On March 9, 1915, a shell wounded a man slightly, and burned off some

of the hair of his head. He was unconscious two days, and on waking

vomited for a time. Shortly after the injury difficulties in standing

and walking set in, with headache, noises in the left ear, difficulty

in the intake of ideas, excitability, and poor memory. Then, slight

improvement. About the middle of June he was no longer closely confined

to bed and could take a few steps with two canes; but the gait was

still unsteady and the left leg tended to make abnormal-looking

movements. There was nystagmus, rapid, though constant, on looking

to the left,--more in the left eye; and nystagmus on looking to the

right,--more in the right eye. Adiadochokinesis absent. Vestibular

nerve somewhat excitable. Deviation outward in finger-pointing test.

According to Cassirer, this case is one largely of psychogenic origin,

with possibly an organic cerebellar nucleus. The knee-jerks absent

(even up to March 31). W. R. negative.

Shell-shock; unconsciousness: Dysbasia, in part hysterical, in part

organic (?).

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

A private, 29, was knocked over by a shell explosion December, 1914. He

was unconscious two days, found that he could not move either right arm

or left leg, got some power back shortly, but, if he tried to stand,

experienced involuntary violent movements in the left leg.

April 1, 1915, response to questions was slow and speech slow. The

right arm and grip were weak. If the left hand was clenched, there was

an associated movement of the right hand; but on clenching the right

hand, no associated movement was produced in the left. The musculature

was equal on the two sides, and the tendon reflexes of the arms were

brisk and equal. Light tactile stimuli were hard to localize. Movements

of the left leg were somewhat weak, though the musculature was equal on

the two sides. The knee-jerks were brisk, the left slightly brisker.

Sometimes a well-marked ankle clonus could be obtained on the left

side, but sometimes not. The plantar reflex was constantly flexor.

Babinski’s second sign (combined flexion of thigh and pelvis) was well

marked on the left side.

On attempts to walk, the left leg would move rapidly from side to side,

round the point of contact of toes with ground. When a step forward

was taken with the right leg, the left one dragged, and made irregular

movements.

This gait seemed obviously hysterical. The patient was kept in hospital

for a month. He was very easily hypnotizable, but even in deep hypnosis

leg movements could not be controlled when he was told to walk. The

first whiff of ether hypnotized but did not cure him.

On the whole, upon review, Hurst believes that there may have been

organic brain changes, which (_a_) the associated movement of the

paralyzed hand when the normal hand was contracting, (_b_) the slightly

increased left knee-jerk, (_c_) tendency to ankle-clonus, and (_d_)

Babinski’s second sign, may show.

Peculiar walking tic.

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

A soldier was found with a peculiar walking tic. He would rest a

good deal longer on the left leg than on the right. He would make a

sudden movement of the right leg forward, as if on a spring. At the

same time, the man’s head would give a violent movement to the right

just as the right leg was receiving the weight of the body. The idea

of this movement seemed to be that the center of gravity would be

shifted and the work of the right leg would be relieved. This peculiar

walk was naturally very slow. If the walk was slowed down, it became

quite normal. There was no pain at the basis of this walk. If the man

hopped, he hopped no more painfully on the right leg, nor with greater

difficulty, than upon the left.

This man was guilty of desertion in the face of the enemy, and of

desertion in the interior in time of war. He said he could not walk

well and that he needed to take care of himself at his mother’s house,

as he was not considered sick in his regiment. He had been wounded

with two bullets, September 28, 1914, which struck him on the internal

aspects of the knees. He was treated in hospital from October to the

end of November, 1914; was held at the dépôt of his regiment from

December to August, 1915. He was then put in hospital a month, and

returned to his dépôt for three more months. He was examined by three

physicians in August, 1915, and the commission decided that he was fit

for service, and a simulator.

Thorough examination, including electrical and X-ray examinations,

showed no lesion. Chavigny observed the patient for a long time, from

the 21st of November, 1916, to January 5, 1917. Shells dropped near the

hospital, December 2, and, following orders, the patients were taken

into a vaulted cellar, and they ran thither very rapidly; but this

patient could not hurry. He walked slowly, with the same tic. Surely

the tic would be rather a difficult one to imagine, and a somewhat

more probable set of symptoms would ordinarily be chosen. The man has

not the unstable nature of the ordinary victim of tic. On the contrary,

he has rather the invincible obstinacy of a hysterotraumatic. On being

shown that he could walk properly without these “para” movements, he

would reply, “I can’t do anything else,” and he shook his head upon

being told that he could be cured.

Reëducation of his anesthetic areas (there was a zone of diminution in

sensibility to pin-prick in the knee region, and a complete anesthesia

of the sole of the foot, with abolition of the plantar reflex),

reëducation by appropriate gymnastics, and mental reëducation, might be

attempted in a special neurological hospital.

_Re_ disorders of gait, Laignel-Lavastine and Courbon divide functional

gait disorders into three groups: (_a_) A group called dynamogenic;

(_b_) an inhibitory group; and (_c_) a group showing both forms of

disorder.

Roussy and Lhermitte have attempted to divide the gait disorders into

two groups: (_a_) A group termed by them basophobic, in which there is

a marked psychogenic and emotional basis; and (_b_) a dysbasic group,

the basis of which is suggestion rather than emotion. Following is a

skeleton of their classification:

1. Astasia-abasia and dysbasia group.

Astasia-abasia.

Pseudo tabetic dysbasia.

Pseudo polyneuritic dysbasia.

Tight-rope walker’s gait.

Scrubber’s gait.

Choreiform dysbasia.

Knock-kneed gait.

Walking as if on sticky surface.

Bather’s gait.

2. Stasobasophobia group.

3. Habit limping.

Mine explosion; unconsciousness: Camptocormia. Hospital rounder twenty

months (bedfast five months) without complete neurological examination.

Cure by persuasive electrotherapy in one hour.

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

MÉGEVAND, February, 1917.)

A man became a hospital rounder to all points of the compass in France

during a period of twenty months, with such diagnoses as myelopathic

disorder, complex spinal trouble, ataxic phenomena.

As a matter of fact he was a camptocormic: trunk bent, knees

semi-flexed, legs in external rotation. He used two canes in

locomotion, made a bowing movement with each 20 cm. step, then another

bowing movement, and another little step with the other foot. Made to

lie down, his legs would elongate, the right completely but the left

with some difficulty, the feet going into hyperextension, with the big

toe raised, others flexed; the feet externally rotating, plantae turned

in. In horizontal decubitus, there was only slight lumbar discomfort,

but the legs stiffened and gave quick convulsive jerks. Taking the

posture several times in succession would diminish these phenomena.

Kneeling, he could bring his heels within 10 cm. of the buttock,

whereas in spontaneous flexion of the leg on the thigh, the knee

remained a distance of 40 cm. from the buttock.

A complete examination showed no joint disorder or any diminution in

muscular strength, or any reflex disorder except that all the tendon

reflexes were rather powerful. There was a question of possible X-ray

demonstration of lesions and ankylosis of the fourth and fifth lumbar

vertebrae, and there was a question of some incontinence of urine. On

the basis of these phenomena apparently, this camptocormic patient had

been saddled with the diagnosis of myelopathic and ataxic disorder

for a period of 16 months. A neurologist was at last consulted, and

on his advice, it proved possible to get the patient evacuated to a

neurological center in a period of four months. Facts of this species

are unfortunately still too common, state Marie, Meige and Béhagne,

February 1, 1917, despite the remarkable and rapid cures obtained in

camptocormia by Souques. In point of fact, no complete neurological

examination had been performed upon this man during a period of 20

months.

This particular patient was given to Souques for treatment (Souques and

Mégevand). His cure was completed by persuasive electrotherapy, in an

hour.

It appears that the man was buried in a mine explosion, June 5, 1915,

lost consciousness and came to twenty hours later, able to rise and

take a few steps, but bent in two with a sharp dorsolumbar pain. The

pain grew more violent and generalized during the next few days, and

he began to lose all power in his legs, so that he could walk with the

greatest difficulty. He was practically bedfast for five months. He

then tried to rise and walk, but suffered so much that he could not get

up except in a camptocormic position. It was in fact only January 23,

1917, at the Salpêtrière, that the diagnosis of camptocormia was made.

The man complained of pains at the lower dorsal and lumbar regions

of the spinal column with slight irradiation sidewise. The following

diagnoses had been made:

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

July 9, 1915. Multiple contusions, commotio spinalis; lesions and

ankylosis of the 4th and 5th lumbar vertebrae (X-ray examination).

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

roots.

Nov. 4, 1916. Myelopathic disorder.

Dec. 5, 1916. Old complex spinal disorder.

Souques remarks that these diagnoses show that knowledge about

camptocormia has not penetrated into most of the sanitary formations

(1917).

Astasia-Abasia.

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

A soldier was evacuated to the 6th Army neurological center for

paraplegia with tremor. He had been in various hospitals _for a period

of a year_. The tendon reflexes of the arms appeared increased; there

was a suspicion of patellar clonus and of foot clonus, and it had been

proposed to invalid the man for spastic paralysis. In point of fact,

the man was suffering from an epileptoid trepidation of the foot and of

the patella. When he was lying down, his motor disorders practically

passed away, though they had been very marked when he tried to stand

upright or to walk. He had much trouble in walking, but could readily

stand for some time on one leg.

The man was forthwith treated by persuasive methods. It is important

to find out the organic lesion which in all probability served as a

starting point for the functional disease, and important to remove or

abolish this lesion however minute if a complete and lasting cure is to

be obtained.

_Re_ astasia-abasia, writers have remarked that it is one of the

commonest hysterical syndromes in the war, though somewhat rare in its

complete form. Roussy and Lhermitte state that it usually follows the

explosion of a large calibre projectile and has a rapid onset. It is

often an isolated phenomenon, without emotional or other Shell-shock

complications. The victim has been thrown to the ground and rolled into

a trench or hollow. Sometimes the victim gets back to the first-aid

post, only to find himself on arrival at the ambulance wholly unable to

walk. The legs, however, are drawn along inertly, as in paraplegia, or

a pronounced contracture interferes with walking.

Astasia-abasia is classified with hysteria major, hysterical

hemiplegia, hysterotraumatic brachial monoplegia, glossolabial

hemispasm, hysterical mutism, and rhythmic chorea, as so characteristic

that differential diagnosis is superfluous. According to Babinski,

no functional spasm and no organic disease can reproduce hysterical

astasia-abasia.

Multiple shell wounds, with persistent slight suppuration of thigh:

Abdominothoracic contracture, tetanic, four months after original

injury.

=Case 403.= (MARIE, 1916.)

A soldier, 31, was wounded in the left arm January, 1915, and received

10 c.c. antitetanic serum; was wounded again July 10 in the face,

scalp, upper part of the thorax, left arm and left leg by shell

fragments, and again received, two days later, 10 c.c. antitetanic

serum. July 13, at the ophthalmological center at Rouen the left eye

was enucleated on account of a shell wound, and four days later a

fragment was removed from a phlegmon of the forearm. Later a number of

operations were made for blepharoplasty. The wounds all healed well

except for an apparently insignificant, small suppuration of the thigh.

November 10, four months after the shell wounds, while apparently in

perfect health, the man began to complain of lancinating, intermittent

pains in the abdomen, thorax and lumbar region. With these pains was

associated a persistent abdominolumbar contracture.

On the suspicion of an abdominal form of local tetanus, chloral was

given; but the condition grew worse. The sudden contractions spread

from the waist to the feet, from November 20 onward, and were felt by

the patient as electric shocks. The arms were not affected. Trouble

with breathing supervened on the night of December 3. Sometimes there

were respiratory pauses for as long as 15 seconds, followed by a slight

polypnea. December 6 the man presented an intense contracture of the

lower part of the trunk. The slightly retracted abdominal wall was of

marbly hardness, but quite painless. Analgesic muscular rigidity took

the place of the former crises of pain. The dorsolumbar contracture was

so marked as to make an appreciable hollow in the back. The patient

could pick up an object from the ground only by flexing his knees to

the maximum, as the trunk could not be flexed. There was a very slight

trismus, but he could open his mouth, drink, eat and talk without

difficulty. There was no trace of neck stiffness or of Kernig’s sign.

The tendon reflexes, normal in the arms, were exaggerated in the lower

extremities, especially on the left (wounded) side. The skin reflexes

were also more marked on the left side, especially the reflex of

the tensor of the fascia lata. There was no longer any evidence of

suppuration of the wound of the left thigh, which had been dried up for

a fortnight. The pulse was somewhat exaggerated (92) and there was a

general hyperidrosis, especially of the face.

Forty c.c. antitetanic serum were given without reaction, and 4 grams

of chloral; five days later, 30 c.c. more serum. After ten days the

abdomen remained hard, though there was a trifling improvement of

the lumbar contracture. There were no longer any spasmodic crises or

respiratory disturbances. There was a slight serous exudation from the

wound. X-ray showed a small shell fragment 6 cm. below the orifice of

the wound.

