  ChÈ non È impresa da pigliare a gabbo descriver fondo a tutto l’universo, nÈ da lingua che chiami mamma e babbo. For to describe the bottom of all the universe is not an enterprise for being taken up in sport, nor for a tongue that cries mamma and papa. Inferno, Canto XXXII, 7-9. In the course of our study of psychoses incidental in the war (Section A) and especially of Shell-shock’s nature and causes (Section B), we have naturally met most if not all of the major diagnostic difficulties. In the present Section we shall study cases for the light they may throw on the more technical troubles of the diagnostician. Who would À priori have felt that such diseases as tetanus, rabies, malaria, would produce practical difficulties in clinical diagnosis in the field of Shell-shock? Mayhap there was no need to emphasize further the values of lumbar puncture fluid examination. Yet the admixture of “functional” and “organic” symptoms in numerous puzzling cases can hardly be over-emphasized. But the interpolation, through the ingenious inquiries of Babinski, of a new or but vaguely suspected series of “reflex” (“physiopathic”) troubles between the organic neuropathic disorders on the one hand and the hysterical psychopathic disorders on the other—the result of these observations, sampled only in Section B, is given more in detail in the present Section. What a split in therapeutic method a recognition of this new group of “physiopathic” disorders might entail is seen also in further cases in the Section that follows this (Section D on Treatment and Results). A number of simulation cases has been added. Chart 11 |
| I. | NEUROSO-ORGANIC ASSOCIATION (NO CAUSAL NEXUS) |
| II. | REFLEX NEUROSES (LESION DISPROPORTIONATELY SLIGHT BY COMPARISON WITH PSYCHONEUROSIS) |
| III. | NEUROSO-SOMATIC ASSOCIATION (Trench Foot, Neuritis, Radiculitis) |
| IV. | FATIGUE OR EMOTIONAL PSYCHONEUROSES (CONSIDER EFFECTS OF PSYCHIC CONTAGION, EDUCATION) |
| V. | PSYCHONEUROSES ON ANTEBELLUM BASIS |
After Grasset
Chart 12
WAR PSYCHONEUROSES
SYMPTOMATIC GROUPS
| I. | EMOTIONAL (Hyper- Hypo- Para-) |
| II. | CONFUSIONAL (Attention and Memory Disorder, Dream States; Deliria) |
| III. | CONVULSIVE AND PITHIATIC (Hysterical) |
| IV. | NEURASTHENIC AND PSYCHASTHENIC |
| V. | SENSITIVOMOTOR AND SENSORIMOTOR—e.g., Limited Paralyses, Contractures, Deaf-mutism |
| VI. | COMPLEX |
| VII. | PHYSIOPATHIC (Babinski) |
After Grasset
Value of lumbar puncture.
Case 371. (Souques and Donnet, October, 1915.)
A colonial soldier arrived at Paul-Brousse Hospital with a hospital ticket showing that ten days before he had had commotio cerebri. He was dull, had a fixed stare, held his head in his hands, was disoriented for time and place, and had lost memory for everything that had happened for eighteen months. There was no sign of wound. There was no motor disorder save that walking was a bit slow and uncertain. Perhaps the right knee-jerk was stronger than the left. Percussion of the right Achilles tendon produced tremor. The plantar reflexes were flexor on both sides; flexion lasted longer right than left. The cremasteric and abdominal reflexes were a little weaker on the right. Arm reflexes were lively. Sensations proved normal. Complaint of headache, frontal and vertical.
Lumbar puncture October 7, that is, on the thirteenth day after the shell-shock, yielded a transparent, slightly greenish fluid, with 92 cells per cm. (lymphocytes with one or two large mononuclear cells and a few sometimes degenerated endothelial cells) and hyperalbuminosis.
October 9, the clouding of consciousness was less marked. The headaches and amnesia were constantly complained of; the reflexes were normal. October 12, there was less headache. October 25, another lumbar puncture showed but 14 or 15 lymphocytes per cm. and hyperalbuminosis. There was now no longer any clouding of consciousness. The amnesia, retrograde and anterograde back to May 9, 1914 (date of his daughter’s birth), and up to September 25, 1915, persisted. The man did not remember the declaration of war, or the mobilization, or his regiment, and the like. Meantime, the man’s judgment and reasoning powers were normal.
If there had been no early spinal fluid examination of this patient, he might well have been considered an hysteric or even a simulator.
Meningeal and intraspinal hemorrhage: Lumbar puncture.
Case 372. (Guillain, May, 1915.)
A gunner from Morocco, who lost consciousness for an hour March 28, 1915, upon the explosion of a large-calibre shell in his trench, was carried to the ambulance. He complained of headache and generalized pains. His status was scarcely modified during five weeks, and a generalized contracture of the body developed whenever movements were attempted. In horizontal decubitus, the muscles of the limbs and neck were of a normal tonicity, but the head went into hyperflexion if the patient was asked to sit. The eyes turned upward, and Kernig’s sign developed. The patient could walk only with short steps, with legs apart and arms held away from the body, the head in a sort of tetanoid dorsal hyperflexion. There was a right-sided hemiparesis with trepidation and the Babinski sign.
Lumbar puncture assured the diagnosis of something organic. The fluid contained blood cells and a marked lymphocytosis. The symptoms evidently depended upon hemorrhages in the meninges and the nervous system, affecting particularly the right pyramidal tract.
Re hypothesis of organic changes in hysterical cases, Roussy and Lhermitte remark in comment upon albuminosis in the cerebrospinal fluid that the albumin is perhaps due (in cases of camptocormia) to the effect upon venous and lymphatic circulation of the spinal curvature. It was Sicard’s claim that camptocormia, or bent back, was due possibly to anatomical changes in the spinal column, that is, that camptocormia was in one sense a spondylitis. In other cases the camptocormia might be due to a ligamentous or muscular change; that is, to a syndesmitis or a psoitis. His idea was that the curvature was in a sense antalgic; that is, a response having the purpose of avoiding pain.
Slight hyperalbuminosis.
Case 373. (Ravaut, August, 1915.)
A farmer, 32, in the 66th Infantry, was lying in a dug-out March 5, 1915, when a bomb threw him on the ground and covered him with earth. He was picked up unconscious, and remained so for an hour. In the ambulance it was found that he could hardly stand, could not speak, and appeared to be completely confused. There was no sign of wound. The next day he recovered consciousness and complained of a violent headache. He was completely deaf in the left ear, and vision was also a little impaired on that side. The puncture fluid was clear, and there was a very slight excess of albumin by the heat test. The next day the headache had entirely disappeared, the left ear was absolutely deaf, but the patient complained of buzzing. Lumbar puncture the following day showed a normal amount of albumin.
March 16 the patient was evacuated to the rear presenting no abnormal symptom except deafness.
Re the spinal fluid, Armstrong-Jones considers that a shock directly sustained by the spinal apparatus through sudden impact to the surrounding cerebrospinal fluid, ought to be felt more by the anterior horn cells than by the spinal root ganglia, since the latter are shielded by the sheath in the intervertebral spaces. Motor symptoms would, naturally, then be more frequent than sensory symptoms. He also believes that the controlling neurones in the intermedio-lateral tracts that have to do with the sympathetic system, would be affected just as anterior horn cells are. Accordingly, the dilated pupils, rapid heart, dyspnoea, and a variety of precordial pains and disorder of the viscera would ensue. The jar would thus be communicated to the neuronic cells of origin of two types: spinomuscular and preganglionic, leaving the gangliospinal neurones relatively intact.
Paraplegia, organic: Lumbar puncture.
Case 374. (Joubert, October, 1915.)
A gunner, 23, was thrown to the ground, according to his story, by the explosion of a large-calibre shell, at eight o’clock in the morning of September 10, 1914. He could not get up but thought he had not lost consciousness. September 13, he arrived at hospital, looking like a man with dorsolumbar fracture of the spine. There was, however, no external injury. There was a marked paresis of the right upper extremity, with diminished sensibility, weakened reflexes, numbness, formication. The right lower extremity was subject to complete flaccid paralysis, with lost reflexes, and anesthesia in all respects reached to the belt level, and stopped sharply at the median line of the abdomen. The left leg, also, was paretic but the muscles could be contracted weakly; the knee-jerk was exaggerated; there was a tendency to epileptoid trepidation, and the sensations were only slightly diminished. There was a Babinski reflex on the right side; the abdominal reflex was absent on the left side; both cremasteric reflexes were present. The feet at times gave formication. Rectal, bladder, and sphincter paralysis. Dark albuminous urine, with a few blood cells, was obtained on catheterization. There was an early sacral decubitus; consciousness was somewhat clouded. The man made no requests except for something to drink, and seemed apathetic.
Lumbar puncture, September 14, yielded hemorrhagic fluid. Three days later, the upper extremity regained its powers and sensations, but the paraplegia had become complete, with abolition of reflexes on both sides, and absolute anesthesia. The feet yielded formication at times, however. Sacral decubitus increased and healed not. The temperature varied between 38 and 39. The patient died September 24, in coma, with anuria and Cheyne-Stokes breathing.
Gunshot wound of spinal column; no penetration or injury of dura mater: At first quadriplegia; later cerebellospasmodic type of disorder.
Case 375. (Claude and Lhermitte, July, 1917.)
A soldier, 22, sustained a gunshot wound in the neck about the level of the fourth cervical vertebra. He immediately became quadriplegic. He recovered arm motion in two months and some weeks later ability to stand and walk.
Three months after the injury, station was difficult, better on a broad base. Rombergism, even with eyes open. Cerebellospasmodic gait. There was no weakness of leg muscles, but there was a certain degree of weakness of the upper extremities, especially in finger flexion. There was hypertonia of the muscles of all the extremities and the hands showed the signs of Raimiste, of Klippel and Weil, and of Dejerine. Static equilibrium was preserved to the will, but the kinetic balance was affected, and as much in the upper as in the lower extremities. Ataxia, tremors, dysmetria, adiadocho-kinesia, and disorder of combined movements in thigh and trunk flexion were all in evidence. Meantime, there was no disorder of sensation whatever except that the ulnar border of the right hand showed a hypobaresthesia, and there was a disturbance of tactile discrimination and absolute astereognosis in the hands. The deep reflexes were everywhere increased, and ankle and patellar clonus were easy to excite, especially on the right side. Bilateral defense reflexes. Bilateral Babinski sign. The hypertonia and ataxia ebbed away during the following three months. Walking became normal, and there was little sign of difficulty except astereognosis of both hands, combined with slight disturbance of deep sensibility and poor response to compass test in palm.
