinski at a meeting of the Neurological
Society, himself obtained definite flexion of the little toes by
stimulating the planta. According to Babinski, therefore, Dejerine’s
cases, far from proving that hysterical anesthesia could abolish the
plantar cutaneous reflexes, proved that hysterical contracture might
mask reflex movements. Hysterical contracture, therefore, may be as
important a factor to consider _re_ reflexes as voluntary muscular
contracture itself. As Babinski pointed out, many normal persons can
keep the leg immobile when the sole is stimulated. Moreover, Babinski
pointed out, many cases regarded as hysterical were actually cases of
a physiopathic or reflex nature which had actually undergone trauma.
It will be noted that the above case of Paulian is just such a case of
trauma.
Shell-shock; unconsciousness: Crural monoplegia; sciatica (neural
changes).
=Case 386.= (SOUQUES, February, 1915.)
A reserve lieutenant, September, 1914, was blown up by a shell and
lost consciousness for an hour. On coming to, he felt pains in the
loins, right thigh, knee and heel, and found himself unable to move
the right leg at all. Urinary incontinence lasted three or four days.
Violent pains lasted weeks, now and then actual crises (sleep only with
hypnotics).
The pains then passed off. The flaccid crural monoplegia lasted. There
was a hydrarthrosis of the right knee and a sciatica (physical nerve
changes?) and a crural monoplegia without trophic, electrical, reflex
or vesico-rectal trouble. Lumbar puncture showed no lymphocytes or
excess of albumin. It would, of course, be difficult to tell whether
this case was hysteria or simulation.
_Re_ hysterical monoplegia, Babinski inquires whether a hysterical
monoplegia can automatically appear as a result of emotion without any
intellectual element whatever. Emotion produces sweat, diarrhea or
erythema, without any intellectual intermediate. Can emotion--that is,
emotional shock--produce a monoplegia in the same way as it produces
an erythema? The narratives of patients might indicate that emotion
can do such things. But according to Babinski there is no genuine case
of monoplegia or paraplegia directly produced by emotional shock. One
must be careful in this discussion not to confuse emotional shock and
emotion of a gradual nature. Babinski wishes to define emotion as a
violent affective change as a result of a sudden mental shock upsetting
physiologic or psychic balance during a usually brief period. As for
the more gradual affective states or emotions, there is obviously so
much of the imaginative and intellectual compounded therewith, that
plenty of opportunity exists for the production by suggestion of such
phenomena as monoplegia, paraplegia, hemi-anesthesia.
_Re_ sciatica, see remarks above under Case 329.
Functional paraplegia and internal popliteal neuritis.
=Case 387.= (ROUSSY, February, 1915.)
A Zouave was taken out from under a trench shelter beam, the night of
December 21, 1914, at Tracy-le-Mont. The beam had fallen upon eight
men, killing one, and striking the Zouave in the hypogastrium. He was
pulled out two hours later, unable to take a step. He was evacuated
on his back, to Paris; stayed a month in the hospital at Croix-Rouge,
bedfast. According to the patient, he was entirely anesthetic in the
legs. He went to Villejuif, January 22, with the diagnosis of spinal
contusion and hemiplegia. He could then walk on crutches, leaning on
the left leg. He felt a sharp pain at the level of the spinous process
of the first lumbar vertebra and all along the sacrum. Spontaneous
movements of the left leg were possible, but they were slow and weak.
The hypesthesia rose to the navel. There was a suggestion of a cauda
syndrome. The knee-jerks were normal, but on the left side the Achilles
jerk was absent. There was a partial R. D. in the posterior muscles of
the left leg.
The diagnosis was functional paraplegia plus left internal popliteal
neuritis. The crutches were removed, he was isolated, and given motor
reëducation. In a week he was able to walk alone with ease.
_Re_ popliteal nerve lesions, Athanassio-Benisty remarks that the
external popliteal nerve of the leg resembles pathologically the
musculospiral nerve of the arm, whereas the internal popliteal behaves
like the median. The musculospiral nerve of the arm shows very variable
and usually slight sensory changes. The median nerve more than any
other nerve in the arm yields painful sensations during its recovery
from section.
_Re_ differentiation of peripheral neuritis and hysterical paralysis,
Babinski gives as signs peculiar to neuritis, and never found in
hysterical paralysis, the following: (_a_) diminution or loss of
bone and tendon reflexes; (_b_) muscular atrophy (except for slight
amyotrophy exceptionally found in hysteria); (_c_) the reaction of
degeneration (only of value after eight or ten days); (_d_) hypotonus;
(_e_) distribution characteristic of peripheral motor sensory and
trophic disorder.