The third injection was given December 27 to prevent mobilization of

the bacilli at operation, and on the 28th, the projectile was removed

under local anesthesia from a small, walled-off, old pus pocket, from

which were cultivated bacillus perfringens and other organisms.

December 31 a distinct improvement set in and January 13 there was

little or no trace of previous disease, except that testing the plantar

cutaneous reflex on the left side produced an exaggerated contraction

of the tensor of the fascia lata. February 15 he was reëxamined and

found quite normal.

This case of tetanus limited to the abdominothoracic muscles (except

for a very mild contracture of the masticators) had as its locus of

origin, doubtless, a wound of the thigh from which the toxin rose along

branches of the lumbar plexus to impregnate the corresponding level of

the spinal cord. Although there was no stiffness of the wounded leg,

yet there was an exaggeration of the tendon reflexes thereof. The first

phase of painful contractures and spasms with respiratory disorder was

succeeded by an analgesic phase of characteristically tetanic rigidity.

The nonfebrile nature of the disease and the preservation of good

general health are worth noting.

Shoulder blade unslung in knock-down by shell splinter: Hysterical (!)

paralysis of arm with anesthesia. Recovery by electricity, massage, and

reëducation (dislocation remaining).

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

A soldier was struck September 27, near Berry au Bac, by a shell

fragment in the right scapular region and was thrown, according to

his story, 15 meters. Upon entrance at Val-de-Grâce, October 13, the

shoulder-girdle was found intact. There was a very painful point in the

spinous process of the scapula, suggesting a fracture; but the bone

was proved intact on X-ray. The scapula was very mobile, as if unslung

from the thorax. The arm was paralyzed. On raising the arm the scapula

followed its movements and detached itself completely from the thorax,

dislocating upwards with lively pain. The fingers could be pushed under

the anterior surface of the scapula, and its internal border proved to

be entirely free of attachment. Pressure along this internal border was

very painful. It seems as if there had been a tearing of the rhomboid

and serratus magnus muscles and probably a part of the latissimus

dorsi under the influence of the violent shock conveyed by the shell

fragment, which had pushed the scapula forward and upward without

injuring the skin.

There was also a complete paralysis of sensation. Paralysis of motion

was complete except for the extensor longus of the thumb. This motor

paralysis had come on progressively three days after the accident. A

radicular paralysis from an evulsion of the plexus was suspected.

Babinski, however, made the diagnosis of psychic paralysis, finding the

muscles reacting perfectly to percussion. After a few electric tests

with the faradic current voluntary movements were obtained in all the

muscles of the arm and hand.

Treatment was then continued by electricity, massage and reëducation,

so that all movements soon regained strength. The patient can now

himself, by raising his arm, still produce his dislocation, which still

provokes a lively pain.

Gunshot wound of left forearm: PARALYSIS of the arm gradually

INCREASING IN DEGREE and extent and associated with pains and

anesthesias.

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

A reservist sustained, October 2, 1914, a gunshot wound of the left

forearm from a distance of about 1400 meters. He fainted, lost much

blood, and was treated surgically, October 7, in hospital (at this time

no complete paralysis of the arm).

In November, however, an incomplete paralysis at first developed.

November 12, the patient was able to flex his thumb but showed some

anesthesia.

Transferred to nerve hospital in December, the patient said that at the

first change of dressings, October 10, he had not been able to move his

arm, and said that pains and paresthesia had existed in the arm ever

since the injury. There was still some evidence of suppuration at the

exit orifice of the bullet. The left arm was now completely paralyzed

and atonic, and hung down in walking, without swinging. The supinator

phenomenon, though present on the right side, was absent on the left.

The triceps reflex was present. The shoulder acted like a flail joint.

On passive elevation of the left arm, the deltoid seemed to contract

slightly at first; later it failed to contract. Fibrillary tremor of

the left thumb.

Suggestive therapy was unsuccessful. There was an anesthesia of the

left arm and the left trunk. The disorder diminished proximally,

being most severe in the hand and the arm. The legs were normal. The

electrical irritability of the left arm was only slightly diminished.

There was a well-marked hypertrichosis of the left forearm, the skin of

which was slightly purple and discolored. The patient himself made an

attempt to burn his arm with a lighted cigar, to see if he could feel

the pain. He showed the scar but had felt nothing. The pectoralis major

muscle did not contract. If the left arm was started actively swinging,

it kept on swinging inertly. The left hand showed hyperidrosis. The

small hand muscles were emaciated but electrically normal.

Glass wound of wrist: Differential glove anesthesias (cold to mid

forearm, pain somewhat higher, touch as far as elbow).

=Case 406.= (_Romner_, March, 1915.)

A German soldier, 37, wounded his right wrist in the glass of a door.

The hand was put up six weeks long with very few changes of the bandage

on account of suppuration, and he noticed that the arm was getting

weaker and weaker, that he was losing feeling in it, and that it was

beginning to sweat a good deal, so that now and then drops of sweat

would stream off. The right hand was found markedly congested and 1.5

cm. larger in circumference. The fingers and hand were especially weak.

There was a marked tremor of the arm. Electric excitability normal. The

sensory disorder was in glove form. Hypesthesia to touch reached the

elbow, analgesia to a point three fingers’ breadth below the elbow,

and anesthesia to cold to a point two fingers’ breadth still lower, a

sort of stepwise dissociation of sensibility resembling what is found

in spinal lesions. The case was presented as one of local traumatic

hysteria.

_Re_ hysterical anesthesia, the rule is that it obeys no definite rule;

that is, it may be a hemianesthesia, a segmentary, an isolated, or even

a pseudo-peripheral anesthesia. It is a question whether Babinski would

attempt to explain Romner’s case on the basis of medical suggestion,

hetero-suggestion, or autosuggestion.

Myers has had a few instances in which anesthesia spread gradually, and

in which analgesia increased after its onset.

_Re_ reëducation of cutaneous sensations, Chavigny recommends the

faradic current in successive applications, marking the extent of the

zone of anesthesia with ink upon the skin. Each time the current is

applied, the inked limits of the area are lessened. By this form of

suggestion, not only does the anesthesia disappear, but very often the

accompanying paralysis also.

Hysterical contracture, edema and vasomotor disorder.

=Case 407.= (BALLET, July, 1915.)

For some unknown reason, a soldier developed a contracture of the

right upper and lower extremities at a time when a basin of water was

offered to him for toilet purposes. Three days later, this contracture

disappeared in the leg but persisted in the arm at the radiocarpal

joint and in the finger joints. There was also an anesthesia to touch

and pain and temperature which ran up the arm to the shoulder. The

tendon reflexes were normal. On the whole, there seemed to be no doubt

that the case was one of hysterical arm contracture. Associated with

this contracture was a white edema of the hand. On account of the

chances of simulation, the hand was done up and sealed in such wise

that the seals would have been broken if the splint had been lifted

down during the night. The bandage was in place from June 25 to June

29. Upon its removal, there was no edema, but the contracture was

still there. The arm was put up upon a cushion so that the hand would

drain to the forearm. The edema was found capable of returning when

the hand was placed below the level of the shoulder, disappearing when

the hand was raised. The contractured hand was warmer than its fellow.

According to Ballet, we here have an anesthetic instance of contracture

associated with edema and vasomotor disorder.

_Re_ edema, Babinski states that no case of hysterical edema has stood

the test of scientific critique. Sometimes a case turns out one of

tuberculous synovitis. Sometimes the patient is shown artificially to

have brought about the edema. The hysterical “blue edema” of Charcot

has not been proved to exist. Some during the war have been found due

to voluntary constriction. Some of these constriction edemas even

become relatively permanent. Babinski regards the above case of Ballet,

as well as cases of Lebar and of Raynaud, as not true cases. Raynaud’s

case was probably vascular.

_Re_ vasomotor disorders in Ballet’s case, the Babinski school, of

course, holds that hysteria cannot cause such disorders.

Hemiparesis with syringomyelic dissociation of sensations.

=Case 408.= (RAVAUT, August, 1915.)

A road-laborer, 42, in the 268th Infantry, had a bomb burst about

a meter away, March 4, 1915. Three men nearby were killed, and two

wounded. The laborer himself was turned over, covered with earth, and

stunned. He could hardly get up. He was carried to shelter and found

paralyzed on the left side, and unable to speak.

Next day, he was carried to the ambulance, and hemianesthesia was found

to exist in addition to the hemiplegia. He could now speak with some

difficulty and stammered. Vision and hearing were also impaired on the

left side. Reflexes weak; no sign of wound. There was a convulsive

crisis of some sort during the day, and afterwards the man complained

of a violent headache, whereupon a lumbar puncture showed a clear fluid

and a marked excess of albumin by the heat test.

The following day, March 6, the patient had much improved; his

hemiplegia was less marked and the arm paralysis had almost entirely

disappeared. He still stammered.

Upon the next day, vision and hearing were normal, and the sensation

was practically normal. A second lumbar puncture, March 8, showed a

diminution in the amount of albumin, although it was still supernormal.

March 9, leg contractured in extension; stammering.

March 12, there was no evidence of disease. March 13, albumin was very

slightly increased over the normal in the puncture fluid. March 16,

there was a slight trace only of weakness in the left leg. The urine

was throughout normal. The patient wrote _Bavo_ April 12, and May 7 he

was well but still felt heaviness and pulling sensations.

July 15 it was reported at Tours that he was not yet well, presenting

a left-sided hemiparesis, especially in the leg, with a syringomyelic

dissociation of sensations, with atrophy of the quadriceps and

diminution of reflexes on the left side. The patient had had a

hematomyelia (Laignel-Lavastine).

Brachial monoplegia, tetanic.

=Case 409.= (ROUTIER, 1915.)

A soldier sustained a penetrating wound of the back of the thorax

on the left side and received an injection of antitetanic serum. A

few days later, May 18, 1915, he came on hospital service very sick,

with high temperature and marked suppuration. The next day he had an

anxious facies, temperature of 40 degrees, and sharp pains in the left

arm. This arm May 21 was still very painful and then began to make

involuntary movements in the shape of incessant clonic contractions.

The forearm would suddenly flex upon the upper arm, and the upper arm

itself would violently push itself forward and outward. Meantime, the

wrist and fingers were not involved in the contractions. The movements

were continuous, but paroxysmally increased in extent.

Babinski, called in consultation, confirmed the diagnosis of an

anomalous form of tetanus. Next day trismus, pleurosthotonos, and stiff

neck developed. Antitetanic serum and chloral had been given from the

beginning, with morphine at night. The patient, however, died with

asphyxia June 3.

_Re_ brachial monoplegia, the hysterotraumatic form first observed by

Charcot has an anesthesia with the shoulder of mutton distribution,

slightly affecting the thorax in front and behind, in addition to the

paralysis.

Paralysis of right leg: Hysterical? Organic? “Micro-organic?”

=Case 410.= (VON SARBO, January, 1915.)

A Lieutenant, aged 28, lost consciousness September 6, 1914, as

the result of a shell explosion. When consciousness returned in

the hospital, he could not remember what had happened. The last he

remembered was that he had been pushing forward with his troop. There

had been no psychic shock whatever. Examined September 15, he showed

a right-sided hemiplegia with stiffness of the right lower extremity

so that it could not be even passively flexed. It was with difficulty

he could walk and he dragged his right foot. Patellar reflex could not

be elicited on the right. Oppenheim and Babinski were absent. There

was a slight nystagmus on looking to the right. Pupils normal. Tongue

deviated to the left. Speech was slow and the man had to think a little

over some expressions. He could not feel touch so well on the right

as on the left and this hypesthesia grew more marked distally. He was

greatly bothered because certain words did not come to him readily,

especially names.

The absence of the Babinski and Oppenheim reflexes was against an

organic hypothesis and the absence of hysterical stigmata and the

non-characteristic sensory disorder, as well as the absence of any

psychic shock in the history, spoke against hysteria. The hypoglossus

paralysis spoke in favor of the organic nature of the disease.

According to von Sarbo we must look for the background of so-called

functional nervous disorders, hysteria and neurasthenia, in structural

changes of the nervous system, the changes that Charcot called

molecular. But the lesions, he believes, do not lead to a degeneration

of neurons. Accordingly we get only the external form of organic

paralysis without concomitant symptoms, such as Oppenheim and Babinski

reflexes. Von Sarbo terms his hypothesis that of “microörganic”

changes. To prove the hysterical nature of a condition we must show

first that the symptoms have taken their rise on a mental or moral

basis.

Shell-shock and momentary burial: Muscular weakness, followed (third

day) by complete paralysis (save neck and head). Diagnostic hypotheses.

=Case 411.= (LÉRI, FROMENT and MAHAR, July, 1915.)

A big shell burst October 3, 1914, a little over 3 meters from a

soldier crouching in a shallow Saint Mihiel trench. The shell made a

hole two meters in diameter and 1.5 meters deep, and covered the man

with loose earth, from which he was readily released. During the next

few days, the man found difficulty in following his comrades on short

marches (1 to 4 kilometers). He was unable to buckle on his knapsack.

The patient was himself not alarmed at his condition.