We here deal with a case of spinal column injury without injury to the dura mater. This cerebellospasmodic form of the superior cervical type of spinal concussion is less frequent than a quadriplegic form with Brown-SÉquard syndrome. It is striking that both types of concussion may recover.
Spinal column trauma, with local signs: Later, hysterical anesthesia and contracture of back muscles homolateral with the trauma.
Case 376. (Oppenheim, July, 1915.)
A musketeer, wounded August 20, 1914, by a shell splinter in right side of vertebral column, fell unconscious, but was able afterward to crawl on all-fours out of the firing line. Severe vomiting and epistaxis followed. August 23, there was pain in the small of the back; the last two ribs were painful on right side; and the muscles were slightly swollen up to the iliac crest. August 30, a slight rise of temperature (at first it had been above 38) still persisted, but the muscular swelling was diminished. Treatment by aspirin and baths. No further rise of temperature after early in September.
On October 9, patient was permitted to get up, whereupon he showed a peculiar curved attitude of the body, reduced almost completely by passive straightening. Swelling of the longitudinal muscles. Radiograph negative, except that one picture showed a change in left twelfth rib, near the transverse process. Pains in left lumbar region.
November 19, on examination, pulse 112. November 23, after massage, vomiting. Temporary use of plaster corset.
On admission to the nerve hospital December 22, the musketeer was unable to extend the trunk, and the long muscles of the back were on the stretch, often as hard as wood, especially those of the left (longissimus dorsi). Patient lay on right half of pelvis. Hemianesthesia and hemianalgesia, left side. Tachycardia. Formerly the patient had done hard work, especially carrying heavy bags. He declined to be examined under general anesthesia. He seemed to be of unreliable character, and his trouble did not prevent him from returning from leave of absence, on one occasion, drunk.
Mine explosion: Combined hysterical and lesional effects.
Case 377. (Dupouy, September, 1915.)
A lieutenant, 23, was in a mine explosion June 23, coming out in complete torpor, with mutism and retention of urine. He was brought to hospital June 26, with jactitation, irregular pulse, markedly exaggerated tendon reflexes, absent skin reflexes, sluggish, dilated pupils, especially right, and general anesthesia. The spinal fluid contained an excess of albumin, altered blood cells and many lymphocytes.
Several hours after puncture he suddenly demanded where he was, thought it was the year 1911 when he was in the Dragoons, talked about his camp, and was confused, irritable and stereotyped in questions. There was no verbal amnesia. Speech was hesitant, explosive and scanning, suggestive of multiple sclerosis. Next day there was still retrograde amnesia. He clung to the belief that it was July, 1911, and asked wearisome, stereotyped questions. The words, “German house” caused a jactitation, stiffening and relapse into a second État, out of which he came with hiccoughs and sighs, and amnestic for this conversation. There was general hypesthesia and muscular weakness especially of legs. The reflexes were as before.
The morning of June 28, he heard the hum of an airplane, whereupon his memory returned. It seems that he had himself once ascended. The memory gap was now limited to the time immediately preceding the mine explosion and the days following, up to the time of hearing the airplane. He told about his military life and also about incidents immediately preceding his blowing up. He complained of malaise and of pains in the vertebral column and limbs.
There was a quadriparesis, more marked, however, on the left; walking with falls to the left; astasia with left foot; double facial paresis; inability to whistle and to close eyes completely; intestinal and bladder paralysis; nocturnal emissions non-pleasurable; partial anesthesia of right leg, of
Improvement was marked and progressive in motor, sensory and reflex fields. At the time of report three months later, there was a definite paresis of the left leg, with anesthesia and absent plantar reflexes, and slight paresis of the orbicularis palpebrarum, scanning speech and syncopal tendencies. Here, then, due to diffuse, non-systematic lesions, with superadded hysterical manifestations, were probably some effects of a permanent nature due to destructive processes.
Re combination of functional and lesional effects, Sollier and Chartier state that in Shell-shock hysteria, physical causes and conditions are the chief factors; that in the so-called hystero-traumatism of Charcot, the psychic and physical factors are of virtually equal importance, and that in ordinary cases of hysteria, the psychic is the chief genetic factor.
Shell explosion: Hysterical and organic symptoms.
Case 378. (Hurst, 1917.)
A champion heavy-weight boxer, 29, was unconscious for two days after being knocked over by the explosion of a shell in December, 1914. He found at first that he could not move the right arm or left leg; and after power had returned to the limbs, he had forcible involuntary movements in the left leg whenever he tried to stand. Examined, April 1, 1915, he answered questions slowly and with slow words; the right arm was weak. When the left hand was clenched, an associated movement took place in the right hand, but not vice versa. There was, however, no diminution in the girth of the muscles. The man was unable to localize light tactile stimuli accurately. Movements of the left leg were somewhat weak, the left knee-jerk was slightly brisker than the right; ankle clonus could be obtained on the left side and Babinski second sign (paralyzed leg rising higher than the normal leg in combined flexion of thigh and pelvis). When the man tried to walk, the left leg moved rapidly from side to side round the point of contact of the toes. When the right leg moved forward, the left dragged behind in irregular movement.
Every effort to cure the patient by means of suggestion during hospital care for a month entirely failed. Although the man was easily hypnotizable, he could not be made to move his leg under the deepest hypnosis. The first whiff of ether hypnotized him, so that the method of etherization could not be used in the endeavor to control the leg movements. Over a year later, July, 1916, the patient had greatly improved mentally but was otherwise in precisely the condition that is above described.
Gunshot wound of buttocks with injury to cauda equina: Urinary disturbance; decubitus; anesthesia. Superimposed paraplegia, regarded as functional and cured by psychotherapy.
Case 379. (Oppenheim, July, 1915.)
A German grenadier, October 11, 1914, was wounded in the left buttock by a missile that passed out through the right buttock. Pains in the abdomen and legs followed. The man had to be catheterized on the battle-field.
October 23, he suddenly fell down with total paralysis of both legs.
November 3, numerous small furuncles appeared on the buttocks, and bedsores developed. The patient lay helpless in bed, was unable to sit up without support, or to turn from one side to the other, and had areas of anesthesia.
During November and December, there was persistent high temperature, between 38 and 40; but January 3 the temperature stood at 36.6.
January 7 the patient was admitted to a nerve hospital. At this time he was able to pass urine unaided, though with tenesmus and pain, sometimes nausea and a tendency to vomit. He complained of pain in the back and pelvic region; the legs lay as if paralyzed. No active movement whatever was performed. There was a marked increase of tendon reflexes (even including the semi-membranosus). The muscles were relaxed through disuse but there was no atrophy. The patient moved his legs about with his hands. Sensibility was preserved except in the region of the pubis. The plantar reflexes were absent. Electrical reactions normal.
The diagnosis was functional paralysis of the legs (previous gunshot injury of cauda equina).
Treatment with psychotherapy met with prompt results; within a few days, the patient learned to move his legs and to walk with support, though making enormous efforts which threw the pulse up to about 160 and made the face congested. The bladder disturbance and the sacral anesthesia persisted.
Spinal concussion with spinal cord lesion: Thermanesthesia and analgesia of right leg and side.
Case 380. (Buzzard, December, 1916.)
An officer was hit in the back by a shrapnel fragment, fell paralyzed, but after a few minutes was able to walk more than a mile to the dressing station. Eventually arriving in London, he had nothing to complain of except the wound, as the foreign body had been removed in France. The wound healed and the patient went to a convalescent home.
However, when taking a bath he could not feel the temperature of the water with the right leg. Muscular power was perfect; reflexes normal; but the heat, cold and pain sense was lacking in the right leg and the right side of the body from the seventh costal cartilage downwards.
One may make a wrong diagnosis of “Shell-shock.”
Case 381. (Buzzard, December, 1916.)
In August, 1915, an officer was blown many yards by a shell, lay unconscious a while, could find no bruises, and carried on for twenty-four hours. Then, finding legs unreliable, he reported sick and was sent home as “Shell-shock.” He remained “Shell-shock” until February, 1916, then being able to walk five or six miles on smooth ground. Going downstairs he took the step with left foot rather than with right, and the right was apt to turn in. The sense of position and movement in regard to the right foot proved to be faulty. He could not balance himself on the right foot, nor could he appreciate tuning fork vibrations as well on this foot as on the other.
An X-ray examination showed a slight fracture, without deformity, in the left post-Rolandic region near the median line. His helmet had been bashed in at this point, and the bruised brain yielded symptoms even eight months later.
Retention of urine after shell-shock.
Case 382. (Guillain and BarrÉ, November, 1917.)
An infantryman underwent shell-shock December 19, 1915, from the explosion of a torpedo nearby. He arrived at the ambulance, unable to speak, and next day had a confusional crisis of convulsions with contractures. He had not urinated since the accident, and two liters of clear urine were withdrawn by catheter; after which, the patient rested quietly and gradually regained consciousness. He was catheterized again in the evening and clear urine withdrawn. He remained unable to urinate spontaneously until December 25, and was catheterized accordingly.
There was no motor, sensory, or reflex disorder in this patient. Lumbar puncture yielded a normal fluid; the pupils were normal, and the only appearance was that of a marked asthenia.
Three months after his shell-shock, in March, 1916, the soldier was once more examined and still complained of headache, weakness, and inability to walk more than four or five hundred meters without a certain trembling of the legs. The reflexes remained normal and no further bladder trouble had supervened.
Re anuria, Babinski remarks that, in days of yore, hysteria was supposed to be able to produce anuria as well as albuminuria, and even such organic changes as vesicles of the skin, ulceration, hemorrhages in the skin or of the viscera, fever, and even gangrene. He remarks that of late years no single identifiable case of this sort proved to be hysterical, has been reported. This is aside, of course, from such superficial and quickly passing vasomotor disorders as erythema and dermatographia. Anuria and albuminuria have consequently passed from the textbooks on hysteria, just as Babinski believes that hysterical edema and hysterical exaggeration of the reflexes are bound to pass. Hysteria cannot imitate everything; it cannot reproduce the characteristic phenomena of organic paralysis.
Retention of urine after shell-shock.
Case 383. (Guillain and BarrÉ, November 1917.)
An infantryman, 27, underwent shell-shock August 16, 1916, at four o’clock, from the nearby explosion of a big shell. He lost consciousness for a period of ten minutes, was sent to the regimental aid post, and twelve hours later brought to a hospital center, in a state of profound muscular weakness. He could not walk although he could make every movement of the legs. There was a marked diffuse cutaneous hyperesthesia. The reflexes were normal; the pupils were unequal, the right myotic. The lumbar puncture yielded a clear fluid under normal pressure, but with an excess of albumin. For three days, retention of urine was absolute, requiring the catheter. There was neither sugar nor albumin in the urine withdrawn. On the fourth day he was able to urinate spontaneously; the asthenia and other symptoms had disappeared in two or three weeks.