_Re_ diagnosis of organic paraplegia as against hysterical paraplegia,
the latter is to be recognized chiefly by the absence of the organic
signs, as (_a_) alteration of tendon reflexes, (_b_) the Babinski
sign (toe phenomenon), (_c_) exaggeration of defense reflexes (dorsal
flexion of foot on sharp pinching of dorsum of foot or leg), (_d_)
muscular atrophy with R. D., (_e_) sphincter disorder, (_f_) skin
changes, such as decubitus.
Bullet in hip: Local “stupor” of leg.
=Case 388.= (SEBILEAU, November, 1914.)
A Moroccan sharpshooter, 20, was wounded September 27, at Soissons.
One bullet scratched the left thigh. A second entered below the
anterosuperior iliac spine at least 6 cm. outside the femoral artery
and emerged above the ischiotrochanteric line, 2 cm. above and 4 cm.
behind the upper extremity of the great trochanter, thus passing
through the tensor of the fascia lata and without breaking a bone.
There was a complete paralysis of the left leg. The man had to walk
with a crutch and a cane, dragging the leg like a weight. There was
no active or passive movement of thigh, lower leg and foot muscles,
except that there was a slight tendency to abduction of the toes, from
innervation of the dorsal interossei of the foot. The iliopsoas was
also involved, as well as the gluteal and pelvic trochanteric muscles.
There was a certain amount of muscular tone preserved, so that the bony
elements of the skeleton were held together. The foot did not fall
and the leg did not elongate, as it might have in a case of paralysis
of the sciatic nerve. Electro-diagnosis showed an early reaction of
degeneration according to one examiner, but Sebileau believes that
there was no R. D. There was anesthesia of a large part of the leg,
which stretched over the anterior and internal aspects of the thigh,
covered the entire territory of obturator and crural nerves but did not
stretch above the fold of the groin. The region of the femorocutaneous
nerve was slightly sensitive and the posterior aspect of the thigh and
buttock was sensitive. There was a slight sensation on the external
aspect of the lower leg. Foot and toes were entirely insensitive.
The anesthesia was for all forms of common sensation. No vasomotor,
thermic or trophic disorder. The reflexes were all abolished, except
for a tendency to cremasteric reflex. It is clear that these conditions
cannot be simulated. Possibly they are hysteric and to be explained
on the basis of a kind of autosuggestion or perhaps, according to
Sebileau, the local and nervous apparatus under the mechanical and
caloric effects of the fragment had undergone a sort of local stupor.
No large nerve could have been affected by the injury, according to the
analysis made by Sebileau.
_Re_ stupor, see Case 253 of Tinel. _Re_ such local “stupor” it may
be noted that this case was published in 1914, before Babinski’s
larger publications on reflex disorders. As for the loss of cutaneous
reflexes, Babinski remarks that immersion in hot water may cause the
cutaneous reflexes in the so-called physiopathic cases to reappear for
a time. He regards the loss of cutaneous reflexes in the physiopathic
cases as due to a circulatory disturbance, and recalls the fact that
compression by an Esmarch bandage can cause the tendon reflexes to
vanish for a time, and can even cause pathologically excessive reflexes
to disappear. The cutaneous reflexes have also been caused to disappear
by compression.
According to Babinski, Sebileau’s explanation that such matters as loss
of reflexes could be explained by autosuggestion is erroneous.
_Re_ muscular hypertonus in reflex cases, Babinski remarks that though
it may be very pronounced, it is as a rule restricted in area. _Re_
sensory disorders in reflex cases, pains are found (they were very
slight ones in the present case); hypesthesia has also been found by
Babinski.
Localized catalepsy: Hysterotraumatic.
=Case 389.= (SOLLIER, January, 1917.)
An invalided soldier had been suffering for a year with marked
atrophies and the right knee in extension. There had been a bullet
wound of the upper third of the tibia, which did not affect the joint.
There was a total anesthesia, both superficial and deep, which stopped
sharply at the upper part of the thigh. At the time of the very
first examination, this apparent ankylosis was reduced, to the great
stupefaction of the patient. There was, however, a peculiar phenomenon
in this subject. There was a localized catalepsy of the limb, which
was able to preserve any desired attitude in which it was placed; and
this attitude could be indefinitely prolonged, just as in cataleptic
hysterics. Here, then, was a case of localized hystero-traumatism
precisely imitating the classical hysteria of Charcot except for its
localization.