Up to the time of his accident, this man, a farmer, had never had

any motor trouble, nor was there any nervous disorder in any of his

relatives. He had been in several conflicts, August 24-25, September

4-6, in the Argonne and in the Haute Meuse, and he had never found it

hard to keep up with his comrades. In fact, once in the Haute Meuse,

he took part in an exceedingly difficult and hasty retreat, and only a

week before the shell-shock above described he had put in a very long

march. Thus a man, perfectly normal before the shock, had fallen into a

general state of slight muscular paralysis.

On the third day very suddenly this paralysis became complete. The

wounded man, while sitting in the trench, found that he could not stand

up either with or without the use of his hands. Now, that very morning

he had marched three kilometers from his cantonment to the trench. He

was supported on the way to the relief post, hardly 200 meters away,

and was then sent to the hospital at Bar-le-Duc. At this time he was so

weak that he had to be fed like a child.

For a period of three weeks he lay, unable to rise or sit up. There was

one exception to the generalization of the paresis: the movements of

the head and neck were normal. A general muscular atrophy set in during

the three months, but gradually diminished in amount. The diagnosis of

myopathy was made, based upon the evident degree of lumbar wasting,

kyphosis, the man’s attitude, gait, manner of rising, galvanotonic

contractions.

The history was, of course, rather against the diagnosis of myopathy,

as well as the marked atrophy of the hands and the existence of an

incomplete R. D. Moreover the fact that he improved may be regarded as

rendering the diagnosis of myopathy doubtful.

Other diagnoses, less likely than that of myopathy, may be

considered,--hematomyelia, recurrent traumatic poliomyelitis affecting

the anterior horns, polyneuritis.

Without making decision as to the nature of this case, Léri proposes

the question whether there is a shell-shock myopathy and whether there

is a myopathy due to gas or to hemorrhage?

Shell-shock: Right hemiplegia with contracture and mutism. Cure by

isolation and suggestion. Question of the relation between plantar

areflexia and (_a_) anesthesia (hysterical) or (_b_) contracture.

=Case 412.= (DEJERINE, February, 1915.)

A territorial infantryman, 36, of a nervous and impressionable

temperament (father alcoholic), was blown up by a bomb October 3,

1914, between Bapaume and Arras. He was evacuated forthwith to the

relief post. According to his own story, he spat blood, could not talk,

and felt his right side weak. He was three weeks at a hospital in

Paimpol, with the diagnosis of right hemiplegia with contracture and

mutism. At Guingamp, an electrical treatment was followed by a gradual

disappearance of the arm contracture.

Examined by Dejerine, January 2, 1915, he was found to be a tall,

stalwart man with right leg contractured in extension, foot in

equinovarus, heel raised. He walked, dragging the leg, which trembled;

the trembling then extended to the rest of the body. In dorsal

decubitus, the leg lay in adduction and internal rotation. He could

lift the leg only 5 cm. above the bed, could only slightly flex leg on

thigh, and could not at all flex thigh on hip. The leg could not be

bent at all if he was requested to hold it stiff. Ankle joint movements

were impossible from contracture. The equinovarus was in contracture

which could not be corrected. Right hip movements were limited and

painful. Muscular atrophy absent.

Whereas on the left side plantar stimulation produced not only the

normal flexor reflex but also the classical defense movements of

flexion of leg on thigh and thigh on hip,--on the right side neither

a needle nor a match, nor any other form of stimulation of the sole,

produced any kind of reaction on the part of the toes, the fascia

lata, or any leg muscles. Tested every day for some weeks, the result

was always the same. The cremasteric reflex was weak on the affected

side. Abolition of the plantar reflex and of the defense movements

on the right side was associated with an anesthesia and a hypesthesia

of the right side of the body, involving complete anesthesia below

the knee and hypesthesia of superficial and deep sensation above the

knee. The buccal and lingual mucous membranes were also hypesthetic.

The bony sensibility was lost in the foot and lower leg, and was

diminished in all of the bones of the right side of the body. There

was no contraction of the visual fields. The right corneal reflex was

diminished. There were no other sensory defects.

The man was also aphonic, being unable to utter a word or a sound

except a jerky whistling sound like the letting off of steam. He was

able to write out his history intelligently. He was very emotional,

wept, and trembled all over when talking of wife and children. The

spinal puncture fluid was in all respects normal. A laryngoscopic

examination showed that the vocal cords were functioning normally. The

long _a_ could be pronounced distinctly, at the expense of great effort

so that the larynx would finally be blocked. The laryngeal reflex was

abolished. The laryngeal mucosa could be touched with a probe without

producing the slightest pain or coughing reflex. By way of treatment,

this case of hysterotraumatism was given isolation and psychotherapy

for two months without effect. But about the middle of March he began

to get better, the symptoms rapidly faded, cure was effected at the end

of March, and the man was evacuated to his dépôt.

_Re_ reflexes and contracture, see the views of Babinski reproduced

under Case 385 of Paulian.

Shell-shock: Tic VERSUS spasm.

=Case 413.= (MEIGE, July, 1916.)

A soldier was bowled over in a trench by a big shell that burst nearby.

He lost consciousness and was carried to the ambulance. But he came to,

and was so absolutely well with a few hours’ rest that he took part in

a lively attack shortly thereafter and got a wound in the left arm,

affecting slightly the ulnar nerve. He was sent to the Salpêtrière for

this ulnar nerve affection, when certain movements of his scalp were

incidentally noted.

The scalp movements were quick, affecting the fronto-occipitalis

muscles as well as the auricular muscles. The displacement was from

behind forward, and then from before backward, with slight oscillations

of the ear; and at the same time, the forehead wrinkled or became

smooth. The movement was involuntary and more convulsive than the

somewhat similar movements that many persons can execute with scalp

and ears. The phenomenon appeared after the shock for the first time.

He had not noticed it himself but the physician at the ambulance had

called his attention to it. The soldier was not disturbed by the

matter, either at that time or later.

The diagnostician would consider, on the one hand, tic, and on the

other, spasm. According to Meige, the man was a victim of tic. No

case of such limited spasm appears to have been observed previously.

However, the sudden development of these movements without previous

history of tic renders the diagnosis somewhat doubtful. There was also

a complete anesthesia to pin-prick in the present case over the whole

right side of the scalp, face, and neck, even passing below to involve

the chest, shoulder, back, and upper part of the right arm, with

hypesthesia decreasing toward the nipple and the elbow. The soldier

was quite ignorant of this sensory disorder and had never before been

examined for sensations. The examination was made with due precautions

to avoid suggestion. The question of anastomosis between the facial

nerve and the auriculo-temporal branch of the trigeminus and the

auricular branch of the cervical plexus, and of their relations to the

anesthesia and tic of this case, is raised.

_Re_ pathological movements such as tremors, tics, and choreiform

movements, Roussy and Lhermitte divide the tremors (see also under Case

337) into typical and atypical.

The atypical ones are either limited, or more usually generalized

when they are merely parts of the Shell-shock syndrome. Sometimes the

tremors are paroxysmal, aggravated by noises. Now and then, a condition

of tremophobia appears (see Case 225). As for the typical tremors, see

classifications under Case 337.

_Re_ tics, the tonic or postural tic is, according to Roussy and

Lhermitte, much less common than clonic or spasmodic movements,

which are Shell-shock phenomena like tremors and usually yield to

psychotherapy if treated early. These tics are usually observed in and

about the head, involving the sternomastoid, trapezius, and platysma

muscles to produce clonic contractions of the neck. Other tics involve

coarser head movements, nodding, eyelid and facial spasms, bilateral

or unilateral, and shoulder movements. Babinski has suggested that

some of the tremors are possibly due to organic disease, in view of

the fact that they are not readily influenced by psychotherapy. Meige

has suggested that some of the tics may also be in some sense organic.

As for the differential diagnosis of tremor and tic, according to

Roussy and Lhermitte, the Shell-shock onset may be an indicator. The

non-rhythmic and irregular nature of the tic movements, and their

exaggeration on voluntary movement, may be of some importance. Most

of the tremors appear to be attended by a certain degree of permanent

contraction of the muscle groups concerned. Tremors cease when these

contractions disappear.

A point in treatment is that complete muscular relaxation should be

obtained by having the patient open his mouth and breathe deeply.

_Re_ diagnosis of neurasthenia in this case, it may be inquired whether

the term is properly used, and whether there is not some confusion

here betwixt neurasthenia and hysteria.

_Re_ hyperalgesia, Myers states that about 25 per cent of his

Shell-shock cases have shown a variety of disorders of the skin

sense. Hyperesthesia and over-reaction is one phenomenon in the list,

but is far less common than hyperesthesia. According to Myers, the

hyperesthesia was more relative than absolute, and was probably due to

increased affective response.

Shell-shock; unconsciousness: Tremors, anesthesias. Recovery by

suggestion.

=Case 414.= (MOTT, January, 1916.)

August, 1915, between Ypres and Flamentières, a Jack Johnson exploded

one day about three o’clock in the morning near an experienced gunner,

who had been on service in the R. F. A. for 15 years, and in France

during the present war 10 months. He came to in the military hospital

at Chatham, two weeks later, and was told he was lucky to be there

at all as the shell had killed many comrades. He was transferred to

Colchester, and thence to the Fourth London General Hospital.

Sitting in a chair, the man showed continuous rhythmic movements of

legs, hands, and jaw, exaggerated when he was spoken to. The tremor

was almost a clonic spasm. Every now and then, the patient would start

and look sidewise and upwards, as if a shell were about to drop.

Hyperacusis was such that the firing of the guns as far off as Woolwich

alarmed him. In telling his story, he would repeat the same words over

and over. He dreamt of shells bursting. His sleep was disturbed with

groaning and moaning. The face was flushed, and the palms sweating.

Because of the constant tremor, he could not stand or walk without

assistance, and it was difficult to test reflexes. The tremor somewhat

resembled the intention tremor of multiple sclerosis. He was unable

to feel the prick of the needle on legs, left arm, or hand. He could

not feel vibrations of the tuning-fork on feet, legs, or hands, though

he could on the forehead. The fork was heard quite well six inches

from the ears. There was some difficulty in recognizing colors. Bitter

fluids could be tasted, but vinegar, salt, and various fluids, could

not be recognized. He could not recognize tincture of assafetida, attar

of roses, or oil of cloves, though nitrite of amyl, ammonia and glacial

acetic acid were recognized.

Major Mott felt that, though this prolonged severe disease in a

long-service man might possibly be related to some organic change in

the brain, he might well treat him by suggestion. Major Mott told him

that the careful examination just made showed that there was no organic

disease, and made it certain that he would recover. In a fortnight,

he sat in a chair without tremors and with a profound belief in Major

Mott.

Hysteria as appendix to traumata.

=Case 415.= (MACCURDY, July, 1917.)

A private, 25, something of a liar and of rather a low personality, had

enlisted in the regular army in 1911, but deserted to become a football

player. He reënlisted, and went to France in September, 1914, enjoying

the first six months. He broke his ankles by falling into a deep

dug-out, and got frost-bite. After three or four months in England, he

found that he did not wish to go back to France. He was two months in

barracks, and then went up the line in a good deal of a panic. Soon

after, he was wounded in the thigh and was able to remain in hospital

a fortnight, exposed, however, to shell-fire and given to starting at

noise and occasional war dreams. Sent to his base, he remained jumpy

and was now permanently afraid of the line. After three weeks in the

trenches, he again got wounds, spent five months in England, came back

to France in May, and fought till September, 1916. He tried to convince

the medical officer that he had appendicitis and trench fever.

About the middle of September he saw with horror a man crushed by a

tank, and thereafter was markedly affected by the sight of blood.

Another slight wound sent him to a rest camp for two weeks, whence

he was again thrown into the line, suffering acutely from fear and

horror of blood. In three days he fractured his left collarbone and

wrist. He gave a pint and a half of blood for transfusion purposes,

and in turn was shipped to England. On removal of the splint, he

found “probably not without satisfaction” that the arm was paralyzed.

It remained paralyzed for five months, until treatment in a special

hospital eventually cured the arm; but upon cure of the arm, nightmares

developed,--an indication, according to MacCurdy, of the strong

resistance he felt to the idea of returning to the front.

Neurasthenic hyperalgesia after peripheral nerve injury.

=Case 416.= (WEYGANDT, January, 1915.)

A German volunteer, a sportsman, was under heavy shell fire after the

middle of October, 1914, and was wounded in the upper arm in November,

with an injury to the median nerve that occasioned severe pain.

These strictly localized pains increased upon any sort of physical

or mental strain. If he walked down steps he kept thinking he might

have an accident, and then the pains set in with greater force. He

became apathetic so that he did not eat, drink or urinate. If his head

were touched he felt pain as if from an electric shock. He also felt

the pain when he saw anybody approaching a door to close it, through

apprehension of the noise. Meantime, the wound was well healed. The

pulse was accelerated. The visual fields were only slightly contracted.

The patient wanted to get well and go back to the service.

Weygandt regards this hyperalgesia after peripheral nerve injuries as

neurasthenic.