Incontinence of urine after shell-shock and burial.
Case 384. (Guillain and BarrÉ, November, 1917.)
An infantryman was subject to shell explosion and burial May 10, 1917. He lost consciousness for a few hours and spat blood for two days. He was carried to an evacuation hospital and thence to the neurological center at Amiens. Incontinence day and night lasted from the period of shock up to May 29, when the patient was transferred again, to another hospital. The man had never, either in childhood or adult life, had incontinence. He showed a slight tendency to latero-pulsion toward the left. Puncture fluid normal.
Guillain and BarrÉ report but 12 cases of sphincter disorder following shell-shock without external wound among hundreds of cases, and among 12 instances of sphincter disorder there were but three of incontinence, of which the above is one example. Incontinence lasted longer in these cases than retention. Guillain and BarrÉ are unable to assign a cause for the findings.
Struck in back by shell splinter: Crural monoplegia; absence of plantar reflex.
Case 385. (Paulian, February, 1915.)
An infantryman, 20, was struck by a shell fragment in the small of the back while lying in the firing position, about 2 P.M. August 22, 1914, at Eth in Belgium. He felt as if he had been struck by the butt of a gun in the lumbar region. He was unable to get back with his comrades. His sack had been cut. He was without ammunition, and getting to a bridge he was able to jump a distance of about 8 meters. He fell and fainted. On coming to himself, his left side felt bad and he could not move his left leg. He dragged himself to the relief post which was being bombarded just as he arrived, and he got a bullet in the left frontal region.
He was evacuated to another ambulance and decided to go back to France. Supported by his Lieutenant, he walked all night making about 35 kilometers on foot. He arrived at Charancy and got by train to Mont-Midi. On alighting, he could not walk. He said he was bent in two, and shuffled on in this position.
The “bent-back” lasted about a month, when he began to stand up again. He passed through various hospitals and was evacuated to the SalpÊtriÈre. He then walked with the left leg in extension on the thigh and the foot in external rotation. He was hardly able to stand on either foot, and especially fell if he tried to stand on the left foot. He made no resistance to passive movements of the left lower extremity. The reflexes were normal except that the left plantar reflex was abolished. On the right, the plantar reflex was normal, and an attempt to elicit this reflex was followed by strong defensive movements. There was a tactile, thermic, and pain anesthesia of the foot and leg as far up as the lower third of the thigh. Above this anesthesia, there was a zone of hypesthesia. Position sense was also abolished in this region, and there was a bony hypesthesia likewise. A slight muscular atrophy (2 cm.) affected the lower leg and thigh.
There were no hereditary or acquired features of importance in the case except that there had been at 14 a chorea for a year. In particular this man appears not to have been an emotional person.
The point in the case is the abolition of the plantar reflex on the left side, in association with a functional paraplegia and hemianesthesia.
Re plantar reflex modification in hysteria, Babinski believes that the same law which holds that hysteria is not in line to alter either the tendon reflexes or the pupil reflexes, is true for the skin reflexes. Dejerine brought forward three cases which appeared to him, however, to demonstrate absolutely that functional anesthesia might abolish or greatly diminish the skin reactions of the sole of the foot, that is, the plantar reflexes and movements of defense. Case 385 was alleged in support of Dejerine, as also were cases of Jeanselme and Huet, and of Sollier. Babinski’s critique of Dejerine’s cases ran to the effect that two of them showed contractures, and accordingly were not pure cases in which to demonstrate plantar reflexes or movements of defense. In the third case, Babinski at a meeting of the Neurological Society, himself obtained definite flexion of the little toes by stimulating the planta. According to Babinski, therefore, Dejerine’s cases, far from proving that hysterical anesthesia could abolish the plantar cutaneous reflexes, proved that hysterical contracture might mask reflex movements. Hysterical contracture, therefore, may be as important a factor to consider re reflexes as voluntary muscular contracture itself. As Babinski pointed out, many normal persons can keep the leg immobile when the sole is stimulated. Moreover, Babinski pointed out, many cases regarded as hysterical were actually cases of a physiopathic or reflex nature which had actually undergone trauma. It will be noted that the above case of Paulian is just such a case of trauma.
Shell-shock; unconsciousness: Crural monoplegia; sciatica (neural changes).
Case 386. (Souques, February, 1915.)
A reserve lieutenant, September, 1914, was blown up by a shell and lost consciousness for an hour. On coming to, he felt pains in the loins, right thigh, knee and heel, and found himself unable to move the right leg at all. Urinary incontinence lasted three or four days. Violent pains lasted weeks, now and then actual crises (sleep only with hypnotics).
The pains then passed off. The flaccid crural monoplegia lasted. There was a hydrarthrosis of the right knee and a sciatica (physical nerve changes?) and a crural monoplegia without trophic, electrical, reflex or vesico-rectal trouble. Lumbar puncture showed no lymphocytes or excess of albumin. It would, of course, be difficult to tell whether this case was hysteria or simulation.
Re hysterical monoplegia, Babinski inquires whether a hysterical monoplegia can automatically appear as a result of emotion without any intellectual element whatever. Emotion produces sweat, diarrhea or erythema, without any intellectual intermediate. Can emotion—that is, emotional shock—produce a monoplegia in the same way as it produces an erythema? The narratives of patients might indicate that emotion can do such things. But according to Babinski there is no genuine case of monoplegia or paraplegia directly produced by emotional shock. One must be careful in this discussion not to confuse emotional shock and emotion of a gradual nature. Babinski wishes to define emotion as a violent affective change as a result of a sudden mental shock upsetting physiologic or psychic balance during a usually brief period. As for the more gradual affective states or emotions, there is obviously so much of the imaginative and intellectual compounded therewith, that plenty of opportunity exists for the production by suggestion of such phenomena as monoplegia, paraplegia, hemi-anesthesia.
Re sciatica, see remarks above under Case 329.
Functional paraplegia and internal popliteal neuritis.
Case 387. (Roussy, February, 1915.)
A Zouave was taken out from under a trench shelter beam, the night of December 21, 1914, at Tracy-le-Mont. The beam had fallen upon eight men, killing one, and striking the Zouave in the hypogastrium. He was pulled out two hours later, unable to take a step. He was evacuated on his back, to Paris; stayed a month in the hospital at Croix-Rouge, bedfast. According to the patient, he was entirely anesthetic in the legs. He went to Villejuif, January 22, with the diagnosis of spinal contusion and hemiplegia. He could then walk on crutches, leaning on the left leg. He felt a sharp pain at the level of the spinous process of the first lumbar vertebra and all along the sacrum. Spontaneous movements of the left leg were possible, but they were slow and weak. The hypesthesia rose to the navel. There was a suggestion of a cauda syndrome. The knee-jerks were normal, but on the left side the Achilles jerk was absent. There was a partial R. D. in the posterior muscles of the left leg.
The diagnosis was functional paraplegia plus left internal popliteal neuritis. The crutches were removed, he was isolated, and given motor reËducation. In a week he was able to walk alone with ease.
Re popliteal nerve lesions, Athanassio-Benisty remarks that the external popliteal nerve of the leg resembles pathologically the musculospiral nerve of the arm, whereas the internal popliteal behaves like the median. The musculospiral nerve of the arm shows very variable and usually slight sensory changes. The median nerve more than any other nerve in the arm yields painful sensations during its recovery from section.
Re differentiation of peripheral neuritis and hysterical paralysis, Babinski gives as signs peculiar to neuritis, and never found in hysterical paralysis, the following: (a) diminution or loss of bone and tendon reflexes; (b) muscular
Re diagnosis of organic paraplegia as against hysterical paraplegia, the latter is to be recognized chiefly by the absence of the organic signs, as (a) alteration of tendon reflexes, (b) the Babinski sign (toe phenomenon), (c) exaggeration of defense reflexes (dorsal flexion of foot on sharp pinching of dorsum of foot or leg), (d) muscular atrophy with R. D., (e) sphincter disorder, (f) skin changes, such as decubitus.
Bullet in hip: Local “stupor” of leg.
Case 388. (Sebileau, November, 1914.)
A Moroccan sharpshooter, 20, was wounded September 27, at Soissons. One bullet scratched the left thigh. A second entered below the anterosuperior iliac spine at least 6 cm. outside the femoral artery and emerged above the ischiotrochanteric line, 2 cm. above and 4 cm. behind the upper extremity of the great trochanter, thus passing through the tensor of the fascia lata and without breaking a bone.
There was a complete paralysis of the left leg. The man had to walk with a crutch and a cane, dragging the leg like a weight. There was no active or passive movement of thigh, lower leg and foot muscles, except that there was a slight tendency to abduction of the toes, from innervation of the dorsal interossei of the foot. The iliopsoas was also involved, as well as the gluteal and pelvic trochanteric muscles. There was a certain amount of muscular tone preserved, so that the bony elements of the skeleton were held together. The foot did not fall and the leg did not elongate, as it might have in a case of paralysis of the sciatic nerve. Electro-diagnosis showed an early reaction of degeneration according to one examiner, but Sebileau believes that there was no R. D. There was anesthesia of a large part of the leg, which stretched over the anterior and internal aspects of the thigh, covered the entire territory of obturator and crural nerves but did not stretch above the fold of the groin. The region of the femorocutaneous nerve was slightly sensitive and the posterior aspect of the thigh and buttock was sensitive. There was a slight sensation on the external aspect of the lower leg. Foot and toes were entirely insensitive. The anesthesia was for all forms of common sensation. No vasomotor, thermic or trophic disorder. The reflexes were all abolished, except for a tendency to cremasteric reflex. It is clear that these conditions cannot be simulated. Possibly they are hysteric and to be explained on the basis of a kind of autosuggestion or perhaps, according to Sebileau, the local and nervous
Re stupor, see Case 253 of Tinel. Re such local “stupor” it may be noted that this case was published in 1914, before Babinski’s larger publications on reflex disorders. As for the loss of cutaneous reflexes, Babinski remarks that immersion in hot water may cause the cutaneous reflexes in the so-called physiopathic cases to reappear for a time. He regards the loss of cutaneous reflexes in the physiopathic cases as due to a circulatory disturbance, and recalls the fact that compression by an Esmarch bandage can cause the tendon reflexes to vanish for a time, and can even cause pathologically excessive reflexes to disappear. The cutaneous reflexes have also been caused to disappear by compression.
According to Babinski, Sebileau’s explanation that such matters as loss of reflexes could be explained by autosuggestion is erroneous.