_Re_ hysterotraumatism, Charcot developed ideas concerning trauma and
localized hysteria in 1886, thereby overthrowing the ideas of Erichsen
concerning the organic nature of “railway spine” and “railway brain” as
developed twenty years before. In a case of local trauma such as the
bullet-wound of Case 388, Babinski’s explanation would be that the pain
and inhibition of movement resulting from the bullet wound at the time
of injury, formed the focus of a process of autosuggestion. According
to Babinski’s figure, the organic factor acts as a _bait_ for the
hysterical symptoms. According to the Salpêtrière experience, hysteria
is incapable of producing a real superficial and deep anesthesia such
as is mentioned for this case. For example, no hysterical patient
in the Charcot clinic, according to Sicard, could undergo a scalpel
operation without some general or local anesthetic. When, therefore,
a true deep anesthesia occurs, Sicard’s conception would be that the
anesthesia is not a truly hysterical one but belongs to the group of
physiopathic phenomena.
Contracture: Hysterotraumatic.
=Case 390.= (SOLLIER, January, 1917.)
A sailor, 41, got hygroma of the right knee in 1915, was operated on in
July, returned to his dépôt a month later, and thence to Vizille Urage
by reason of contracture in extension of the right leg. It was thought
he was simulating (since there was no muscular atrophy), and he was
sent to the neurological center, where under anesthesia the joint was
found free. This man developed, when the knee was bent, extraordinary
cracklings in the joint, and he showed pain unequivocally, making a
defensive movement, partly reflex, partly voluntary, when the leg was
flexed beyond a certain point. There was 3.5 cm. atrophy in the thigh,
a reflex atrophy due to the joint disorder. There were no other signs
of hysterotraumatic contracture.
According to Sollier, the diagnosis of hysterotraumatic contractures
depends upon: first, a characteristic special attitude of the
contractured limb; secondly, the participation of the antagonists as a
group (_global_); thirdly, the superposition of sensory disorder upon
motor disorder (Charcot’s law); fourthly, the segmentary topography
of sensory disorder; fifthly, the extension of the contractured
joint; sixthly, the persistence of the contracture in the same form,
whether at rest or in attempted movements; seventhly, muscular
rigidity; eighthly, normal tendon reflexes; ninthly, normal electrical
reactions (though R. D. is hard to determine in muscles contracted to
the maximum); tenthly, special reactions during attempts to reduce,
such as pains, and equal and regular resistance to changed attitude,
pseudoclonus in cases of foot contracture; eleventhly, immediate
reproduction of the contracture after reduction under chloroform;
twelfthly, co-existence of various hysterical stigmata.
Crural monoplegia, tetanic. Recovery.
=Case 391.= (ROUTIER, 1915.)
An ensign was wounded by a shell splinter in the right scapular region
September 25, 1915. A large hematoma was drawn off and drains inserted.
Antitetanic serum was given 24 hours after the trauma. The wound looked
well. The patient complained merely of the heaviness of his arm, and
after September 27, the temperature fell to normal. Magnesium chloride
solution was applied every other day, and progress was so good that
evacuation was ordered.
However, October 8, the patient suddenly began to complain of a sharp
pain in the right thigh, which next day became intolerable and threw
the muscles into a slight contracture, the adductors being extremely
stiff. Headache developed in the course of the day, with slight
stiffness of neck, exaggeration of reflexes in the right leg, and
ankle clonus. Temperature: 37.6 morning, 38.5 evening. The patient was
isolated and given chloral.
October 10, paroxysmal crises of pain, more marked stiff neck,
and lumbar stiffness appeared, with nervousness, photophobia, and
hyperesthesia to noise. The wound seemed to be doing well. Chloral was
given.
Slight trismus developed October 11. The tongue became dry and the
patient drank little. The condition held and the same treatments
were repeated up to October 15, when the temperature fell and the
contractures and pains were diminished. The chloral was continued.
There were still a few cramps in the neck. October 22, however, the
patient was practically well.
We are here dealing with an instance of local tetanus of monoplegic
form, developing a fortnight after the wound (there is an early group
developing, as a rule, from the fifth to the tenth day, and a group of
later development, after the twentieth day; the interval in this case
was of intermediate duration). According to Courtois-Suffit and Giroux,
the differential diagnosis is not easy, since, besides tetanus, must
be considered tetany, spastic monoplegia of cerebral or spinal origin,
partial hemiplegia, peripheral neuritis, contractures due to bone,
joint, muscle or tendon lesions, strychnine intoxication and hysterical
contractures. Three cases out of six described by Routier were fatal.