Military training: Peripheral neuritis in lead workers.

=Case 417.= (SHUFFLEBOTHAM, April, 1915.)

Among fourteen cases of lead poisoning, members of the territorial

forces, largely from North Staffordshire, was a patient suffering from

peripheral neuritis. He had been in the dipping-house. Two years before

going into the service he had been suspended for lead poisoning by the

factory surgeon. Giving up his work at the pottery, he became a general

laborer in a non-lead process factory.

Three weeks after enlistment, the man began to complain of pains,

tenderness in the arms, weakness of the wrists, headache, giddiness,

nausea, and constipation. The bowels were opened by a large dose of

epsom salts. On blood examination the hemoglobin was found diminished

40 per cent; cells with basophilic granules were found to the number

of 500 per cu. mm. The face was characteristically pasty. There was

albuminuria. Alcohol could be excluded. The man had to be discharged.

All Shufflebotham’s cases occurred from three to seven weeks after

mobilization, nor have any cases ever been reported in territorials

after their annual training. Constipation was invariable. In two cases

returned to service, there was a recurrent attack. An epidemic could be

excluded. Shufflebotham suggests that the altered conditions of life,

especially the marching and drilling, caused increased metabolism,

setting free lead compounds from the muscles and organs of the body. It

is true that a glost placer always works very hard with his muscles,

but not with the muscles used by the soldier.

“Peripheral neuritis” cured by faradism.

=Case 418.= (CARGILL, February, 1916.)

A Naval Service man, 20, was thought to have peripheral neuritis. A

long history of pain and numbness in arms and legs, a well-marked

analgesia and anesthesia over the anterior aspects of forearms and

legs, and an anesthetic band across the front of the chest, seemed

consistent with the diagnosis. The calf muscles tightly squeezed

yielded no pain. Pins could be thrust without pain into the anesthetic

areas. When told to say _yes_ when the pin was felt, and _no_ when it

was not felt, the man persistently said _no_ when the areas noted above

were touched. The deep reflexes were normal. Faradism by wire brush

at two sittings yielded a complete cure. It seems that once this man,

after seeing his sister fall in a fit on returning from a funeral,

retired to the garden and had a similar fit himself.

Cargill found in 1052 sailors fifteen cases of total absence of one or

both ankle-jerks; seven of the fifteen were probably cases of tabes.

_Re_ peripheral neuritis and hysteria (see under Case 387).

_Re_ differential diagnosis between peripheral neuritis and reflex

(physiopathic) paralysis, Babinski and Froment offer the following

table:

_Peripheral Neuritis._ _Reflex Paralysis

and Contracture._

1. Motor disorder, degenerative 1. More or less segmentary

amyotrophy, and sensory disorder topography.

corresponding topographically to

anatomical distribution of nerve

(neuritic) topography.

2. Amyotrophy very pronounced, 2. Amyotrophy variable;

regardless of localization. ordinarily well-marked

but not so severe as that

of neuritis.

3. Reaction of degeneration, especially 3. Reaction of degeneration

weakening or abolition of faradic absent, never marked

excitability of muscles. weakening of faradic

excitability, which is

often normal and may even

be exaggerated.

4. Tendon reflexes, corresponding to 4. If reflexes are altered,

the muscular territory of the they are as a rule

nerve, weakened or abolished. exaggerated and never

abolished.

Multiple wounds; signs of late tetanus 7-8 weeks later: Pain and

contracture of neck, tetanic, 14 weeks after trauma. Dysentery.

Recovery.

=Case 419.= (BOUQUET, 1916.)

A soldier invalided for endocarditis July 8, 1908, went back to the

colors on his own request August 8, 1914. He was wounded at noon

September 6, 1914, in the attack at Abbaye Woods. He lay in the woods,

with several comrades as badly wounded as himself, until September 10,

eating berries and drinking rain water. He had five wounds in all; in

left lower leg, thigh, left external malleolus, right calf, and left

forearm. Moreover, he had dysentery.

He was picked up by the Germans September 10 and carried by them

to the ambulance at Saint André, where he was given belated first

dressing. When the enemy retreated September 12 he was left behind and

finally carried back September 13 into the French lines by a French

physician who had been a prisoner likewise. A second dressing was given

September 14 at Rambluzin. He was then carried in a sanitary train to

Bar-sur-Aube, where, September 15, injection of antitetanic serum was

given. He left Bar-sur-Aube on December 18, 1914, practically cured,

though one of the wounds still needed care. The dysentery was still

present and walking was difficult. He was then cared for at Auxiliary

Hospital No. 102 in Paris.

It seems that about six weeks after his entrance in the hospital at

Bar-sur-Aube he had had some difficulty in opening his jaws, with acute

pains at the temporomaxillary joint. Similar pains appeared a few days

later in the neck, with a sensation of stiffening. The jaws still

opened easily enough December 18, yet the man got pains in his jaws as

soon as he began to speak. The pain and contracture in the neck region

were sharp and permanent. Sometimes the contracture got more marked,

and the board-like muscles could be felt stiffening under the examining

finger. During such crises the patient had to lie or sit down.

Sometimes the pains descended below the shoulders along the vertebral

column. The crises occurred more often in the night, in bed.

The diagnosis of late tetanus was made, and alcohol rubs were given.

The phenomena gradually disappeared. The dysentery also had not yielded

to therapeutics until eight or ten days before the patient left the

hospital. There was still, at the time of report, a certain difficulty

in walking, with a tendency to use the external border of the left foot

rather than the sole.

Shell-shock: Spasmodic neurosis and neurasthenia. Treatment without

great success.

=Case 420.= (OPPENHEIM, July, 1915.)

August 19, 1914, a shell exploded very close to a soldier, whose

bread bag, cartridge container, and field flask were pulled away from

him, but who was not himself wounded. He fell down. Shortly developed

headache, vertigo, palpitation. In running he fell down repeatedly.

Spasms soon appeared in the legs. He had previously suffered from

gastric disturbances, and heavy food did not agree with him.

At the time of admission to hospital he complained of great

irritability, nervous twitching, formication in his limbs, war dreams,

tachycardia. The heart boundaries were normal. The muscles of lower

extremities were attacked by tonic spasms, and felt board-like.

This tonic spasm occurred on each attempt at motion, very gradually

disappearing when at rest. Passive movements also had the same effect.

Fibrillary tremor affected the left quadriceps. On each attempt at

motion, pains were felt in the legs. At first the cramps were so severe

that all locomotion or even standing was impossible.

Treatment: Cold-water pack (Priessnitz), hyoscin injections, magnesium

sulphate injections (5 to 10 c.c. of ten per cent solution), perineural

injections, lumbar spinal analgesia,--all without success. Fibrillary

tremors persisted in the quadriceps and in the extensors of the toes.

The tonic spasms on increased attempts at motion became combined

with clonic twitchings. From the end of November on the patient made

attempts to walk with straddling legs, and under considerable vibratory

tremor. Picture of severe crampus-neurosis, combined with neurasthenia

gravis.

CHART 13

SHELL CONCUSSION

CAUSE PHYSICAL FROM EXPLOSIVES--AMNESIA FOR SHELL EPISODE

AND FOR A SUBSEQUENT PERIOD--FOLLOWED BY TRAUMATIC NEUROSIS

SHELL HYSTERIA

SHELL HEARD--VICTIMS ALREADY UNSTABLE--RUM ISSUE

PREPARATORY?--OVEREMOTIONALISM--SENSORY AND MOTOR DISORDER

SHELL NEURASTHENIA

HEADACHE, DIZZINESS, INSOMNIA, ANOREXIA, VISCERAL

PAIN--VICTIMS, OLDER MEN

After H. P. Wright

(_a_) Bullet-wound of forearm: Combination of hysterical (brachial)

monoplegia, and reflex (physiopathic) disorders. (_b_) Refrigeration:

Combination of hysterical paraplegia and reflex (physiopathic)

disorders.

=Case 421.= (BABINSKI, 1916.)

The forearm of a soldier was pierced in its lower part by a bullet,

which produced no lesion of large nerve trunks or blood vessels. A

complete brachial monoplegia followed. Every movement of the different

segments of the arm was abolished. The hand and forearm were slightly

atrophied, and were of a reddish salmon color. The temperature of the

affected hand and forearm was about three or four degrees lower than

that on the other side. The sphygmometric oscillations of the forearm

were twice as small in the paralyzed limb as in the healthy limb,

but the systolic blood pressure was normal. There was a mechanical

over-excitability of the muscles, and a slight exaggeration of the bone

and tendon reflexes. The paralysis was in part of reflex (physiopathic)

nature. On account however, of the completeness of the monoplegia, and

the fact that the reflex paralyses as a rule affect only the distal

portion of the limb, the diagnosis of hysteria had to be made in

addition to the diagnosis of reflex disorder.

As a result of freezing, this patient had also a complete crural

paraplegia. He showed vasomotor disorders and hypothermia of both feet,

together with mechanical over-excitability of the muscles; and these

latter disorders appeared to be of a reflex nature. The paraplegia,

however, was of a hysterical nature.

_Re_ refrigeration, see Case 309 (Binswanger) of glossolabial spasm.

Differential diagnosis of organic (central) monoplegia and reflex

(physiopathic) contracture and paralysis. (Babinski-Froment.)

_Organic Monoplegia_ _Reflex Contracture and Paralysis_

1. Paralysis often affects the 1. Paralysis almost always partial.

whole extremity, either arm In arm paralysis, affects as a

or leg. rule fingers and hand. The leg

is often affected at its origin,

and then only partially.

2. After several weeks of flaccid 2. Paralysis may remain flaccid for

paralysis, as a rule contracture a long time, and frequently

occurs. coexists with contracture,

hypertonicity and hypotonicity

of different muscular groups.

3. The upper extremity shows flexion 3. The upper extremity in

with clawhand. The lower hypertonic cases often shows the

extremity shows contracture of _main d’accoucheur_, the _main

extensors. The patient walks en bénitier_ (holy-water vessel

throwing his leg sidewise hand), the _doigts en tuile_

(_Démarche helicopode_). (crowded fingers). The lower

extremity does not exhibit the

sidewise movements.

4. Tendon reflexes, a few weeks 4. Reflex status variable.

after paralysis begins, Hyperreflexia often absent even

exaggerated. in hypertonic forms.

5. Babinski sign in crural 5. Babinski sign absent. The skin

monoplegia. reflex may be abolished but may

be reproduced on warming the

foot.

Slight bullet wound of hand: Flaccid paralysis with vasomotor and

thermic disorder. A case “non-organic” in the ordinary sense and

non-hysterical, _i.e._, reflex or physiopathic.

=Case 422.= (BABINSKI and FROMENT, 1917.)

Struck by his observations upon the persistence of tendon reflexes

in narcosis in a wounded soldier, Babinski continued observations in

the same general direction in a case which may be termed briefly one

of hypotonia of the extensors of the hand following the passage of a

bullet through the arm without nerve trunk lesion.

This patient had flaccid paralysis of hand and fingers following

wound in second dorsal interosseous space and vasomotor disorder and

local hypothermia in the hand. There was a slight diffuse atrophy

of the muscles of the hand, forearm, and arm; but this atrophy was

not systematized, and there was no R. D. The tendon reflexes of the

extremity were preserved. There were no signs of organic disease of the

central or peripheral nervous system; that is, in the ordinary sense of

these terms.

Was it a question of hysteria or of simulation?

Babinski was struck by the following symptoms:

First, the remarkably intense hypotonia, especially noteworthy in the

thumb, a hypotonia quite equal if not superior to that observed in

paralysis following marked nerve lesions;

Second, mechanical over-excitability of high degree in the muscles of

the hand and forearm, with retardation of the muscular response; and

Third, electric over-excitability of the muscles, with what Babinski

calls “anticipated fusion” of the faradic reactions.

It appears that this patient had been wounded in September, 1914,

and that the paralysis had developed five months later. Before the

development of this paralysis, there had been simply a meiopragic state.

Without perforating the hand, the bullet had remained in the wound,

being excised therefrom three months after the trauma.

In January, 1916,--that is, some sixteen months after the injury and

eleven months after the recovery of the paralysis,--the vasomotor

disorder and the hypothermia, and the faradic, voltaic and mechanical

over-excitability of the hand and forearm muscles, were in evidence.

Hypotonia was marked, permitting an overflexion of the hand upon the

forearm. If the patient moved his forearm, the affected hand would hang

and oscillate inertly; likewise in walking, seeming to obey only the

laws of physics.

In May, 1916, the patient was invalided and found to be still in

possession of the above-mentioned signs. Similar phenomena have been

found in the _main figée_ acrocontracture, and _main d’accoucheur_,

and belong, in the opinion of Babinski, to a group which is neither

hysterical nor organic in the ordinary sense of the terms. Vasomotor

and thermic phenomena are in the foreground of the picture, and are, in

fact, practically constant, though they vary somewhat in degree. They

react abnormally to the temperature of the surrounding medium; there is

undoubtedly a local perturbation of the vasomotor and heat-regulating

mechanism. There is also certain evidence of vascular spasm. The

vasomotor and thermic disorders run parallel with the mechanical

over-excitability of the muscles and the slowness of the response.