Re muscular hypertonus in reflex cases, Babinski remarks that though it may be very pronounced, it is as a rule restricted in area. Re sensory disorders in reflex cases, pains are found (they were very slight ones in the present case); hypesthesia has also been found by Babinski.
Localized catalepsy: Hysterotraumatic.
Case 389. (Sollier, January, 1917.)
An invalided soldier had been suffering for a year with marked atrophies and the right knee in extension. There had been a bullet wound of the upper third of the tibia, which did not affect the joint. There was a total anesthesia, both superficial and deep, which stopped sharply at the upper part of the thigh. At the time of the very first examination, this apparent ankylosis was reduced, to the great stupefaction of the patient. There was, however, a peculiar phenomenon in this subject. There was a localized catalepsy of the limb, which was able to preserve any desired attitude in which it was placed; and this attitude could be indefinitely prolonged, just as in cataleptic hysterics. Here, then, was a case of localized hystero-traumatism precisely imitating the classical hysteria of Charcot except for its localization.
Re hysterotraumatism, Charcot developed ideas concerning trauma and localized hysteria in 1886, thereby overthrowing the ideas of Erichsen concerning the organic nature of “railway spine” and “railway brain” as developed twenty years before. In a case of local trauma such as the bullet-wound of Case 388, Babinski’s explanation would be that the pain and inhibition of movement resulting from the bullet wound at the time of injury, formed the focus of a process of autosuggestion. According to Babinski’s figure, the organic factor acts as a bait for the hysterical symptoms. According to the SalpÊtriÈre experience, hysteria is incapable of producing a real superficial and deep anesthesia such as is mentioned for this case. For example, no hysterical patient in the Charcot clinic, according to Sicard, could undergo a scalpel operation without some general or local anesthetic. When, therefore, a true deep anesthesia occurs, Sicard’s conception would be that the anesthesia is not a truly hysterical one but belongs to the group of physiopathic phenomena.
Contracture: Hysterotraumatic.
Case 390. (Sollier, January, 1917.)
A sailor, 41, got hygroma of the right knee in 1915, was operated on in July, returned to his dÉpÔt a month later, and thence to Vizille Urage by reason of contracture in extension of the right leg. It was thought he was simulating (since there was no muscular atrophy), and he was sent to the neurological center, where under anesthesia the joint was found free. This man developed, when the knee was bent, extraordinary cracklings in the joint, and he showed pain unequivocally, making a defensive movement, partly reflex, partly voluntary, when the leg was flexed beyond a certain point. There was 3.5 cm. atrophy in the thigh, a reflex atrophy due to the joint disorder. There were no other signs of hysterotraumatic contracture.
According to Sollier, the diagnosis of hysterotraumatic contractures depends upon: first, a characteristic special attitude of the contractured limb; secondly, the participation of the antagonists as a group (global); thirdly, the superposition of sensory disorder upon motor disorder (Charcot’s law); fourthly, the segmentary topography of sensory disorder; fifthly, the extension of the contractured joint; sixthly, the persistence of the contracture in the same form, whether at rest or in attempted movements; seventhly, muscular rigidity; eighthly, normal tendon reflexes; ninthly, normal electrical reactions (though R. D. is hard to determine in muscles contracted to the maximum); tenthly, special reactions during attempts to reduce, such as pains, and equal and regular resistance to changed attitude, pseudoclonus in cases of foot contracture; eleventhly, immediate reproduction of the contracture after reduction under chloroform; twelfthly, co-existence of various hysterical stigmata.
Crural monoplegia, tetanic. Recovery.
Case 391. (Routier, 1915.)
An ensign was wounded by a shell splinter in the right scapular region September 25, 1915. A large hematoma was drawn off and drains inserted. Antitetanic serum was given 24 hours after the trauma. The wound looked well. The patient complained merely of the heaviness of his arm, and after September 27, the temperature fell to normal. Magnesium chloride solution was applied every other day, and progress was so good that evacuation was ordered.
However, October 8, the patient suddenly began to complain of a sharp pain in the right thigh, which next day became intolerable and threw the muscles into a slight contracture, the adductors being extremely stiff. Headache developed in the course of the day, with slight stiffness of neck, exaggeration of reflexes in the right leg, and ankle clonus. Temperature: 37.6 morning, 38.5 evening. The patient was isolated and given chloral.
October 10, paroxysmal crises of pain, more marked stiff neck, and lumbar stiffness appeared, with nervousness, photophobia, and hyperesthesia to noise. The wound seemed to be doing well. Chloral was given.
Slight trismus developed October 11. The tongue became dry and the patient drank little. The condition held and the same treatments were repeated up to October 15, when the temperature fell and the contractures and pains were diminished. The chloral was continued. There were still a few cramps in the neck. October 22, however, the patient was practically well.
We are here dealing with an instance of local tetanus of monoplegic form, developing a fortnight after the wound (there is an early group developing, as a rule, from the fifth to the tenth day, and a group of later development, after the twentieth day; the interval in this case was of intermediate duration). According to Courtois-Suffit and Giroux, the differential diagnosis is not easy, since, besides
Re differential diagnosis of tetanic conditions, see Courtois-Suffit and Giroux in the Collection Horizon. The cases as a rule appear in subjects that have had serum treatment, and may occur in subjects in whom no trismus ever develops (the above case showed slight trismus).
The recognition of localized tetanic contracture is based upon (a) the intensity of the contracture, which causes the limb to feel wooden (in one case the foot, leg, and thigh were welded to the pelvis like an iron bar); (b) paroxysmal contractions resembling those of tetanus, confined to one limb, and started by a variety of external causes, forming the principal symptom in the disease; (c) contracture of comparatively brief duration (hardly ever over two or three weeks). A slight fever may help in the differential diagnosis.
Wound of left leg: Local spasms, later contracture, and painful crises (these associated with suppuration), the whole treated as tetanic.
Case 392. (MÉriel, 1916.)
An infantryman was wounded by shell fragments September 28, 1915, at Virginy and was given a first dressing an hour later and a second at the ambulance, where antitetanic injection was also made. October 3, the patient arrived at Foix, showing a superficial wound of the left frontal region, a penetrating wound of the upper third of the left thigh, and another in the lower third of the left lower leg.
The evening of October 8, the man began to feel pain in the left leg, though the wounds looked well and there was no fever. October 9, sudden involuntary contractions of the left leg developed, and these increased in amplitude if the limb was touched. The other extremities were normal. Temperature 38.2; pulse 102. Restlessness at night.
Next day 10 c.c. of antitetanic serum was administered and more on the 11th, with chloral and isolation; but on the evening of the 11th, with the contractions still completely localized to the left lower extremity, came an extremely painful crisis interfering with sleep and at last requiring morphine. Up to the 15th the antitetanic injections, chloral and morphine were continued, but on the 15th the contractions were replaced in part by a contracture affecting the muscles of the posterior aspect of the thigh. In the meantime, the patient howled with pain, especially in the night. Chloral and morphine were given.
During the next five days the contractures and pains became still more violent, and on the 21st the antitetanic injections were begun once more and kept up through the 26th in 5 c.c. doses.
The patient began to urinate in bed and to be delirious. The contractions now disappeared, but the contracture persisted. Antitetanic serum was given every other day from October 28 to November 2; every third day from November
The tetanic symptoms of the left leg now gradually diminished. The leg, which had been flexed at a right angle, began to extend little by little, and the toes, which had been strongly flexed, reassumed their normal position. The wounds suppurated freely during the tetanic crises, but then healed. In January the man could get up and walk, dragging his leg somewhat, and January 20 a complete recovery had been obtained. There was no hysteria in the history of this patient, although the man was subject to “professional” alcoholism, being carter for a wholesale wine dealer, drinking 5 liters of wine a day.
Shell-shock by windage: Hysterical paraplegia, flaccid type, develops 10 days later, after strain, capture, privation, recapture. Paraplegia at first complete. Recovery by suggestion (one sÉance).
Case 393. (LÉri, February, 1915.)
A corporal, 21, told how at Goselmind, during the Sarrebourg retreat, August 20, 1914, a shell burst a meter behind him, flattening his knapsack, throwing him to the ground, blowing him forward (as he said, by the pressure of the air) seven or eight meters, leaving him stunned though conscious for about twenty minutes. Uhlans fell upon him but did not trouble themselves further with him as he could not walk. He crawled along on elbows and knees about a kilometer and a half to some Frenchmen in a wood. He now found himself able to walk a whole day supported by two comrades, making about 12 kilometers. He got by carriage to GerbÉviller, but here fell again into the hands of Germans, who left him nine days in the corner of a barn without care. GerbÉviller was retaken, and he was evacuated to Bayon.
He had now had for some time pains in the kidney region below the point struck, some difficulty in turning his head, and some numbness and jerkings in the legs; and the legs that had carried him 14 kilometers were unable to move at all, even in bed. It was only 8 days later that he could perform the slightest movement, and two months followed before he could go a few steps on crutches. December 14, three months and a half after his accident,—he was demonstrated as “spinal contusion.” Upon examination, however, there were no reflex disorders, no sensory disorders, and the muscular weakness was equal in all parts of the lower extremities and trunk. On crutches, he lunged the trunk forward, painfully dragging his legs one after the other, the right foot in external rotation, never passing the left foot, toes scraping ground,—a functional flaccid paraplegia, completely dissolved by suggestion at a single sitting.
Scalp wound; probably no loss of consciousness: Quadriparesis, later paraplegia; tremors; profound sensory disorders, some apparently hysterical; cataleptic rigidity of (anesthetic) legs on passive movement. Diagnosis?
Case 394. (Clarke, July, 1916.)
A soldier, 40, got a scalp wound but probably did not lose consciousness. However, when observed three months after the injury, though fat and well-looking, the patient could not stand or walk, and his hands and arms were feeble. He complained of headache, insomnia and anorexia, and remained in a state of mental inertia. All efforts to read and write produced fatigue. Memory was bad both for remote and for recent events. He was able to feed himself slowly, execute a few movements of arms and hands, and raise his feet from the bed. Upon passive movement, there was a sort of spastic state, which did not amount to a true rigidity. Now and then a clonic spasm was induced by such passive movements. After the repetition of those few voluntary movements which were possible, the muscles passed into a flaccid condition. There was a tremor of a type called swooping; the tremor resembled that of Friedreich’s disease, such as is thought to occur in cases of marked loss of muscular sense. The deep reflexes were exaggerated. Concentric narrowing of the visual fields was easily induced by testing them. There was a general slight dulness of perception on sensory tests. There was astereognosis, and apparently an absolute loss of position sense. Movements of the large joints through an angle of 90 degrees were, however, vaguely recognized. Although the patient could not touch, for example, his left forefinger with his right, yet, if he had once seen the position of a limb and it was not moved, he could remember its position and touch it after some time. His localizing sense was from two to four inches out in the hands, the localization being generally of points proximal to the point tested.