_Re_ differential diagnosis of tetanic conditions, see Courtois-Suffit
and Giroux in the _Collection Horizon_. The cases as a rule appear in
subjects that have had serum treatment, and may occur in subjects in
whom no trismus ever develops (the above case showed slight trismus).
The recognition of localized tetanic contracture is based upon (_a_)
the intensity of the contracture, which causes the limb to feel wooden
(in one case the foot, leg, and thigh were welded to the pelvis like an
iron bar); (_b_) paroxysmal contractions resembling those of tetanus,
confined to one limb, and started by a variety of external causes,
forming the principal symptom in the disease; (_c_) contracture of
comparatively brief duration (hardly ever over two or three weeks). A
slight fever may help in the differential diagnosis.
Wound of left leg: Local spasms, later contracture, and painful crises
(these associated with suppuration), the whole treated as tetanic.
=Case 392.= (MÉRIEL, 1916.)
An infantryman was wounded by shell fragments September 28, 1915, at
Virginy and was given a first dressing an hour later and a second at
the ambulance, where antitetanic injection was also made. October 3,
the patient arrived at Foix, showing a superficial wound of the left
frontal region, a penetrating wound of the upper third of the left
thigh, and another in the lower third of the left lower leg.
The evening of October 8, the man began to feel pain in the left leg,
though the wounds looked well and there was no fever. October 9, sudden
involuntary contractions of the left leg developed, and these increased
in amplitude if the limb was touched. The other extremities were
normal. Temperature 38.2; pulse 102. Restlessness at night.
Next day 10 c.c. of antitetanic serum was administered and more on
the 11th, with chloral and isolation; but on the evening of the 11th,
with the contractions still completely localized to the left lower
extremity, came an extremely painful crisis interfering with sleep and
at last requiring morphine. Up to the 15th the antitetanic injections,
chloral and morphine were continued, but on the 15th the contractions
were replaced in part by a contracture affecting the muscles of the
posterior aspect of the thigh. In the meantime, the patient howled with
pain, especially in the night. Chloral and morphine were given.
During the next five days the contractures and pains became still more
violent, and on the 21st the antitetanic injections were begun once
more and kept up through the 26th in 5 c.c. doses.
The patient began to urinate in bed and to be delirious. The
contractions now disappeared, but the contracture persisted.
Antitetanic serum was given every other day from October 28 to November
2; every third day from November 4 to November 19; every fourth day
from November 22 to December 3; and every fifth day from December 3 to
December 17. The chloral was diminished from 15 to 5 grams per diem and
by the 20th of December all administration of chloral had ceased. The
morphine was given up December 25.
The tetanic symptoms of the left leg now gradually diminished. The
leg, which had been flexed at a right angle, began to extend little
by little, and the toes, which had been strongly flexed, reassumed
their normal position. The wounds suppurated freely during the tetanic
crises, but then healed. In January the man could get up and walk,
dragging his leg somewhat, and January 20 a complete recovery had
been obtained. There was no hysteria in the history of this patient,
although the man was subject to “professional” alcoholism, being carter
for a wholesale wine dealer, drinking 5 liters of wine a day.
Shell-shock by windage: Hysterical paraplegia, flaccid type, develops
10 days later, after strain, capture, privation, recapture. Paraplegia
at first complete. Recovery by suggestion (one séance).
=Case 393.= (LÉRI, February, 1915.)
A corporal, 21, told how at Goselmind, during the Sarrebourg retreat,
August 20, 1914, a shell burst a meter behind him, flattening his
knapsack, throwing him to the ground, blowing him forward (as he
said, by the pressure of the air) seven or eight meters, leaving him
stunned though conscious for about twenty minutes. Uhlans fell upon
him but did not trouble themselves further with him as he could not
walk. He crawled along on elbows and knees about a kilometer and a
half to some Frenchmen in a wood. He now found himself able to walk a
whole day supported by two comrades, making about 12 kilometers. He
got by carriage to Gerbéviller, but here fell again into the hands of
Germans, who left him nine days in the corner of a barn without care.
Gerbéviller was retaken, and he was evacuated to Bayon.