Chloroform to demonstrate asymmetry of reflexes.

=Case 423.= (BABINSKI and FROMENT, 1917.)

A soldier, 26, sustained, September 22, 1914, a bullet injury of the

right calf. There was no fracture, as X-ray showed, but healing was

slow, taking no less than three months. The right knee-jerk was a

little stronger and a little sharper than the left, but the difference

was controversial; and the difference between the two Achilles reflexes

was still more doubtful.

Chloroformed October 10, 1915: As the patient was going to sleep, even

before the phase of excitation and motor agitation had passed, the two

knee-jerks and left Achilles jerk had disappeared. They grew rapidly

less marked before disappearing, and none of the tendon reflexes

presented any phase of exaggeration while the patient was going under.

At this point anesthesia was arrested. The right Achilles reflex,

which had not disappeared, was sharply defined. It was even stronger

than in the normal state and polykinetic. During the whole phase

of awaking from the chloroform, the right Achilles reflex remained

strong and polykinetic, without, however, any ankle clonus. Thus, the

difference between the two Achilles reflexes became indisputable; also

the right knee-jerk reappeared before the left, and became stronger

without any patellar clonus. At this time, the difference between the

two knee-jerks was sharp and beyond cavil. This status, in which the

knee-jerk and Achilles reflexes were asymmetrical, lasted about ten

minutes after anesthesia ceased and lasted a little longer for the

knee-jerks than for the Achilles jerks.

Reflexes under chloroform.

=Case 424.= (BABINSKI and FROMENT, October, 1915.)

A soldier sustained a clean-cut wound of the supero-external aspect

of the right thigh without much destruction of tissue or any adherent

scar. He showed marked lameness, September 15, 1915, walking with

his right leg extended and the foot in external rotation. There was

a slight limitation of the movements of the hip joint in respect

to internal rotation and flexion of thigh. The right knee-jerk

was a little stronger than the left, and this condition persisted

several days. After a few tests, the knee-jerk became even slightly

polykinetic. The Achilles jerks were normal and equal. There was no

epileptoid trepidation of the foot, and no patella clonus. There was

a slight hypothermia of right leg, with ill-defined muscular atrophy.

Walking caused pain.

Chloroform anesthesia, September 20, 1915, yielded an exaggeration of

the knee-jerks with a suggestion of patella clonus even before the

phase in anesthesia of motor excitation had set in. As anesthesia

proceeded the exaggeration was rapidly lost on the left side but

progressively increased on the right. In the phase of complete muscular

resolution, when all the other tendon reflexes (such as the knee-jerk,

Achilles jerk on the left side, the radial and olecranon reflexes on

the left side) were abolished, the patella clonus on the right side was

perfectly distinct and could be elicited either by the usual method or

by raising the thigh and letting it fall. On percussion of the patella

tendon, a strong polykinetic reflex was obtained; right Achilles jerk

preserved; right leg in external rotation. Internal rotation could be

passively performed better than in the waking state, but this movement

was still limited. As the man was waking from anesthesia, when reflexes

were reappearing, there was a suggestion of left patella clonus--right

clonus as strong as before. At no time any trepidation of the foot. The

patella clonus on the right side lasted an hour after waking, at which

time all the reflexes returned to their previous state.

Reflexes under chloroform.

=Case 425.= (BABINSKI and FROMENT, October, 1915.)

A soldier sustained a bullet wound, September 22, 1914, in the right

calf. There was no fracture, as X-ray showed. Cicatrization was slow

and took at least three months. He was examined October 2, 1915, at

the Pitié,--not complaining of pains, but lame. There were no pains,

limitation of movement, or joint sounds in the hip joint, and X-ray

was negative. There was a slight atrophy of the limb, 1.5 c.m. less

in circumference on the right. There was a sharply defined local

hypothermia of the right leg up to the knee. The right knee-jerk was a

little stronger and brisker than the left, yet it was difficult to be

sure of this, and there was a still more doubtful difference between

the Achilles reflexes.

The man was anesthetized with chloroform, October 10. As he was going

to sleep, before the phase of excitement and agitation had ceased, the

two knee-jerks had disappeared. At the same time, the left Achilles

jerk vanished, followed by the plantar cutaneous reflexes. Anesthesia

was then stopped. The right Achilles jerk, which had not disappeared

at any time, remained distinct. It was stronger than in the waking

state, and polykinetic. During the waking phase, this reflex remained

strong and polykinetic, but there was no epileptoid trepidation of

the foot. Accordingly, under chloroform, the difference of the two

Achilles reflexes had become very sharp. The right knee-jerk reappeared

before the left and became stronger, though without patella clonus.

This difference was much more striking than in the waking state. This

asymmetry of the patella and Achilles reflexes lasted about 10 minutes

after anesthesia was stopped, and lasted a little longer for the

patella reflexes than for the Achilles reflexes.

Shrapnel wound above clavicle: Brachial monoplegia, partly hysterical,

partly organic.

=Case 426.= (BABINSKI and FROMENT, 1916.)

Babinski speaks of certain symptomatic incompatibilities which emerged

in the study of cases of combinations of hysteria, organic nervous

disease, and the so-called physiopathic disorders. An example of

such an incompatibility might be that of a patient who should, three

months after a sudden hemiplegia, show complete or almost complete

flaccid paralysis and but slight exaggeration of tendon reflexes--yet

the Babinski reflex. Of course, the Babinski reflex would permit a

diagnosis of pyramidal tract disease. Yet a sudden intense hemiplegia

lasting three months, if it were merely a matter of pyramidal tract

disorder, ought to show hyperreflexia of a pronounced degree as well as

contracture. An example from the arm is as follows:

A soldier got a shrapnel wound in the left supraclavicular region,

and had a complete paralysis of the arm, which had lasted more than a

month. Electrical examination showed marked reaction of degeneration

in the muscles controlled by the musculo-cutaneous nerve, as well as

a diminution of electrical excitability in the muscles innervated by

radial branches. On the contrary, in the circumflex territory, ulnar

and median, electrical excitability was normal. There were no vasomotor

disorders. The diagnosis of an association of hysteria and organic

disease was made. Babinski affirmed that electrification would effect a

partial cure; and in point of fact, the patient, after having submitted

to the current for several minutes, was able to use all the muscles

whose faradic contractility was normal or almost normal. Thus, he could

raise his arm, flex the thumb, flex the fingers, close the hand, and

extend the hand and fingers. Flexion of the forearm on the arm was

still difficult, since there was, in fact, a reaction of degeneration

in the muscles of the anterior region of the arm. The fact that the

movements could be partially executed was dependent upon action of the

supinator longus.

Gunshot fracture of upper arm; recovery with motor power in five weeks:

Six weeks later, Erb’s palsy (plus). Hypothesis: “Reflex paralysis”

preferred.

=Case 427.= (OPPENHEIM, January, 1915.)

A reservist, 26, was shot through the middle of the left upper arm,

sustaining an oblique fracture of the humerus, August 26. The external

wounds healed in a month; the fracture somewhat later. The left arm

was at first stiff and motionless, but in five weeks it could again be

moved. Pains disappeared with return of motility.

About the middle of November the arm began to lose power to move again,

especially the muscles of the upper arm. November 20, the patient

showed atrophic paralysis (left deltoid, biceps, brachialis internus,

and supinator longus) suggesting at first glance the appearance of

an Erb’s palsy; but the triceps and the adductor of the upper arm

were also unable to move and there was a slight paresis in the distal

muscles of the extremity. There were no pains or other objective

disorders.

The diagnosis of subacute poliomyelitis was considered. Electric

excitability, however, was found to be normal, both faradically and

galvanically.

When patient walked, the left arm swung helpless without sign of

innervation or any tonus. Abduction of the shoulder could also not be

performed, though a slight flexion of the forearm shortly began to be

demonstrable. If the patient inclined his head to the right, extended

his hand at the wrist, and flexed the fingers forcibly, he could then

flex the forearm somewhat, and a slight tension of the biceps and

supinator longus developed. Sometimes fibrillary tremors developed in

deltoid and biceps.

Of course a transient peripheral palsy can be produced by pressure of

the radial nerve without any change of electrical excitability, but

such a change is not associated with atrophy.

Neuritis and poliomyelitis producing an Erb’s palsy without any effect

upon the electrical reactions is an hypothesis not to be entertained.

Accordingly, the hypothesis of psychogenic or hysterical palsy may

be set up. Yet an atonic atrophic palsy with loss of tendon reflexes

(supinator) is inappropriate. According to Oppenheim, this case falls

into the category of the arthrogenic atrophies. A simple muscular

atrophy may follow disease of joints and bones. However, such cases

have rarely shown a complete palsy, as in Oppenheim’s case.

In short, we return to the old doctrine of reflex paralysis, conceiving

that a stimulus passing from the periphery influences the gray matter

in its trophic functions.

How much effect had the psyche upon this condition? The patient had

stuttered from childhood and had sustained a fracture of the skull at

9, following which his school work, especially mental arithmetic, had

been poor. The lack of psychic inhibitions may play some part in the

situation, but on the whole, the reflex hypothesis is preferred by

Oppenheim, the nerve conceived to be dynamically affected, the muscles

organically.

Paralysis: Hysterical? organic?

=Case 428.= (GOUGEROT and CHARPENTIER, May, 1916.)

A soldier, 20, was wounded May 15, 1915, by a large number of shell

fragments, 15 of which struck the right leg, two producing serious

injuries,--the one, a penetrating wound of the popliteal space followed

by stiffness of the knee, later cured by extraction of the fragments;

the other, causing a deep wound at the internal malleolus. The fragment

was extracted June 3, but osteomyelitis persisted and a fistulous

contraction was developed in January, 1916. There was a slight equinism.

By contrast with these deep bony lesions of the right leg, on the left

side a fragment had struck the dorsum of the left foot at about its

middle point, along the extensors of the fourth and fifth toes. The

fragment was removed toward the end of June, 1915. The wound closed in

a fortnight, leaving a loose 20 mm. scar. The man complained of pains,

which he called electrical, in the third and fourth toes, if one bore

down on this scar, a symptom suggesting that the dorsal nerves had been

injured. Immediately after the wound both legs had been paralyzed,

according to the soldier. He had been able only to drag himself along

on his shoulders. This indeterminate paralysis lasted three days. It

may have been hystero-traumatic, or it may have been a sort of diffuse

inhibition. Just after the injury, the left foot was in contracture,

which gave place a month later to paralysis. Only the great toe was

still able to move a little. In December, 1915, the patient still could

extend and flex the toes on the left side very badly, though he could

execute movements easily on the right side. There was no stiffness of

joints; there were no tendon reflex disorders. There were no trophic

vasomotor or secretory disturbances.

The diagnosis of hysterical paresis seemed warranted, but electrical

examination showed that the troubles were organic. There was an

increase in the faradic and galvanic excitability of the external

popliteal nerve. The response was more sudden than normal, and there

was an increase in faradic and galvanic excitability in the tibialis

anticus. There was a decrease of faradic and galvanic excitability in

the extensor communis of the toes and in the external peroneus.

Thus, this patient after being wounded in both feet May 15, 1915,

paralyzed in both feet for a period of three days, undergoing a

contracture of the left foot for a month, giving place to paralysis

of foot and toes, with slow improvement from the end of July, 1915,

was still in this latter state in March, 1916; though without trophic

disorder, he showed faradic and galvanic over-excitability of the

external popliteal nerve and of the tibialis anticus, _pari passu_ with

diminished electrical excitability for other muscles.

Paralysis: Hysterical? organic?

=Case 429.= (GOUGEROT and CHARPENTIER, May, 1916.)

A man was wounded Oct. 11, 1914, on the back of the right hand. Two

hours later, he was attended at the relief post. At this time, his

hand was straight, with fingers extended. He said that he could not

move his fingers, although there was no pain in them. Three hours

after the wound, the hands swelled and the edema spread as far as

the middle of the forearm. There was a long suppuration, complicated

by lymphangitis. All of the fragments were removed October 26, 1914;

healing was complete in three months. The swelling, however, persisted

to June, 1915, and when the swelling disappeared, the hand began to

show drop-wrist. The wound was sutured between the second and third

metacarpals, and the X-ray showed that the bones had not been injured,

nor had the nerves of the forearm muscles been touched. The situation

was such that the case was catalogued “functional paralysis.”