Two months later the patient was somewhat less dull and apathetic. His memory had improved. He was able to read, and he was successfully making a rug; but the legs were worse, having become anesthetic to touch and pain. When the legs were placed in any position, they would assume a cataleptic rigidity, and remain rigidly fixed in any position for some time. The patient could sit up in bed. The muscles were well nourished and the electric reactions were normal.
Re catatonic rigidity, see Case 389 (Sollier).
Shell explosion; pitched in air: Spasmodic contractions of sartorii, persistent in sleep.
Case 395. (Myers, January, 1916.)
A private, 23, was admitted to a casualty clearing station and the next day told the examiner, Major Myers, that the Germans had been sending whizz-bangs and coal-boxes over, and the last he remembered was being on guard and then digging himself out of fallen sandbags. His comrades told him that he had been pitched in the air, but this he did not remember. He remembered running to the shell trench, but finding this “too hot,” he returned to the firing trench, noticing on the way that he could not see well. He lay in the dug-out, flinching at each shell, and “trying to get into the smallest possible corner.” He tried to do guard duty that night, but, when some one noticed involuntary spasmodic movements, he was ordered to go back to the dug-out, was helped to the regimental aid post by two men, and was sent to hospital. He had been in France eight months and had been shaken up somewhat four months before, when bombs threw dirt in his face. At that time, his hands and handwriting had become tremulous, but he had not reported sick. He was depressed and wanted Major Myers to make him well. It seems that he had shrugged his shoulders and made leg movements, diving beneath the bedclothes, and bringing his knees to his chin. When Major Myers examined him, the leg movements were due solely “to strong periodic simultaneous contractions of the two sartorius muscles, the rate of contraction of which varied from 60 to 70 per minute, increasing to 90 during the excitement of examination.” There were special changes of sensibility in the right leg and arm and right side of the face and chest, not involving the abdomen. The patellar reflex was exaggerated; plantar reflexes could not be obtained. The legs were tremulous, especially when the patient lifted them, whereas the hands and tongue were only faintly tremulous.
Under light hypnosis, events in the amnestic period were recalled, and details as to the shell’s direction, process of lifting up, and fall. Under deeper hypnosis, the sartorius contractions diminished but did not disappear. Appropriate suggestion was made, and upon arousal from hypnosis, the movements ceased, the headache disappeared, memory was recovered, and the unilateral disturbances of sensibility had vanished.
As to the possibility of malingering in this case, Major Myers calls attention to the disorders of sensibility which he believes could hardly have been simulated, to the persistence of spasmodic movements during sleep, to their confinement to the sartorii, and to the spastic condition of legs, such that when the thighs were passively raised the knees remained extended.
Re persistence of hysterical phenomena in sleep, Ballet felt that he could prove that some hysterical contractures persisted during sleep, and Sollier has written a special article to the same effect. Ballet’s case had a contracture developing after an operation on the first metacarpal bone. The contracture which followed would be then probably, upon Babinski’s analysis, a reflex contracture and not a hysterical one. Duvernay, Sicard, and Babinski himself have noted the persistence of reflex contractures during sleep, to say nothing of their persistence under an advanced stage of chloroform narcosis. In fact, these reflex contractures are exactly as fixed and persistent as contractures of clearly organic origin. It is probable that Babinski would define Myers’ case (395) as a physiopathic one; yet against this diagnosis would be the disappearance of the movements after hypnosis. As against hysteria, it will be noted that the patellar reflex was exaggerated, and that the plantar reflexes could not be obtained.
Shell-shock: Brown-SÉquard syndrome, hematomyelic?
Case 396. (Ballet, August, 1915.)
A soldier, 24, went to the front November 12, 1914, and June 1, 1915, had a shell burst near him in the trench, on the occasion of which he felt a violent shock, as if a blow in the kidneys. He felt suddenly paralyzed in both legs. He was crouching at the time of the shell burst. His legs felt dead, and he had such violent pain in the thorax as to make breathing difficult. He was carried to a shelter. After a few hours, the left leg began to move again.
He was carried to the ambulance, remaining there five days, unable to walk, though able to move and turn in bed, slightly constipated, with persistent pains in back. He was then carried to Auxiliary Hospital 231, at Paris, and a bullet (!) was found superficially lodged in the region of the left scapula. Neither patient nor physicians had hitherto observed the bullet, which could have had nothing to do with any spinal lesion.
The pains, in the course of a month, grew less, and at the end of two or three weeks he began to walk and was sent to the psychoneurosis service at Ville-Évrard, July 10. He then complained of pain in the right thorax, especially on movement or after sitting up some time. He could hardly bring himself to the sitting posture from the bed, and found difficulty in raising the right leg therefrom. In walking, the right leg was dragged behind. The reflexes were increased on the right side. There was ankle clonus without Babinski sign. Anesthesia to touch over the whole of the left leg. Anesthesia to pin prick and temperature as far as the umbilicus. Cold was not felt on the left side.
The water of a bath seemed lukewarm on the left side and warm on the right. The left side of the scrotum and the left half of the penis showed the same disorder of sensibility. There was a zone of hypesthesia on the right side of the thorax in the region of the lower ribs. The patient compared his
Re Brown-SÉquard’s syndrome, see Athanassio-Benisty with respect to spinal cord symptoms associated with lesions of the brachial plexus. It appears that the combination of spinal cord and brachial plexus injury is not uncommon. Note in this case that a bullet was found in the left scapula region. According to Ballet, this bullet could have had nothing to do with a spinal lesion.
Violence to back: Dysbasia. Antebellum injury.
Case 397. (Smyly, April, 1917.)
A man (also injured in 1906 by the fall of a heavy weight on his back) went to France in 1914 as a soldier, and eight months later was hurled into a shell hole so that his back struck the edge. He was rendered unconscious. Upon recovery of consciousness, the right leg was found to be swollen, and there were severe pains in the legs and back.
Upon return home the patient went from one hospital to another, for the most part unable to walk, suffering from agonizing pain in head and eyes. Insomnia and waking dreams.
He was able to bring himself to an upright position and to rush a few steps. He has now acquired considerable control of the feet by the aid of crutches. Insomnia persisted.
Dysbasia: Psychogenic (cerebellar nucleus (?))
Case 398. (Cassirer, February, 1916.)
On March 9, 1915, a shell wounded a man slightly, and burned off some of the hair of his head. He was unconscious two days, and on waking vomited for a time. Shortly after the injury difficulties in standing and walking set in, with headache, noises in the left ear, difficulty in the intake of ideas, excitability, and poor memory. Then, slight improvement. About the middle of June he was no longer closely confined to bed and could take a few steps with two canes; but the gait was still unsteady and the left leg tended to make abnormal-looking movements. There was nystagmus, rapid, though constant, on looking to the left,—more in the left eye; and nystagmus on looking to the right,—more in the right eye. Adiadochokinesis absent. Vestibular nerve somewhat excitable. Deviation outward in finger-pointing test.
According to Cassirer, this case is one largely of psychogenic origin, with possibly an organic cerebellar nucleus. The knee-jerks absent (even up to March 31). W. R. negative.
Shell-shock; unconsciousness: Dysbasia, in part hysterical, in part organic (?).
Case 399. (Hurst, May, 1915.)
A private, 29, was knocked over by a shell explosion December, 1914. He was unconscious two days, found that he could not move either right arm or left leg, got some power back shortly, but, if he tried to stand, experienced involuntary violent movements in the left leg.
April 1, 1915, response to questions was slow and speech slow. The right arm and grip were weak. If the left hand was clenched, there was an associated movement of the right hand; but on clenching the right hand, no associated movement was produced in the left. The musculature was equal on the two sides, and the tendon reflexes of the arms were brisk and equal. Light tactile stimuli were hard to localize. Movements of the left leg were somewhat weak, though the musculature was equal on the two sides. The knee-jerks were brisk, the left slightly brisker. Sometimes a well-marked ankle clonus could be obtained on the left side, but sometimes not. The plantar reflex was constantly flexor. Babinski’s second sign (combined flexion of thigh and pelvis) was well marked on the left side.
On attempts to walk, the left leg would move rapidly from side to side, round the point of contact of toes with ground. When a step forward was taken with the right leg, the left one dragged, and made irregular movements.
This gait seemed obviously hysterical. The patient was kept in hospital for a month. He was very easily hypnotizable, but even in deep hypnosis leg movements could not be controlled when he was told to walk. The first whiff of ether hypnotized but did not cure him.
On the whole, upon review, Hurst believes that there may have been organic brain changes, which (a) the associated movement of the paralyzed hand when the normal hand was contracting, (b) the slightly increased left knee-jerk, (c) tendency to ankle-clonus, and (d) Babinski’s second sign, may show.
Peculiar walking tic.
Case 400. (Chavigny, April, 1917.)
A soldier was found with a peculiar walking tic. He would rest a good deal longer on the left leg than on the right. He would make a sudden movement of the right leg forward, as if on a spring. At the same time, the man’s head would give a violent movement to the right just as the right leg was receiving the weight of the body. The idea of this movement seemed to be that the center of gravity would be shifted and the work of the right leg would be relieved. This peculiar walk was naturally very slow. If the walk was slowed down, it became quite normal. There was no pain at the basis of this walk. If the man hopped, he hopped no more painfully on the right leg, nor with greater difficulty, than upon the left.
This man was guilty of desertion in the face of the enemy, and of desertion in the interior in time of war. He said he could not walk well and that he needed to take care of himself at his mother’s house, as he was not considered sick in his regiment. He had been wounded with two bullets, September 28, 1914, which struck him on the internal aspects of the knees. He was treated in hospital from October to the end of November, 1914; was held at the dÉpÔt of his regiment from December to August, 1915. He was then put in hospital a month, and returned to his dÉpÔt for three more months. He was examined by three physicians in August, 1915, and the commission decided that he was fit for service, and a simulator.