He had now had for some time pains in the kidney region below the point
struck, some difficulty in turning his head, and some numbness and
jerkings in the legs; and the legs that had carried him 14 kilometers
were unable to move at all, even in bed. It was only 8 days later
that he could perform the slightest movement, and two months followed
before he could go a few steps on crutches. December 14, three months
and a half after his accident,--he was demonstrated as “spinal
contusion.” Upon examination, however, there were no reflex disorders,
no sensory disorders, and the muscular weakness was equal in all parts
of the lower extremities and trunk. On crutches, he lunged the trunk
forward, painfully dragging his legs one after the other, the right
foot in external rotation, never passing the left foot, toes scraping
ground,--a functional flaccid paraplegia, completely dissolved by
suggestion at a single sitting.
Scalp wound; probably no loss of consciousness: Quadriparesis, later
paraplegia; tremors; profound sensory disorders, some apparently
hysterical; cataleptic rigidity of (anesthetic) legs on passive
movement. Diagnosis?
=Case 394.= (CLARKE, July, 1916.)
A soldier, 40, got a scalp wound but probably did not lose
consciousness. However, when observed three months after the injury,
though fat and well-looking, the patient could not stand or walk, and
his hands and arms were feeble. He complained of headache, insomnia
and anorexia, and remained in a state of mental inertia. All efforts
to read and write produced fatigue. Memory was bad both for remote
and for recent events. He was able to feed himself slowly, execute
a few movements of arms and hands, and raise his feet from the bed.
Upon passive movement, there was a sort of spastic state, which
did not amount to a true rigidity. Now and then a clonic spasm was
induced by such passive movements. After the repetition of those few
voluntary movements which were possible, the muscles passed into a
flaccid condition. There was a tremor of a type called swooping; the
tremor resembled that of Friedreich’s disease, such as is thought to
occur in cases of marked loss of muscular sense. The deep reflexes
were exaggerated. Concentric narrowing of the visual fields was
easily induced by testing them. There was a general slight dulness of
perception on sensory tests. There was astereognosis, and apparently an
absolute loss of position sense. Movements of the large joints through
an angle of 90 degrees were, however, vaguely recognized. Although the
patient could not touch, for example, his left forefinger with his
right, yet, if he had once seen the position of a limb and it was not
moved, he could remember its position and touch it after some time.
His localizing sense was from two to four inches out in the hands, the
localization being generally of points proximal to the point tested.
Two months later the patient was somewhat less dull and apathetic.
His memory had improved. He was able to read, and he was successfully
making a rug; but the legs were worse, having become anesthetic to
touch and pain. When the legs were placed in any position, they would
assume a cataleptic rigidity, and remain rigidly fixed in any position
for some time. The patient could sit up in bed. The muscles were well
nourished and the electric reactions were normal.
_Re_ catatonic rigidity, see Case 389 (Sollier).
Shell explosion; pitched in air: Spasmodic contractions of sartorii,
persistent in sleep.
=Case 395.= (MYERS, January, 1916.)
A private, 23, was admitted to a casualty clearing station and the next
day told the examiner, Major Myers, that the Germans had been sending
whizz-bangs and coal-boxes over, and the last he remembered was being
on guard and then digging himself out of fallen sandbags. His comrades
told him that he had been pitched in the air, but this he did not
remember. He remembered running to the shell trench, but finding this
“too hot,” he returned to the firing trench, noticing on the way that
he could not see well. He lay in the dug-out, flinching at each shell,
and “trying to get into the smallest possible corner.” He tried to do
guard duty that night, but, when some one noticed involuntary spasmodic
movements, he was ordered to go back to the dug-out, was helped to the
regimental aid post by two men, and was sent to hospital. He had been
in France eight months and had been shaken up somewhat four months
before, when bombs threw dirt in his face. At that time, his hands and
handwriting had become tremulous, but he had not reported sick. He
was depressed and wanted Major Myers to make him well. It seems that
he had shrugged his shoulders and made leg movements, diving beneath
the bedclothes, and bringing his knees to his chin. When Major Myers
examined him, the leg movements were due solely “to strong periodic
simultaneous contractions of the two sartorius muscles, the rate of
contraction of which varied from 60 to 70 per minute, increasing to 90
during the excitement of examination.” There were special changes of
sensibility in the right leg and arm and right side of the face and
chest, not involving the abdomen. The patellar reflex was exaggerated;
plantar reflexes could not be obtained. The legs were tremulous,
especially when the patient lifted them, whereas the hands and tongue
were only faintly tremulous.
Under light hypnosis, events in the amnestic period were recalled, and
details as to the shell’s direction, process of lifting up, and fall.
Under deeper hypnosis, the sartorius contractions diminished but did
not disappear. Appropriate suggestion was made, and upon arousal from
hypnosis, the movements ceased, the headache disappeared, memory was
recovered, and the unilateral disturbances of sensibility had vanished.