October 5, 1915, the hand was still drooping, fingers extended, and

middle finger and ring finger trembling. A slight stiffness of wrist

and fingers did not interfere with movements. Extension of the wrist

could be made very slightly above horizontal. Flexion was not quite

complete, nor were adduction or abduction. Extension of the fingers

could be performed normally, as well as that of the thumb, but flexion

was not quite complete. There was a slight palmar retraction. Such

were the movements that could be produced electrically. Voluntarily,

flexion of the wrist was good, abduction and adduction incomplete;

extension could not be executed to the horizontal position. There was

a tendency to flexion of the ring finger. When the patient tried to

flex the middle and index fingers, these fingers trembled but did not

flex. Weak extension and abduction of the thumb but without opposition

could be voluntarily performed; adduction good; flexion of the first

phalanx, weak; of second phalanx, better. Slight muscular atrophy of

the forearm, which was one centimeter less in circumference than the

left. The hand was subject to a general atrophy; the skin reddish and

moist. The X-ray showed a decalcification of all the bones of the hand

and wrist; trophic disturbance of the small carpal bones although

the trauma had affected only the second interosseous space. No joint

lesions or periosteal thicknesses were found by X-ray. There was a

slight hypesthesia of the palmar surface of the middle finger and of

the index finger. The patient complained of sharp transient pains in

hand and fingers.

In this case, therefore, a wound of the back of the hand produced an

immediate inhibition of muscular action in the forearm, a rapid edema

of the hand and arm, lasting for eight months and followed by reflex

disorders.

There was a considerable diminution in faradic excitability of the

flexor brevis of the thumb, the anterior cubital, the flexor brevis

minimi digiti, and of the dorsal interossei, and slighter evidence of

diminution of galvanic excitability in some of the muscles.

Sollier is said to have been the first to remark trophic bone disorders

in cases of neuropathic contracture.

_Re_ bone changes, Babinski enumerates trophic changes in the tissue of

bones and joints amongst objective signs that permit us to distinguish

the reflex or physiopathic disorders from the hysterical or pithiatic

disorders. Objective signs of this group (indicators of reflex or

physiopathic disorders) are: (_a_) Well-marked and persistent vasomotor

and thermic disorder; (_b_) alterations of muscular tone (either

hypotonus, hypertonus, or a combination of the two); (_c_) increase in

the mechanical excitability of the muscles and sometimes nerves; (_d_)

quantitative changes in the electrical excitability of the muscles, but

without R. D.; (_e_) muscular atrophy and atrophy of skin, bones, and

joints. For cases of this nature, see especially Cases 431 and 432 of

Delherm.

Paralysis: Hysterical? organic?

=Case 430.= (GOUGEROT and CHARPENTIER, May, 1916.)

A man, 22, was wounded September 17, 1914, in the left hand, the bullet

passing from the lower part of the fourth interosseous space out

through the palmar face. The bones were not injured, and it was evident

that only a few nerve filaments could have been injured; but he had

a paralysis extending far beyond this region, which increased little

by little from November, 1914, to August, 1915. Babinski, examining

him in November, 1914, had made the diagnosis of psychic paresis of

the extensors with diminution of electric excitability, with a very

slight slowing of the contraction of the last two interossei and the

hypothenar eminence, connected with lesion of the branches of the ulnar

nerve. The disorder spread to the flexors of the fingers and the thumb

muscles. The fifth finger was flexed at rest; there was no stiffness

of joint or tendon retraction. The extensors and flexors of all the

fingers and the thumb, and the abductor of the thumb showed paresis.

The thumb was able to oppose; the hands were cyanotic. Augmentation

of these phenomena in a period of months, their bizarre distribution,

and the preservation of the opposing power of the thumb suggested

a hystero-organic disease, and Babinski’s notes read, “Partial and

incomplete paralysis of the ulnar nerve, attacking slightly the

hypothenar eminence and the last two interossei; psychic paresis of the

extensors and flexors of the fingers and thumb and of the abductors of

the thumb.” Electrical examination showed, however, that there was not

only electrical disorder of the common extensors of the fingers, the

extensor proprius of the index and of the ring fingers, of the long

and short extensors of the thumb, but also there was a considerable

diminution to faradic and galvanic reaction in extensor ossis metacarpi

pollicis, the radials, the supinator longus, the pronator teres, the

large and small palmar, the common and superficial flexors of the

fingers, the muscles of the thenar eminence, the anterior ulnar, and

the anterior biceps and brachial. In short, there was an irradiation

of seemingly organic phenomena in the domain of the radial, median, and

the non-injured part of the cubital distribution, as well as in the

distribution of the musculo-cutaneous. Apparently, organic paralytic

disorder had spread even to the biceps and had increased over a period

of many months after the wound had healed.

_Re_ what he terms _organo-hysterical association_, Babinski

proposes to distinguish it from hystero-organic association. In

Babinski’s organo-hysterical association, the organic symptoms are

preceded by hysterical symptoms. These cases of organo-hysterical

association,--_e.g._, a case in which a hysterical monoplegia is

followed by a musculospiral crutch paralysis,--are one of the mainstays

of the proof that hysteria and simulation cannot be confounded.

Babinski concedes that he has sometimes said that hysteria was a sort

of semi-simulation; yet a semi-simulation is not a simulation.

As for Babinski’s _hystero-organic association_, we here deal with

cases of organic paralysis or contracture in which the fundamental

disorder is organic, and the psychic disorder is grafted upon it. Both

the fundamentally organic and the fundamentally hysterical associations

are instances, according to Babinski’s phrase, of symptomatic

incompatibilities. In such instances, the hysterical part of the

disorder, whether grafted or original, is dissolved by psychotherapy.

There is a third group of symptomatic incompatibilities, namely, the

_hystero-reflex associations_, in which, _e.g._, a hysterical gait

is combined with vasomotor and thermal disturbances. There may even

be combinations of all three types of disease, namely, the type of

structural disease, of vasomotor disorder, and of hysteria, in what

would then be termed a _hystero-reflex-organic association_.

Wound of toes--Wound of arm: Reflex or physiopathic paralyses,

diagnosis and treatment.

=Cases 431 and 432.= (DELHERM, September, 1916.)

A soldier was wounded in the soft parts of the last two toes and in the

furrow between toes on the left side, September 15, 1914, arriving in

the Central Physiotherapeutic Service of the 17th Army Region, December

27, 1915, left foot in varus, with marked contracture of tibialis

anticus, though passive movements of flexion, extension, adduction and

abduction were well performed. There was a slight atrophy of the leg

(33 cm. left to 34 cm. right). The scar was a little painful, and there

was a slight degree of hypesthesia of foot and lower leg. The foot was

cold and cyanotic; the reflexes were normal. An electric examination in

the region of the external popliteal branch of the sciatic nerve showed

that there was no electrical disorder either faradic or voltaic.

Another case was wounded in the right arm by a shell fragment September

7, 1914, and showed two scars above the epitrochlea and along the

internal border of the triceps. Examination December 30 showed a

normal elbow movement, pronation and supination, with slight flexion

in repose of the palm of the hand and the fingers. Active flexion

movements of the fingers could be performed only imperfectly, and the

finger pad could only be brought within three fingers breadths of the

palm, despite the greatest effort on the part of the patient. Minute

passive movements were entirely possible. The fifth finger could not

be abducted and both abduction and adduction of the third and fourth

finger could not be made on account of the nerve lesion. The thumb was

in a condition of contracture which placed it in abduction in front of

the index finger, and the thumb could not oppose. Passive movements,

on the other hand, were entirely possible. The hand was flexed upon

the forearm through hypertonia of the flexors, which could be easily

overcome with slight but distinct resistance. The hand was in the

position of a radial paralysis. There was a slight degree of muscular

atrophy. Tendon reflexes were normal. Electric examination showed that

stimulation of the ulnar nerve at the elbow was unable to produce

flexion of the last two fingers or any movement in the hypothenar

eminence, of which the muscles were also not excitable. The interossei

could, however, be made to contract. The median and radial nerves were

normal electrically. The above examinations were with the faradic

current.

With the galvanic current the ulnar nerve proved unexcitable at

the elbow, and the muscles of the hypothenar eminence contracted

more slowly. The median and radial nerves and their muscles were

electrically normal.

In short, there was a complete R. D. of the hypothenar and partial R.

D. of the interossei as a result of the lesion of the ulnar nerve.

There was nothing abnormal in the other nerves or muscles of the arm.

The attitude of radial pseudoparalysis is due to the contracture of the

muscles of the thenar eminence.

As to therapy, the general movements of flexion of the fingers, thumb

and hand yielded a marked improvement, but such results cannot be

expected in like cases unless a physician or experienced masseur treats

the case. Babinski and Froment have tried thermotherapy and diathermy

in these cases, finding that the paralysis diminishes and becomes

partial if the limb is warm, although it is important that it should

not become too warm. Sometimes a few treatments with diathermy will

produce movements in a case of long standing paralysis. Babinski and

Froment counsel not only diathermy, but a general motor reëducation.

The idea of the diathermy is that the deeply penetrating heat affects

blood vessels and muscles, bringing about a vasodilatation or even a

direct addition of needed calories. In like manner, galvanism, light

baths, or simple baths in combination, and with diathermy, especially

with the diathermy, act favorably. Casts and apparatus have also proved

without avail, as well as faradic or galvanic reëducation.

The above two cases show how in one instance there may be no electrical

change and in another instance a slight one. In these cases, reflex

hypertonic contracture, hypotonic paralysis, vasomotor disorder,

decalcification of the skeleton (X-ray), mechanical overexcitability

of muscles, unmodified tendon reflexes (except elective exaggeration

of reflex under anesthesia, _e.g._, a persistent unilateral patellar

clonus when all other reflexes have been abolished), and disorders of

electrical excitation are enumerated by Babinski and Froment.

Delherm sums up the electrical disorders as follows: Muscle faradized:

(_a_) No change.

(_b_) Subexcitability.

(_c_) Overexcitability.

(_d_) Diminished contractility to faradism, associated with

increased contractility by galvanism (Charpentier).

(_e_) Anticipated fusion of shocks (Babinski and Froment).

(_f_) Slow contraction and decontraction on faradism

(Charpentier).

(_g_) Rapid exhaustion of rhythmic faradic contraction with

metronome.

Muscle galvanized:

(_a_) No change.

(_b_) Subexcitability.

(_c_) Overexcitability.

(_d_) Suddenness of galvanic contraction with subexcitability.

_Re_ decalcification and osteo-articular changes, Babinski points out

that the reflex or physiopathic phenomena run historically back to

John Hunter, Charcot, and Vulpian. Charcot and Vulpian called especial

attention to the peculiar amyotrophy and paralysis which occurred in

joint disease, and upon the lack of parallelism betwixt the intensity

of the joint disease and the severity of the paralysis or atrophy. The

atrophy was without R. D.

Shell-shock: Functional blindness (monosymptomatic).

=Case 433.= (CROUZON, January, 1915.)

A shell burst above the head of a sergeant in a battle near Neuf

château, August 22, 1914. The man was kneeling at the time; felt a

terrible shock, slipped prone, lost consciousness and woke in the

evening blind. Next day he could hardly distinguish light from dark.

Yet the light reflexes were normal; the fundus was normal.

This Crouzon calls the symptomatic triad for functional nerve blindness

of Dieulafoy. There have been similar cases following eclipse of the

sun and nervous shock. The eclipse cases suggest that the bright flash

might have something to do with the sudden blindness (yet blindness has

appeared in cases in which the shell burst behind the patient).

The diagnosis of temporary blindness, with a prognosis of early

recovery, was made. The neurological examination was normal.

For its suggestive effect, glycerophosphate injections and progressive

reëducative measures were adopted. The patient was shown that he could

see, first, the contour of objects, then details and colors, then large

letters and later small letters. In a month the blindness was almost

well. Five months afterwards there was still a certain haze over the

field of vision and a slight difficulty in distinguishing certain

colors.

Jousset states that aside from visual alterations as the result of

cranial trauma, and aside from various transitory amblyopias such as

scintillating scotoma, the main varieties of amblyopia are:

_First_, Congenital amblyopia.

_Second_, Amblyopia due to cerebral intoxication.

_Third_, Retrobulbar neuritis and toxic amblyopia.

_Fourth_, Amblyopia ex anopsia.

_Fifth_, Hysterical amblyopia.

The most frequent amblyopias among the soldiers are exanopsia. Aside

from a few amblyopias caused by prolonged occlusion of the eyelids,

ptosis, or blepharospasm, the most frequent are due to opacities,

ametropia, and strabismus. The hysterical amblyopias are, as a rule,

associated with blepharospasm due to intense photophobia, and are

sometimes associated with constant lacrimation. Vision at a distance

is poor. The patient succeeds in reading but shows an asthenopia of

fatigue. The cornea and the conjunctiva are anesthetic, and sometimes

the eyelids also,--the so-called anesthesia _en lunettes_. The pupils

are large but react properly. The patient complains of many species

of disorder; loss of the sense of the third proportion, micropsia,

megalopsia, diplopia, erythropsia, diplopia in two colors, inverted

image, hemierythropsia, rotatory amblyopia. There is concentrated

limitation of visual fields, exaggerated by fatigue and by intense

light; reduced in dim light or when the patient is provided with smoked

glasses; enlarged upon the instillation of atropin or with convex

glasses. As a rule, with unilateral amblyopia, the functional disorders

start in binocular vision. Practically the most important diagnostic

feature is the anesthesia, since this cannot be readily simulated.

Sometimes corneal anesthesia is found in non-hysterical persons, who

may perhaps be regarded as potential hysterics.