Thorough examination, including electrical and X-ray examinations, showed no lesion. Chavigny observed the patient for a long time, from the 21st of November, 1916, to January 5, 1917. Shells dropped near the hospital, December 2, and, following orders, the patients were taken into a vaulted cellar, and they ran thither very rapidly; but this patient could not hurry. He walked slowly, with the same tic. Surely the tic would be rather a difficult one to imagine,
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
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
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,
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
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
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
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
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 amyotrophy, and sensory disorder corresponding topographically to anatomical distribution of nerve (neuritic) topography. | 1. More or less segmentary topography. |
| 2. Amyotrophy very pronounced, regardless of localization. | 2. Amyotrophy variable; ordinarily well-marked but not so severe as that of neuritis. |
| 3. Reaction of degeneration, especially weakening or abolition of faradic excitability of muscles. | 3. Reaction of degeneration absent, never marked weakening of faradic excitability, which is often normal and may even be exaggerated. |
| 4. Tendon reflexes, corresponding to the muscular territory of the nerve, weakened or abolished. | 4. If reflexes are altered, they are as a rule 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
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 whole extremity, either arm or leg. | 1. Paralysis almost always partial. In arm paralysis, affects as a rule fingers and hand. The leg is often affected at its origin, and then only partially. |
| 2. After several weeks of flaccid paralysis, as a rule contracture occurs. | 2. Paralysis may remain flaccid for a long time, and frequently coexists with contracture, hypertonicity and hypotonicity of different muscular groups. |
| 3. The upper extremity shows flexion with clawhand. The lower extremity shows contracture of extensors. The patient walks throwing his leg sidewise (DÉmarche helicopode). | 3. The upper extremity in hypertonic cases often shows the main d’accoucheur, the main en bÉnitier (holy-water vessel hand), the doigts en tuile (crowded fingers). The lower extremity does not exhibit the sidewise movements. |
| 4. Tendon reflexes, a few weeks after paralysis begins, exaggerated. | 4. Reflex status variable. Hyperreflexia often absent even in hypertonic forms. |
| 5. Babinski sign in crural monoplegia. | 5. Babinski sign absent. The skin 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 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
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
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,
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
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
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,
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
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
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,
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 ?; 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
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
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
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
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.)
A motor-cyclist, 36, with the colors from the outbreak of the war, about April, 1916, grew very weary, suffering from headache and seizures without loss of consciousness. Finally there was a voice: “Sleep, you must sleep.” Then other voices; then ideas of thought transference with people around him.
Observed in the psychiatric center, May 12, 1916, he had the same ideas of thought transference, and he made as if to talk with the attendants by responsive-looking gestures. Sometimes, he said, fluid struck his forehead, calling on his thought. Whereupon he listened. The man made no complaints about his plight, was not astonished in any wise at what was happening, nor did he seek to explain it. There was nothing in his history to suggest psychopathy except perhaps that his father was unknown.
The diagnosis of a chronic hallucinatory psychosis was made, but the outcome promptly overset the diagnosis. The man talked with ward-mates, and particularly with another patient who also talked about thought transference. This shook the man in his convictions, and he decided that it was but imagination and delirium.
He now told his story: How it seemed that he had in his thoughts the phrase, “Sleep, you must sleep;” how he had gotten up, saying, “No;” had noticed the others paying no attention to him; had gone back to his work and from that moment had begun to go into delirium. During this delirium or delusional state, his whole life from birth up, came back to him, as if some one were telling him. The headaches, which he at first felt due to Hertzian waves, suddenly ceased.
Shortly, however, a new phase had set in, in which he felt himself surrounded by spies and that others had control of his thoughts and were reading them. In fact, he grew a
On arrival at hospital, he had not known what was going forward. The nurses were giving him milk to destroy the taste of sulphur; the delirium then grew less and less. The room-mates were neutrals, war-weary; he seemed to be reading the newspapers before his mates, and they seemed to be talking of thought transference. May 20, the ward was changed. The new ward-mates did not believe in thought transference and laughed, causing the man to doubt.
June 2, the cure was in full process, and the ward was changed again; but in the new ward was a patient who had the same ideas of thought transference as the patient. At this time, the man’s autocritique saw through the delusion. He talked with his telepathic comrade and pretended to engage in a fake conversation about it. The delusions shortly disappeared, having lasted about six weeks.
Ordinary gunner’s life; a few days’ feeling of moral and physical discomfort: Obsession leading to fugue.
Case 445. (Mallet, July, 1917.)
An artilleryman, 32, gave himself up a few kilometers back of the lines, three days after deserting his post. The man was a very good gunner and had never been punished once. Moreover, the battery was not under any special bombardment, and he had been in the same place a number of weeks.
He explained that he had gotten tired during the last few days. Everything was well at home and in the regiment, but he felt sad, his head felt bad, and he couldn’t sleep. Something drew him to leave, but then “sang froid came back to me, and I gave myself up.” He had lived the three days without eating and without sleeping. He was very emotional over what he had done, but he began to work and asked that he be sent back.
His mother had been very nervous. There was a marked facial asymmetry and faulty arrangement of teeth. The man was not alcoholic.
According to Mallet, in these cases of fugue, and in other cases of absolute delirium of apparently sudden onset, there is a feeling of moral and physical discomfort for some days before the outbreak. The outbreak itself is sudden on the occasion of some idea, either an obsession or a hallucination. Of all the prodromal signs, headache is the most striking. According to Mallet, such fugues are the expression of a mental imbalance allied to the onirism of RÉgis.
Aprosexia and bird-like movements.
Case 446. (Chavigny, October, 1915.)
A soldier of the dragoons, 25, entered Chavigny’s service May 30, 1915. He acted like a mechanical figure, requiring guidance. The face was without expression except for the mobile eyes, and sudden bird-like movements of the head, continually attracted to new noises and objects. An interlocutor was glanced at but not responded to. If an intense electrical shock was passed through his abdomen, for example, the man would look for a moment in that direction, but only the most fugitive defence reaction would be made, and the stimulus could be repeated with the same result, a moment later.
After three days, this aprosexia began to clear, and in four or five days, answers to questions and ordinary associations set in. Memory reappeared. It seems that he had been in concealment in the loft of a barn, when he saw his commanding officer carried by, having lost an arm and a leg. He lost consciousness and fell three meters, through the trapdoor of the loft. There was thus a combination of trauma and emotional shock. No external lesion was produced in the fall. His memory showed a very sharply defined gap for the period of his aprosexia with the bird-like movements, of eight days, and his memory was perfectly good up to the time of the fall. This is one of five cases observed by Chavigny, who remarks that there is something in the attitude of the young child which recalls the aprosexia of these patients. (Perhaps the phrase of James, “buzzing, blooming confusion” might be used.) One must go back to a period in the child’s development when he is not yet able to smile or keep his glance fixed on a shining object. On the whole, the resemblance is closer to the attitude of certain caged birds.
Re aprosexia and bird-like movements, see discussion under Case 353. See also Case 334.
Shell-shock; unconsciousness (45 days): Mutism (monosymptomatic).
Case 447. (LiÉbault, 1916.)
A soldier, 32, had a large caliber shell burst one meter from him September 26, 1915, lost consciousness and remained comatose 45 days. He then got progressively better but did not recover speech. He was neither blind nor deaf. He was examined at the neurological center at Nantes and there MiralliÉ called him a case of hysterical mutism, finding no paralytic disorder of any sort and finding the patient able to write his story, to read and to understand what he read, but without much power of retention. He was placed in the phonetic reËducation service March 30, but made no progress. In the effort to speak the patient made strong generalized contractions, including contractions of his face and winking of his eyes, contractions of the jaw, and movements of the neck muscles. In fact, he seemed to be agitated by a sort of cervico-facial tic, and sometimes, although not always, he succeeded in getting out a loud voice sound, in which one could imagine the syllable that he was trying to utter.
In this case the mutism was evidently secondary to motor disorder. It is an example of functional dyskinesia (Benon). As long as this functional dyskinesia remains, the patient will not speak. The respiratory muscles are disordered, since the respiratory capacity does not go over 3 liters. This approaches the normal, however, and if the subject cannot speak it is because his diaphragm is subject to jerky or cramplike movements and because the lips and tongue do not execute the proper movements either for sounds, syllables or words. Such a patient cannot protrude the tongue or even bring it beyond the teeth.
Shell-explosion: Recurrent amnesia.
Case 448. (Mairet and PiÉron, April, 1917.)
A shock case of Mairet and PiÉron had a disorder of memory. Association paths were open one day and closed the next. Subjected to shell-shock, September 18, 1915, he was found wandering in the woods a few days later, having completely lost his memory, even for his name. In November he recovered his surname but not his given name. On stimulation he was gotten to remember his city, his father, the street, and the like. Shortly he could get back his memories more quickly; after a week it took only 35 seconds to remember that he was born at Paris. However, his recollection of the Trocadero and of the Eiffel Tower, which had come back to him in November, 1915, was lost again in April, 1916, to return once more in August. December, 1915, he could not write to dictation, but copied writing as he would a design. He suddenly felt himself able to write in the Morse code (he was a telegrapher); then ordinary writing returned. February, 1916, however, he had forgotten what the Morse code was. In April, he was taught numbers. One day he would know left from right, but had forgotten it by evening.
Shell-explosion: Comrade killed: Amnesia.
Case 449. (Gaupp, April, 1915.)
F. K., a 23-year old soldier, in civil life a turner, of Polish descent, and of a somewhat nervous and easily excitable disposition, early in August went from Strassburg into the Vosges and Lorraine. On the 26th a number of shells exploded near him. The troop was excited and took refuge in a cellar. K.’s best friend was torn to pieces by a shell. When his body was removed, K. felt sick and lost consciousness. He arrived at the clinic in TÜbingen in a stuporous condition, by hospital train, on August 31, 1914. He walked weakly to his bed, supported by two men, and lay in the bed, apathetic and reacting to questions only with a stare. Things put in his mouth were swallowed. He remained motionless.
Next evening he answered a low Yes to a nurse’s question about eating. A little afterwards he said he supposed he was a prisoner in the enemy’s country. A little later he got properly oriented but still did not know how he had come. September 2, however, he was much clearer and said he had awakened out of a long dream. There was a complete amnesia, however, from the moment when he went to help remove the torn body of his friend up to September 1. Memories became clearer for the period before the shell explosion. The patient became very lively, talking vividly of war experiences, imitating shell hissing with an expression of intense anxiety, getting accustomed to battle scenes, saying that he was now seeing everything again as if real. He remained anxious for some days, complaining of weight on his chest and of feelings of internal restlessness and tension.
Amnesia for the period of August 26 to September 1 remained; all that K. could add to the story of those days was that he had been thrown sidewise for some distance by the air pressure of the shell.
From September 6 onwards, he grew calmer but he was still very labile, given to lively imaginings and emotion. By the middle of September he was well and discharged for garrison duty.
Shell-explosion: Recurrent amnesia.
Case 450. (Mairet and PiÉron, July, 1915.)