As to the possibility of malingering in this case, Major Myers calls
attention to the disorders of sensibility which he believes could
hardly have been simulated, to the persistence of spasmodic movements
during sleep, to their confinement to the sartorii, and to the spastic
condition of legs, such that when the thighs were passively raised the
knees remained extended.
_Re_ persistence of hysterical phenomena in sleep, Ballet felt that
he could prove that some hysterical contractures persisted during
sleep, and Sollier has written a special article to the same effect.
Ballet’s case had a contracture developing after an operation on the
first metacarpal bone. The contracture which followed would be then
probably, upon Babinski’s analysis, a reflex contracture and not a
hysterical one. Duvernay, Sicard, and Babinski himself have noted the
persistence of reflex contractures during sleep, to say nothing of
their persistence under an advanced stage of chloroform narcosis. In
fact, these reflex contractures are exactly as fixed and persistent as
contractures of clearly organic origin. It is probable that Babinski
would define Myers’ case (395) as a physiopathic one; yet against this
diagnosis would be the disappearance of the movements after hypnosis.
As against hysteria, it will be noted that the patellar reflex was
exaggerated, and that the plantar reflexes could not be obtained.
Shell-shock: Brown-Séquard syndrome, hematomyelic?
=Case 396.= (BALLET, August, 1915.)
A soldier, 24, went to the front November 12, 1914, and June 1, 1915,
had a shell burst near him in the trench, on the occasion of which he
felt a violent shock, as if a blow in the kidneys. He felt suddenly
paralyzed in both legs. He was crouching at the time of the shell
burst. His legs felt dead, and he had such violent pain in the thorax
as to make breathing difficult. He was carried to a shelter. After a
few hours, the left leg began to move again.
He was carried to the ambulance, remaining there five days, unable to
walk, though able to move and turn in bed, slightly constipated, with
persistent pains in back. He was then carried to Auxiliary Hospital
231, at Paris, and a bullet (!) was found superficially lodged in the
region of the left scapula. Neither patient nor physicians had hitherto
observed the bullet, which could have had nothing to do with any spinal
lesion.
The pains, in the course of a month, grew less, and at the end of two
or three weeks he began to walk and was sent to the psychoneurosis
service at Ville-Évrard, July 10. He then complained of pain in the
right thorax, especially on movement or after sitting up some time. He
could hardly bring himself to the sitting posture from the bed, and
found difficulty in raising the right leg therefrom. In walking, the
_right leg_ was dragged behind. The reflexes were increased on the
right side. There was ankle clonus without Babinski sign. Anesthesia
to touch over the whole of the _left leg_. Anesthesia to pin prick and
temperature as far as the umbilicus. Cold was not felt on the left side.
The water of a bath seemed lukewarm on the left side and warm on
the right. The left side of the scrotum and the left half of the
penis showed the same disorder of sensibility. There was a zone
of hypesthesia on the _right_ side of the thorax in the region of
the lower ribs. The patient compared his sensations while at rest
and without contact to a sensation of painful pressure occurring
intermittently, or rather in paroxysms, not advancing beyond the median
line of the back. Here was a question of Brown-Séquard syndrome,
probably due to a slight hematomyelia, but associated with no external
lesion or any injury to the vertebral column.
_Re_ Brown-Séquard’s syndrome, see Athanassio-Benisty with respect to
spinal cord symptoms associated with lesions of the brachial plexus. It
appears that the combination of spinal cord and brachial plexus injury
is not uncommon. Note in this case that a bullet was found in the left
scapula region. According to Ballet, this bullet could have had nothing
to do with a spinal lesion.
Violence to back: Dysbasia. Antebellum injury.
=Case 397.= (SMYLY, April, 1917.)
A man (also injured in 1906 by the fall of a heavy weight on his back)
went to France in 1914 as a soldier, and eight months later was hurled
into a shell hole so that his back struck the edge. He was rendered
unconscious. Upon recovery of consciousness, the right leg was found to
be swollen, and there were severe pains in the legs and back.
Upon return home the patient went from one hospital to another, for the
most part unable to walk, suffering from agonizing pain in head and
eyes. Insomnia and waking dreams.
He was able to bring himself to an upright position and to rush a few
steps. He has now acquired considerable control of the feet by the aid
of crutches. Insomnia persisted.
Dysbasia: Psychogenic (cerebellar nucleus (?))
=Case 398.= (CASSIRER, February, 1916.)