Retrobulbar neuritis (nitrophenol).

=Case 434.= (SOLLIER AND JOUSSET, April, 1917.)

A soldier of the 54th Artillery entered hospital 45, November 4, 1916.

He had had a slight paralysis of the left brachial plexus in 1913,

following a shoulder dislocation, but the only relic of this when the

war began was a deltoid paresis. He had been working from August 13,

1915, at the factory in Saint-Fons, and was as yellow as the majority

of the workers there. He had never shown xanthopsia.

The first symptoms of his left brachial plexus neuritis had begun

six months before, after 9 months’ work in the factory, and showed

themselves in an increase of the deltoid paresis, with pains in the

hand and forearm, and cramps of the hand, interfering with work,

formication in the right hand and in the feet, diminution of visual

peculiarity (objects forgotten and reading difficult). It was only in

November that he got perturbed about these difficulties, which had

begun in May. There was a paralysis of the levators and rotators of

the left shoulder, with a slight atrophy of the deltoid and of the

supra- and infraspinatus muscles. The arm could be extended almost

to the horizontal with difficulty. There was one centimeter atrophy.

The forearm and hand were not atrophic but slightly weak. There was

an anesthesia of the shoulder-joint region, and of the outer surface

of the arm; a hypesthesia of the posterior surface of the forearm and

dorsal surface of the hand and fingers; tendon and periosteal reflexes

normal. Sometimes the hand would contract firmly and could be opened

only by the aid of the other hand. The nerve trunks of the axilla,

upper arm, and forearm, were painful on pressure, especially on the

left side, and the ulnar nerve was thickened and rolled under the

finger. The knee-jerk and Achilles jerk were abolished on the right;

plantar reflex diminished; right posterior tibial nerve painful on

pressure, and its territory was hypesthetic. There were cramps in the

feet.

Gymnastics and electrotherapy and rest reduced these phenomena. The

eye grounds were normal; there was a paresis of accommodation, and an

absolute blindness to green, with retraction of fields to 15 degrees

in the right eye, and 20 on the left. There later developed a slight

edematous neuritis of the nerve, corresponding to the evolution of a

chronic retrobulbar neuritis of toxic origin.

It is the chronic retrobulbar neuritis which is typical of the

so-called nitrophenol neuritis, developing in soldiers employed in

making explosives. The above case is accordingly exceptional in its

association of a severe peripheral neuritis with the optic neuritis.

Typically, after six months to a year in the factory, the cramps

and formication of the legs are felt, and the gradual diminution

of vision with transient blindness, finally leading to inability

to read, sets in. The green blindness, the accommodative paresis,

and diminution of central vision, the concentric contraction of the

visual fields, are the usual story. At first the eye grounds are

normal; there is then an edematous neuritis, and finally a white

atrophy. According to Sollier, the accommodative paresis is like that

in post-diphtheritic paralysis--a disease due to cerebral cortex

intoxication. In fact, the photomotor reflex is normal, and what we

have is an inversion of the Argyll-Robertson sign. These symptoms are

those of retrobulbar neuritis, of nicotino-ethylic origin, and it may

be thought that the melinite was simply acting by creating a soil for

alcoholic intoxication, but none of the patients examined has been

alcoholic, nor has any been permitted to smoke in the factory. The

injurious agent is probably a body in the nitrophenol series, perhaps

dinitrochlorobenzol, but whether this substance is absorbed through

the skin, inhaled, ingested from the hands, or by all three routes,

is doubtful. These workers are often cyanotic while at work because

the nitre products produce vasodilatation. Possibly this dilatation of

vessels has something to do with the neuritis. The workmen will not use

the spectacles and antitoxic masks given them, and even do not use the

rubber gloves constantly. In some factories only, a liter of milk is

given as counterpoison, every day.

Slight wound of occiput: Ophthalmoplegia externa, influencible,

however, by tests and replaced by spasmodic convergence of globes with

myosis; hysterical stigmata and convulsions.

=Case 435.= (WESTPHAL, September, 1915.)

A German volunteer, 20, was slightly wounded in the occiput by

revolver-shot at Ypres. Then followed headaches, vertigo, and

complaints of pains in the eyes such that he could not open them or

see sidewise. May 5, 1915, he showed a picture of an ophthalmoplegia

externa: complete immobility of the two bulbi, lively blepharoclonus,

rapidly passing into blepharospasm, photophobia. The visual field for

white was practically limited to the fixation point. Central scotoma

for all colors. Otherwise normal.

On further examination, the apparently immobile bulbi were found to

pass into convergence upon request to look to the right or left.

_Thereafter_, this position of convergence was assumed if any test

made by a strong light, such as that of a pocket flash, was used.

The pupils contracted to the maximum during this assumption of the

convergent position of the globes, and no further light reaction could

be observed. The convergence gradually passed off when the light was

removed. The appearance of bilateral external ophthalmoplegia had

disappeared.

If the patient was requested to follow a finger moved to one side, the

globe of that side to which the finger was being moved, stood unmoved

in its central position, but the other globe followed the eye and

placed itself in the convergent position. The patient complained of

diplopia. Even after the closure of one eye a double vision appeared

(monocular diplopia). There was achromatopsia. The cornea failed to

react to stimulation.

There was an analgesia of the skin of the whole body, with a

hypesthesia for tactile stimuli on the left side. Smell and taste

absent. The convergent position of the globes with myosis was preserved

in the midst of convulsive seizures, which could be produced by

exciting the patient. When it was attempted to dissolve the eye

troubles by hypnosis, convulsive attacks occurred. The patient was

pronouncedly hysterical.

The case is beyond question hysterical,--the phenomena consisting of

an ophthalmoplegia externa, alternating with spasmodic contracture of

the internal recti, associated with myosis and loss of light reaction.

The influencibility of this situation during the process of tests, to

say nothing of the other stigmata, clinches the diagnosis--an important

one, since the development of an external ophthalmoplegia after

occipital trauma might possibly be regarded as an organic disease due

to hemorrhage in the region of the eye-muscle nuclei.

Sandbag drops on head: Internal strabismus and diplopia. Various

diagnoses. Cure by lenses.

=Case 436.= (HARWOOD, September, 1916.)

A four-pound wet sandbag fell eight feet on the head of a

sergeant-major, 28, lying in a Gallipoli dug-out, November 24, 1915.

The sergeant-major was removed to Lemnos with headache and giddiness,

and a week later developed bilateral internal strabismus with double

vision and head noises. The diagnosis was “brain tumor” or “syphilitic

meningitis of the base.” On the voyage home, the diagnosis was altered

to “multiple neuritis or neurasthenia.”

He was admitted to the King George Hospital, January 1, 1916, unable

to move the eyes outwards; they moved rather poorly up and down. There

was a slight lateral nystagmus. The patient had been unable to read or

stand since the accident. The visual acuity of each eye was less than

6/60, but with an arrangement of lenses he could get 6/5 with either

eye. He had perfect binocular vision and could read ordinary type

comfortably. In a week’s time he was able to stand without support and

walk with a stick. Whenever he took off the glasses, the strabismus and

diplopia immediately returned. Other combinations were tried but failed

to relieve symptoms. The lenses given were +0.375 c. Vert. and L. +0.25

S. +0.25 C. 75 do.

Hemianopsia: organic or functional?

=Case 437.= (STEINER, October, 1915.)

A 19-year old volunteer, never ill (no nervous disease in the family),

after a period of training went into the field, October 3, 1914.

November 5, a shell struck the trench nearby but failed to explode. Up

to that time everything had been quiet. The soldier had been looking

out of the loophole, surveying the terrain. He felt a great fear, got

a blow in the neck, fell down unconscious, remained unconscious for

an unknown time, and later walked back with his comrades. About an

hour later, this volunteer,--who was a very intelligent young man,

possessing much knowledge of biology, including the nature of visual

fields,--noticed a black spot in the field of vision, which came and

went, but after a few hours remained continually without disappearing.

Otherwise, there was no complaint except a feeling of dizziness when

stooping.

Upon examination there could be found no disorder of the internal

organs. Neurologically there was blinking, vasomotor excitability,

slight reddening of the face, and dermatographia. An expert in

ophthalmology confirmed the existence of a homonymous defect in the

fields of vision. This defect could not be influenced by suggestion or

by any other treatment, nor did any other change whatever occur in the

condition.

Steiner inquires whether this hemianopsia is to be taken as organic

or functional. The air-pressure of the shell hissing past might have

produced a concussion, or the falling unconscious might have produced

a commotio cerebri or a slight hemorrhage. The tic-like blinking and

vasomotor excitability, however, suggest functionality.

Hysterical pseudoptosis.

=Case 438.= (LAIGNEL-LAVASTINE and BALLET, January, 1916.)

Laignel-Lavastine and Ballet present a case of what they term

hysterical pseudoptosis in a patient who showed no signs of organic

disease of the nervous system, and moreover no special mental disorder.

This soldier, 30 years of age, working in the auxiliary service,

suffered from a troublesome lowering of his left upper eyelid. He went

to the front in February, 1915. Aside from suffering a few mild and

temporary blindnesses (_éblouissements_), he was entirely well up to

the time of being wounded, March 18, 1915, by a bullet in the arm, and

a bullet occasioning a superficial and slight wound 2½ centimeters

above the middle of the left eyebrow. About three years later, a shell

burst near him and made a large contusion about the right eye, without

hurting the globus. He was then evacuated to Châlons-sur-Marne, and

there remained for 48 hours, totally blind, probably on account of

spasmodic closure of his eyelids. He then began to be able to use the

left eye, which remained, however, very photophobic. A fortnight later,

the wounds were healed, but the patient found himself unable to open

his right eye. Three months later he returned to his dépôt, and left

for the front October 24.

He was reëvacuated November 4, as unsuitable for service. He was then

examined by an ophthalmologist at Chartres, who found a very mobile

right pupil and a slightly atrophic right papilla; vision ½; left eye

normal; vision ⅔; total paralysis of right levator palpebrae superioris

without contracture of orbicularis. There was also paresis of the left

upper lid, which ceased when the right eye was closed. The right half

of the face was anesthetic, but there was no corneal anesthesia.

November 15: Right eyebrow lower than left; if the head was moved

backward, the right eyelid followed the movements, and in this position

there was no ptosis.

November 16: Analgesia in the super- and sub-orbicular region. November

17: frontalis and orbicularis functions normal.

At time of examination, patient complained of not being able to open

his right eye, and that he could only partly open the left eye. To

catch a view of his examiner, he had to throw his head back and to the

right. He could not open his eyelids, and in the effort to do so, the

forehead muscles contracted; and whereas the left eyebrow was properly

elevated, the right eyebrow was only partially elevated. Associated

movements could be noted in the musculature of the lower part of the

face. In looking to the right, the eyelids, especially the left, were

elevated slightly. The patient complained of photophobia. From time

to time, he felt completely blind, and at the end of these spells of

blindness, he had a severe headache. His head felt heavy. Sometimes on

looking to the left, he saw objects double, although this diplopia had

grown less marked of late. All the muscles of both eyes appeared to

work normally. Upon pressure on the right globus, especially pressure

directed from above and behind on the internal part, the patient would

raise his left eyelid, but the paresis reappeared the moment the

pressure was released; a fact which the patient himself noted while a

tampon was being placed upon his eye.

It seems there had been a wound at the external angle of the eye, some

nine or ten years before, as a consequence of which the eyelid of this

side could never be parted as well as before. The accident in question

had happened in 1905, and there had been a slight suppuration of a

wound 2½ centimeters from the external angle of the palpable fissure.

The patient then went through a period of reëducation. It seemed that

when he was trying to raise his eyelids, there was a mental inhibition

which could be overcome only by effort. An attempt may be made to

resolve the phenomena into three groups:

First, enophthalmia of the right side (post-traumatic, antebellum, a

predisposing cause).

Secondly, a situation corresponding to so-called hysterical

pseudoptosis of Charcot and Parinaud (eyelid falling without wrinkles,

head thrown back, frontalis contraction on effort to open eyes, eyelid

lowered). The diagnosis of hysteria was supported by the transient

opening of both eyelids when a sudden sharp order was given to move the

eye-_balls_, and further supported by synergic automatic lid-movements

when the patient voluntarily raised his eyes. He could not raise his

eyelids to order.

Thirdly, functional ocular palpable synergy (left eye opening upon

compressing the right eye).

Shell-shock Rombergism.

=Case 439.= (BECK, June, 1915.)

A soldier, 24, had sundry signs of traumatic neurosis. A curious and

unexplained feature is the fact that in the course of testing for

Rombergism he would fall forward like a log if his head were held in

the vertical position, but if it were turned to the right he fell to

the right; if it were turned to the left, he fell backward. Tests

showed that he had no disease of the vestibular apparatus and no sign

either of cerebral or of cerebellar disease.

The question is raised whether shell-shock can produce a differential

Rombergism such as hitherto would have been explained on the basis of

some organic vestibular disease.