A man, 33, had suffered shell-shock early in December, 1914. His intervening history is not reported, but he showed on admission to the service of Mairet and PiÉron, May 5, 1915, a remarkable amnesia. There was a complete cutaneous anesthesia, anosmia, and ageusia, and he was mute. He lived only in the specious present. His previous life was completely abolished for him. He could dress himself, eat, use a fork and spoon, and a glass. He understood ordinary words; such words as man, woman, day and night, however had no meaning. He was observed for 15 months and presented four phases.
In phase one, there was a measure of success in reËducation, such that he grew able to recognize a few persons, to find his bed, and name objects. He was got to copy writing, to learn the alphabet, and to say a few words. He could not write from dictation, however. Less than two seconds after looking at an A, he had forgotten how it looked and could not trace it. This first phase lasted about two months.
The second phase began with fatigue, headaches, and the rather quick effacement of all he had relearned. If an errand was given him to do, he would run to do it before he should forget it; but if the trip required more than 4 or 5 seconds, he had to stop, not knowing what to do with the thing in his hands. He was still able to recognize 4 or 5 persons, but could add no more to his repertoire; and when one of them had been absent for a fortnight, he did not recognize him on his return. He could not remember the time for his meals.
The third phase was ushered in by improvement after vomiting; his speech came back in a feeble voice, November 16, 11 months after the shock. ReËducation could now be undertaken again. He easily relearned a number of things, feeling the greatest astonishment at his new acquirements as to the sun and the moon, the trees and the flowers, and the like. He expressed a curiosity to see his own home,
At this time began the fourth phase, April, 1916—a phase of decline once more, in which a large portion of his acquisitions were again lost and he fell back to his condition in the second phase.
See discussion under Case 353 and under Case 367. Re confusional mental states, Roussy and Lhermitte, after distinguishing stuporous confusion from simple confusion, go on to differentiate what they call obtusion (see also discussion under Case 353). These authors say that RÉgis, in common with most psychiatrists, fails to distinguish the slow thinking and amnesia of true mental confusion from the temporal and the spatial disorientation that characterize the so-called obtusion. Of course, in all attacks of confusion, both attention and memory are affected, but there are special types in which attention defects and memory defects stand out in relief. The first of these types is the aprosexic type with birdlike movements, described by Chavigny (see for an example, Case 446). This aprosexia may be combined with mutism, deafness, or convulsions. The form of confusional disease in which amnesia is the out-standing feature is due to toxic or infectious disease, or is a Korsakow phenomenon, i.e., in the psychiatry of peace times; but the war has brought out amnestic confusion in other states than the toxic, infectious, and alcoholic states (RÉgis, Chavigny, Dumas, Roussy and Lhermitte). The amnesia may be incomplete, a sort of dysmnesia, or twilight memory, but as a rule, the amnesia is lacunar. The toxic and infectious amnestic confusions have a loss of memory for events following the onset, but these war cases of amnestic confusion have the loss of memory running back far into the patient’s past, slipping from the mind his name, his parentage, age, and vocation. Instead of being like the toxic confusional amnesia, an anterograde amnesia of fixation, the Shell-shock amnesia is apt to be antero-retrograde. These antero-retrograde amnesias, whether due to emotion or to
LÉpine distinguishes amongst the confusions, five forms as follows: Simple confusion, hallucinatory confusion, acute delirium, stuporous confusion (under which LÉpine also considers the battle hypnosis of Milian, see Case 365, and Roussy’s narcolepsy), and amnestic confusion. All these phenomena from the clinical point of view are connected with an acute and fleeting insufficiency of the most delicate or, as it were, psychic portions of the cerebral cortex, the delirium, so to speak, being activity of the unconscious, whereas a confusion is due to a clouding of the centre O of Grasset’s polygon.
Soldier’s heart, both neurotic and organic.
Case 451. (MacCurdy, July, 1917.)
A territorial, 19, who had enlisted in January 1914, reached France in September, 1916. He was of neurotic make-up (night terrors, fear of dark, giddiness in high places, fear of tunnels, enuresis until 10 years, worry about seminal emissions), and had always had a tendency to short wind. Enlisting at 16, he found it hard carrying his pack at first but soon grew stronger. The trench life was distasteful. He began to wish that he might be killed, or at all events removed from the trenches. Pains developed under the heart, with shortness of breath, palpitation, dizziness, and faint feelings. The man connected these heart symptoms with what he called his weakness of gall bladder (namely, enuresis). He was several times sent off duty for heart treatment. After three months in and out of hospital, he got trench foot, was sent to England, and transferred to a special heart hospital. Here the pulse test was positive, in that the rate did not diminish as it normally does after two minutes’ rest. After graduated exercises for several months, the pulse test had become negative and the heart had gradually improved from the organic standpoint. The patient, however, insisted that his heart trouble was as bad as ever, and was probably consciously hoping that his symptoms might persist.
Re soldier’s heart, Abrahams classifies cases that come to the military surgeon for heart symptoms as (a) functional fatigue cases; (b) nicotine and drug cases; (c) organic heart disease and Graves’ disease; (d) the true soldier’s heart, occurring in men with a neurasthenic soil that lose control of the vasomotors and inhibitors of the heart.
Soldiers heart, neurotic.
Case 452. (MacCurdy, July, 1917.)
An Australian gunner, 35, of a neurotic make-up (night terrors; horror of blood; fear of thunderstorms, high places, tunnels, horses; shy with both sexes), benefited by military training physically, but remained as neurotic as ever. On the way to his first service in Egypt, he feared shipwreck, and in Egypt was troubled by the weather and occasional palpitations and sinking feelings. He was transferred to the French front, May, 1916. He was terrified and depressed under shell fire, and horrified by blood. Peculiar sinking sensations or feelings that the soul was leaving the body came to him as he was going off to sleep; from which he woke at times with sudden starts. Later he had nightmares of things, mainly shells, falling on him. He worried, wanted death, and thought of suicide. In May, 1917, he was blown off his feet by a shell. Thereafter he began to feel that shells were being especially aimed at him, and four days later got a pain in the side, and began to tremble and breathe with difficulty, as if his throat were swelled up and he were going to choke. He ascribed this to gas. The bombardier finally sent him back to a hospital, where he grew weaker and screamed aloud on being awakened by his dreams. After six weeks in a special heart hospital, all the symptoms cleared up except the choking feelings and fear of instant death. Organically the man appeared normal. An initial pulse of 96 ran up to 168 after exercise, and down to 84 after two minutes’ rest.
Re soldier’s heart, Abrahams speaks of sundry hypotheses that he regards as erroneous. Soldier’s heart has been thought to be (a) athlete’s heart; others regard it as (b) a toxemic condition, possibly of bacterial origin; (c) hyperthyroidism (a larval form of Graves’ disease has been incriminated); (d) excessive cigarette smoking; and (e) deficiency of buffer salts in the blood, have been proposed by other authors.
Gallavardin has especially studied the tachycardial cases revealed by the war, cases in which auscultation is frequently unable to detect aught. These tachycardiacs are often hypertensive. Sedentary service should be found for them.
Re pulse 168 after exercise, Gallavardin found 8 per cent of 500 non-organic and non-tuberculous cases to run up from 150 to 175 (125 to 150 in 27 per cent; 100 to 125 in 37 per cent; 75 to 100 in 26 per cent; 50 to 75 in 2 per cent).
Re cardiac neuroses, Brasch points out that cardiac neuroses in the male in war time have found a strange new association with hyperesthesia of the skin. The patients showed dermatographia and hyperreflexia. The hyperesthetic zones of Head and Mackenzie were found by Brasch in all cases of organic cardiac disease, but also in two cases of cardiac neurosis in hysterics.
Moore calls attention to somewhat similar phenomena in the somatic group of nervous and depressed cases found in the war. These patients are fatigued, exhausted, sleepless, tremulous, vascular, and cardiac cases, with dermatographia, areas of paresthesia, and pains in the neighborhood of wound scars.
War Strain; Shell-shock: Hysteria (question of malingering).
Case 453. (Myers, March, 1916.)
A sergeant, 32, with 11 years’ service and eight months’ service in France, was admitted to a base hospital for inquiry as to possible malingering. It seems that he had taught in an army school for seven years before the war. He found heavy marches in France too much for him and fainted in the retreat from Mons and during the fighting on the Aisne, where he had reported sick for dysentery. The field ambulance where he was treated was near the shell fire, and a shell knocked him into a ditch. The ambulance had to move to a cave. Thereafter the patient suffered from tremor when spoken to or when watched. After discharge, he was employed as a dispatch rider on a motor cycle, but after three months lost his nerve for this work and took charge of fatigue parties. He found the work too much for him. He had been a total abstainer. Finally the malingering charge was brought up.
The patient was nervous, delicate-looking, with widely dilated pupils, prominent eyeballs, tremor of right arm, and pulse of 102. The tremor was markedly lessened when he was alone, and was somewhat under control. He felt that his memory was defective, and tests demonstrated the defect.
In hospital patient slept better, the pupils grew smaller, the pulse rate diminished. There was a reduction in sensibility to pain over the right side of the head and body and over the right limbs. A prick of the right arm or leg was described as a finger touch. There was also almost complete hemi-anosmia and complete hemi-ageusia on the right side. Visual acuity was diminished on the right, and there was general limitation of right field; left-sided vision and field normal.
After a month in hospital at home and two months’ leave, the patient was discharged no longer physically fit for service. He is now weak physically and mentally, subject to
Re malingering, Sicard denies the existence of unconscious malingerers (presumably regarding this phrase as a figure of speech in relation to hysteria), and divides malingering into a creative and an acquired form. The simulateur de crÉation assumes attitudes and symptoms to attract attention or pity; the simulateurs de fixation having been sick in the beginning, perpetuate their disease, in brief, crystallize their neuroses. The fixateur may be very realistic in all this, seeing that he has known from his own experience what a real disease is. The formula runs: The simulateur de crÉation improvises; the simulateur de fixation repeats.
According to Mott, malingering in the form of an assumed Shell-shock is not uncommon amongst soldiers, and is rather hard to distinguish from a neurosis developing on the basis of an idÉe fixe.
Ballet’s definition of simulation is “a subjective or objective disorder which the patient invents with the idea of voluntarily and consciously misleading the observer.” Closely related to simulation is exaggeration or prolongation, conscious or intentional, of a real disorder. Babinski states that cases of genuine simulation are very rare, and that the subject under suspicion should be given the benefit of the doubt. Especially the word simulation, or similar words, should not be uttered in the presence of the patient. Practically speaking, psychotherapy applied as in cases of hysteria may often cure the simulator and the exaggerator.
The officer who could not kick.
Case 454. (Mills, January, 1917.)