_Re_ Rombergism, see especially Bourgeois and Sourdille’s (edited

by Dundas Grant) remarks on disturbances of balance which, if of

labyrinthine origin, obey Romberg’s law, namely, are greatly increased

with the eyes closed. Upon test, however, normal equilibrium,

tottering, or a tendency to fall will be usually found. The tendency to

fall is, as a rule, toward the side of the affected labyrinth, yet it

varies according to the position of the head; that is to say, actually

upon the position of the labyrinth with relation to the body. If there

is a lesion of the right labyrinth, for example, and the head is turned

to the right, falling is to the right; but if the head is turned 90

degrees toward the right, the patient tends to fall backward because in

fact the injured right labyrinth has now become posterior in position.

But if the head with the injured right labyrinth is displaced 90

degrees to the left, the tendency would be to fall forwards.

According to Beck, there was in his case of Shell-shock Rombergism no

ear disease or any evidence of cerebellar or cerebral disease.

Walking with the eyes open yields in marked instances a sidewise

bending or even the classical staggering called the duck’s walk and

drunken gait upon a broad base. The most delicate test, according to

Bourgeois and Sourdille, is the Babinski-Weil test of walking with the

eyes shut. A man with labyrinthine disease deviates from the straight

path (he is made to walk forwards and backwards ten times in a clear

space); bends pretty constantly to one side when walking forward,

and pretty constantly to the other side when walking backwards.

Spontaneous and Babinski’s induced nystagmus (rotation; caloric) and

Babinski’s voltaic vertigo test are the other tests commonly employed

in equilibrium investigation.

Otology and neuropsychiatry should go hand in hand.

=Case 440.= (ROUSSY and BOISSEAU, May, 1917.)

A soldier in the engineers, 29, entered the neuropsychiatric center

at Scey-sur-Saône, August 23, 1916. His diagnosis was: organic shock

syndrome with right-side deafness and tremors. He carried a ticket

showing an otological examination: tympanum normal; Rombergism absent;

walks with eyes closed swerving to right; tends to fall, eyes closed,

on standing on one foot; vertigo produced by rotation in either

direction; no nystagmus either spontaneous or by test; deafness

especially on the right side; equilibrium function insufficient.

The patient had undergone shock in April, 1915, being buried and then

losing consciousness for twenty-four hours. The tremors appeared next

day, and also deafness but without speech disorder. Nine comrades

are said to have been killed beside him. The hospital ticket, April

13, said: deafness and multiple contusions from shell explosion. The

patient was evacuated to Clarmont-Ferrand and went back to service with

the same tremor and auditory disorder. He was shortly sent back to the

interior for six months and returned improved to the front August,

1915. But he heard the cannon in the distance, and, under the influence

of emotion and the fatigue of the journey, the tremors and deafness

reappeared.

The tremor was generalized, involving both arms and legs and a slight

lateral movement of negation of the head every ten or twelve seconds.

Occasionally tonic contracture of the face, lips, cheeks, forehead;

tremors of tongue; winking. The tremors were somewhat suggestive of

toxic tremors.

The deafness was evidently exaggerated. Voltaic vertigo tested normal.

Reflexes normal.

The diagnosis psychoneurosis was made and the patient was rigorously

isolated, given a long psychotherapeutic talk concerning the nonreality

of his deafness and his vertigo and the possibility of cure by means

of a very disagreeable electrical treatment. He made improvement upon

psycho-electrical treatment and the next day both tremors and deafness

had greatly diminished. September 4, the patient was considered

completely well. There was a slight diminution of hearing in the right

ear, the whispered voice was heard at 50 centimeters on the right side,

the watch at 25 centimeters on the right and 60 on the left.

October 5 the patient was sent back to his corps. On the evening of

his departure, angry at not having received leave, he boasted to his

comrades of having passed but three days at the front since his injury.

It is remarkable, according to Roussy and Boisseau that this patient

had passed sixteen months without ever having been taken for a

neuropath or treated as one. The otologists gave the diagnosis

of labyrinthine shock, but did not attend to the tremors. The

pseudo-symptoms disappeared in six days at the neurological center and

the cure had lasted six weeks at the time of report.

_Re_ otology in these cases, see Bourgeois and Sourdille’s book

mentioned under Case No. 439, particularly Chapter III, upon the

functional examination of hearing. In the present instance, it will be

noted that voltaic vertigo tested out normal. According to Bourgeois

and Sourdille, the Babinski electrical test is the most convenient

one to begin with, to learn in a few moments whether the vestibular

system is working normally or not. These authors found amongst twelve

patients, three normal reactions and one instance of hypo-excitability

amongst four subjects who, by other tests, failed to show vestibular

disturbance. Inexcitability as to voltaic vertigo was found in

one man with a destroyed labyrinth. There were four instances of

hyperexcitability in Babinski’s cases with marked equilibrium disorder.

A case of Ménière’s disease yielded the same results. According to

the intensity of the current, the following phenomena (in addition to

the pricking sensation) are noted; (_a_) salty taste; (_b_) sidewise

swaying with slight vertigo; (_c_) nystagmus with more pronounced

vertigo; (_d_) sensations of sound. In short, nerve branches that go

through the petrous bone, namely, the chorda tympani, the vestibular

nerve, and the cochlear nerve, have been successively stimulated.

Babinski’s test was published before the Barany work on induced

nystagmus, but Barany’s rotation test for the physiological excitation

of the semi-circular canals, and his caloric test for the investigation

of the ears and canals separately are to be utilized in addition to

the Babinski voltaic test. Babinski’s law of voltaic vertigo is that a

normal subject inclines to the side of the positive pole; a pathologic

subject falls to the side to which he tends to incline spontaneously.

If the labyrinth has been destroyed, there has been no reaction.

_Re_ Case 440, Roussy and Boisseau in their capacity as

neuropsychiatrists, point out the inadequacy of an otological

examination taken by itself. They insist that neuropsychiatrists

should be called in. It is probably equally true that neuropsychiatric

work upon deaf cases is often inadequate on account of the lack of

otological examinations. According to Bourgeois and Sourdille, the

expert otologist’s problems are as follows: (_a_) Deafmutism; here

Gault’s cochleopalpebral reflex is of value. The hearing of a sudden

noise causes contraction of the orbicularis palpebrarum on the side

upon which the noise is suddenly and unexpectedly made. Eyelash tips

are particularly watched.

(_b_) Complete bilateral deafness. This is practically never organic;

complete bilateral deafness is a phenomenon either of traumatic

hysteria or of simulation. Sundry methods of surprising the patient

into hearing have been adopted. The practice of teaching lip-reading to

simulators and hysterics has led to some difficulties in diagnosis, but

tests have been produced by Gosset (of one sound with the lips set to

form another, and the like) which are of service.

(_c_) Extreme bilateral dulness of hearing.

(_d_) Total unilateral deafness. For the minutiae of tests for these

types of hearing disorder and their simulation and exaggeration, see

the War Manual of Bourgeois and Sourdille.

Jacksonian syndrome: Hysterical.

=Case 441.= (JEANSELME and HUET, July, 1915.)

A Lieutenant of Infantry, 32, was struck by a bullet September 6,

1914, in the upper part of the left temporal fossa 4 cm. above the

external auditory meatus. He did not lose consciousness, but had the

sensation as if his head had been shot off, and about three minutes

later he turned about, fell down, and lost consciousness. However, he

regained consciousness a few minutes later and walked with support

for about an hour. At the ambulance, he lost consciousness again, for

half an hour. He was then carried to Amalie-les-Bains. The trip lasted

108 hours. The left side of the face was now swollen so that he could

not open the eye nor could he chew from swollen mucosa folded between

the jaws. The bullet was removed Sept. 12, from just below the scalp

outside the bone, the point being slightly bent back. The bone had

been depressed slightly for an area the size of a franc piece, and

pressure at this point yielded a feeling of pain and discomfort. There

was no suppuration. After a week, the man got up. He returned to his

dépôt October 3 or 4 and was about to rejoin his corps when he had a

sensation of pressure in the head and fell. When he came to himself he

found that there was a frothy saliva at the left side of the mouth and

that the whole left side of the body felt weak. The tongue had not been

bitten nor had urine been passed, and twenty minutes later he felt as

well as ever. He returned to the front in the Argonne, having from time

to time similar crises,--at least once a week. Ordered to take a trench

the night of January 17, he failed the first time, about midnight, but

succeeded at four in the morning,--just afterward falling exhausted in

another crisis, with unconsciousness. The stretcher bearers took him

back and he was evacuated to Perpignan. He had two convulsions.

While with his family the crises grew in number to three or four a

week, and sometimes twice a day. Upon request, he was sent to hospital

in the Pantheon May 5.

There was always a sensory aura, consisting in a violent shock felt in

the left side of the cranium like a blow of a club. There immediately

followed a crawling sensation in the fingers and hand of the left

side, running up the arm, with loss of consciousness coming on before

the crawling reached the elbow. The seizure would last two or three

minutes. There was no initial cry. The face grew pale. There was apnea,

and frothy fluid running out of the left side of the mouth. There was

no jerking of face or limbs; at the end of the seizure there were no

deep inspirations. The extremities of the left side were rather flaccid

during the attack.

A hemianesthesia was found affecting both skin and mucosae of the left

side, and a slight retraction of the visual field on the left side

was found. There were no other sensory disorders; the knee-jerks were

lively on both sides but not actually exaggerated. Plantar stimulation

was not perceived on the left side. The toes, except the great toe,

were slightly extended. The fascia lata reflex failed to demonstrate

itself. On the right side the great toe went into flexion on forcibly

stimulating the sole. Sometimes the abdominal reflex on the left side

was weak or even absent. The patient, who had never been nervous, had

now become so since his attacks. He had had nocturia up to 12. There

was no evidence of neurosis or psychosis in the family. Bromides

diminished the crises a little in number. Static electricity was given

from January 8,--no attacks for 8 to 10 days.

According to Jeanselme and Huet, this is a case of Jacksonian syndrome

of an hysterical nature, about which it may be noted that the bullet

struck the left side of the skull and the hemianesthesia and muscular

resolution appeared on the same side as the injury.

Leg tic: Phobia against crabs.

=Case 442.= (DUPRAT, October, 1917.)

A man, shell-shocked in 1916 (with loss of consciousness,

disorientation and confusion followed by nightmares, memory

disorder, attention disorder, irritability, mental instability and

over-emotionalism) later still showed a choreiform tic. He had a

knife-grinding movement of the left leg which made standing and

walking difficult. There were no signs in the reflexes or reactions of

organic disease. The man himself said that he felt a sensation like

little electric shocks when his foot touched the ground, a sensation

like pinching. He also had certain hysteriform crises. He was able to

remember nightmares in which he felt as if he had fallen into a hole

where there were crabs. In point of fact, he had a true phobia against

crabs, crayfish, lobsters and the like; if he saw one, he always felt

as if he were going to have a new crisis. The defense movement of the

leg and foot was against a supposed pinch of the crab. At rest, there

was no trace of the choreiform movement. The tic was especially marked

when the man was suddenly asked to get up and walk. In a few days,

when he had become more clearly conscious of his phobia and had slept

better, the tic grew appreciably less.

Convulsions reminiscent of fright.

=Case 443.= (DUPRAT, October, 1917.)

A soldier, 28, was blown up February 8, 1915, by a shell burst. He

sustained no contusions but became completely mute. On July 3, he began

to speak in a low voice. The _torpillage_ treatment was unsuccessful

because the man felt a morbid apprehension that the vibration of a loud

voice or even of a rapid walk would resound in his brain. He had a sort

of noise phobia, probably maintained by nightmares which frequently

woke him up with a jerk though he could not remember their content.

On the way back to his dépôt this man got off the train at the first

station and went to a hospital complaining that the vibration of the

train was going to be transmitted to his brain. Hysteriform crises

developed in a few days.

According to Duprat these crises are nothing but a psychomotor

development of the initial complex. The clonic and tonic convulsions

are reminders of his states of extreme fright, a phenomenon of revival

of the ideo-affective process, aggravated however by the oniric or

post-oniric images.

_Re_ diagnosis of hysterical fits, the absence of facial cyanosis,

sub-conjunctival hemorrhages, petechiae of skin, and the Babinski

reflex are suggestive for hysteria. Babinski points out that the

initial cry, the fall, the loss of consciousness, the tongue-biting,

the bloody frothing at the mouth, the urinary incontinence, and the

post-convulsive prostration can all be consciously or unconsciously

imitated. Hysterical convulsive movements are apt to be of wide range,

gesticulatory, and opisthotonic.

Babinski announces to the supposed hysteric that he is going to

reproduce the attack, as he is perfectly able to do by electricity.

A mild current or mere electrode application suggests a fit in a

hysteric, often very quickly. Babinski now announces that he can arrest

the fit; carries out some selected procedure, and stops the fit. During

the hysterical fit, the patient of course hears what is being said and

during this time wrong suggestions must not be offered.

Fugue in a motor cyclist, with prodromal fatigue and subsequent

delusions--recovery in six weeks.

=Case 444.= (MALLET, July, 1917.)