An officer had had a bullet in the right calf, of which nothing was evident months later but small scars of entrance and exit. Nevertheless he complained of pain, especially after walking, and of inability to dorsiflex the foot beyond a certain point. No wasting could be found and no impairment of sensation. The muscles were faradically normal. Mills thought the symptoms were exaggerated and so remarked to the officer.
Under anesthesia, however, the dorsiflexion also proved to be impossible, and after exerting considerable force, Dr. Dunhill was able to rupture a massive fibrous band of adhesions that had prevented extension. The officer made a good recovery.
Dr. Mills confessed his error to the officer who had naturally resented the suggestion of malingering. The officer forgave him.
Re malingering, Moore states that no diagnosis of malingering should be made without the most careful examination and consideration of the individual as such, on account of the fact that the erroneous diagnosis dejects the patient and postpones recovery. It is particularly unwise to term the trouble “imaginary,” or to talk about “suggestion” or use similar terms in the presence of the patient.
Craig has found very few cases of actual malingering and states that tremors and paroxysms are often mistaken therefor. Bispham remarks that few malingerers are found among the patients of a doctor who is known to be a thorough examiner.
Re orthopedic cases like Case 454, Gleboff remarks upon the simulation of joint affections and upon methods of surprising the malingerers into sudden movements made in obedience to request in the course of medical examination.
Doubtful accounts by patient concerning arm palsy: Incorrect diagnosis of simulation.
Case 455. (Voss, November, 1916.)
A volunteer, 18, just before the war had a fall in which apparently he injured his skull. In December, 1914, he hurt his left forearm. About this injury he sometimes said he fell in a storming attack in a trench and broke his arm, and again he said his arm had been smashed by stones from a falling house. From that time forward there was paralysis of the left forearm with flexor contracture. May, 1915, slight hypesthesia could be demonstrated on the ulnar side of the arm, suggesting ulnaris injury. There were, however, no considerable electrical changes.
Six months later the man was sent up with a suspicion of simulation. In the meantime the contracture had resolved and there was a typical hysterical paralysis with all signs of neurosis. Six months later he was well enough to be examined for military service.
Here was a case in which the incorrect data offered by the patient himself as to the origin of his paralysis gave rise to the suspicion of simulation, whereas, as a matter of fact, the man was clearly hysterical.
Re incorrect data supplied by the patient to his own disadvantage, Lumsden remarks on the great difficulty of diagnosis in cases where hysteria and malingering have been combined, and Morselli states that, if the doctor has really made up his mind that the man is shamming, he should send him back to the fighting line at once.
Forearm wound: Hysterical edema?
Case 456. (Lebar, July, 1915.)
A corporal, 26, formerly a farmer, was struck in the forearm by a shell fragment on the mid-portion of the radial border. The wound was slight (the fragment entering and emerging hardly 2 cm. apart) but bled profusely, according to the patient, who was evacuated next day but one to a hospital in the interior. By this time the right hand was swollen, nor could any movement of hand or fingers be made. Massage, mechanotherapy, passive movements did no good.
The man entered the neurological center of the Eighth Region, July 7, 1915, when there were already a few skin changes with dorsal thinning and palmar thickening. There was cutaneous anesthesia not only of hand and fingers but of the forearm to the elbow, and this anesthesia included heat and cold. Position sense was preserved. There was no evidence of atrophy except for the skin changes. An electrical examination showed normal conditions.
July 13, a sealed bandage was put on, but at the end of five days the hand looked as before. July 19, a new treatment was announced to the patient. With a hot needle a number of pricks were made on the dorsal surface of the hand and a few c.c. of fluid were withdrawn (containing a slight amount of albumin and a few lymphocytes), whereupon a dry bandage was put on. The next day a few finger and thumb flexion movements could be made and sensation had returned. Sensation completely returned July 21. The flexion movements were still incomplete, by reason of the edema and dryness of the skin. However, July 22, flexion was better and the swelling had gone down sixty per cent. Jacquet’s biokinetic treatment (active gymnastics of the hand and fingers) was given for four hours. July 25, the edema had greatly diminished and normal motion had returned.
Examination excluded renal disease. There was no sign indicating phlegmon. Quincke’s disease had other features.
Re hysterical edema, see remarks under Case 407. In the case above, of Lebar, Babinski calls attention to the fact that the edema and the contracture diminished though they did not entirely disappear after the scarifications. This physical treatment did not act, according to Babinski, wholly as a matter of suggestion, and he fears that some cases of so-called hysterical edema are really cases of physiopathic vasomotor disorder; in fact, three of the cases published (and amongst them, the present case of Lebar), were cases of edema associated with contracture and developing in an injured limb. To prove a case of anything to be hysterical is, of course, according to the Babinski school, to submit it to a therapeutic test and cure it by suggestion.
Shell splinters in head: Suspicion of (a) simulation, (b) hysteria. Case actually surgical.
Case 457. (Voss, November, 1916.)
A man, injured by shell fragments in the head and sustaining fracture of both arms and a thigh, got well of his wounds, but fell into a nervous state with headache and dizziness. He was given prolonged observation psychiatrically and then sent back to the front as fit for service, but was shortly returned to hospital and sent to Cologne under the suspicion of simulation.
The picture was of unilateral increase of tendon reflexes, accelerated pulse, disorder in the intake of ideas, difficulty in finding words and delayed associations. His gait suggested a psychogenic disorder. X-ray showed two shell fragments in the vault of the skull.
According to Voss, it is a sad fact that victims of skull injuries are frequently charged with simulation or exaggeration. In the above instance, moreover, this charge was undoubtedly inaccurate.
Re simulation, see remarks under Case 453. Re neurological cases, the Neurological Society of Paris sent to the War Ministry a special note pointing out how tardy was the reference of sundry neurological cases to the special neurological service. They pointed out how important it was to send to these special services all cases of bullet and shrapnel lesions.
Re the malingering question, there is a wide divergence of opinion, even amongst experienced workers in the same city. The late Professor Dejerine said he had not seen a single case of malingering. In fact, he thought that malingering amongst soldiers and amongst injured industrial workers had been much exaggerated. Marie, however, working in the examination of many surgical cases, found malingering relatively common. Amongst forty of his cases, he regarded at least nine as malingerers or exaggerators.
“Sciatica,” torticollis, stiff arm: The desire to avoid active service plus functional disease.
Case 458. (Collie, January, 1916.)
A man enlisted September, 1914, went to France after six months’ training, immediately put himself on sick list, and was admitted to a base hospital: Diagnosis, sciatica. Later, he ceased complaining of sciatica and developed spastic torticollis. He was sent back to England, was treated with radiant heat and so on, and was eventually sent to the Royal Bath Hospital at Harrowgate.
He recovered from torticollis after six weeks’ treatment; but then developed a spasmodic contracture of the right shoulder and forearm. He was massaged for this and also given high frequency treatment. Then came two transfers (massage).
Early in December, 1915, he came under Collie’s observation. He then showed right wrist bent at right angles to the forearm; hand tightly clenched, so firmly that it seemed as if the wrist were ankylosed. The case was obviously a functional one. The man refused to enter hospital at Collie’s suggestion. He was sent to the Maida Vale Hospital. Previously he tried to persuade the medical officer that further hospital treatment was unnecessary, stating that he was now able to straighten his arm and that he was applying a splint to keep it straight. He progressed slowly in the institution. Told, if he would recover within fourteen days, he would be classified “for home service only”—before the fourteen days were up, he had suspended his weight on a trapeze and pulled himself up to his chin on it; had also lifted a 28-lb. weight with his paralyzed hand. In short, he wholly recovered. He is now doing duty with his unit.
Collie says this is not deliberate malingering but a mixture of functional disease and an obvious desire to avoid active service. When he appeared before the board for a final decision, there was a tendency to assume the old
Conclusion: The direct personal treatment of his mental condition and an appeal to his lower instincts were immediately curative and of much more value than the radiant heat or high frequency treatment.
Re Collie’s case, Russel finds surprisingly large numbers of malingerers; he found many at the time of the battles at Loos. It was particularly easy in cases of epilepsy to demonstrate a close relation between hysteria and malingering. In the psychogenesis of these conditions, Russel emphasizes the initial element of deception, which soon enormously increases either through the patient’s convictions of his ability to deceive or through a process of autosuggestion. Cases of semi-malingering are not uncommon. In England, Russel found more cases of a clearly psychogenic nature; yet in these, also, there was always primarily an element of deception.
Yes-No test of value re anesthesia.
Case 459. (Mills, January, 1917.)
The “Yes-No” test proved of special value in the case of an Australian private. Shortly after landing at Gallipoli this man had a bullet graze his ankle and fell some thirty feet over the bow of a ridge. He was picked up unable to move his legs and insensitive therein.
The paraplegia and anesthesia lasted three months. “Fracture dislocation of the dorsal spine” was the diagnosis made, and laminectomy was even contemplated. The sphincter reflex was normal and there was no atrophy, no rigidity and no reflex disorder. Asked to say “no” when he could not feel a pin-prick and “yes” when he did feel it, he replied “no” to each prick to the anesthetic area and changed his reply to “yes” when the sensitive parts of the body were examined. At another time the answers were found not to correspond with those given before.
The soldier was assured that he would get well and that as soon as he could walk he would be boarded and returned to Australia.
After a number of weeks he became able to walk.
Arabian fever.
Case 460. (Roussy, April, 1915.)
An Arab fell on his knee, one day in the trenches. A contracture of the left arm, with great pain, and a temperature of 38 to 40 degrees, with hemoptysis, developed. This man had been considered tuberculous. One day, however, the thermometer went up to 41 degrees. It was discovered that he took artificial means to push the mercury up, and that the spitting of blood was voluntary. All these phenomena disappeared after he was put in the guardhouse for 24 hours.
Shrapnel scratch of head: Hysterical amaurosis “?” On isolation in a dark room, the patient began to see light!
Case 461. (Briand and Kalt, February, 1917.)
A man may seek to exaggerate an anomaly of his eye which had existed before the war, in order to live comfortably far from the front.
A soldier sustained a slight scratch from a shrapnel bullet in front of the left ear, which scarred over in a few days. The soldier said, however, that the bullet had gone through his skull and a few hours after his wound said he could not see. Sent to the hospital he continued to say he was blind and finally brought up in an asylum for the blind near Lyons where he was taught to cane chairs and to write in Braille. This happened in July, 1915.
In October he was sent to the Hospital at Quinze-Vingt where a diagnosis of hysterical amaurosis was made with a large interrogation point. He was then sent to Brequet where there was a section reserved for disciplinary cases and very nervous cases not wanting to get well, a service under the charge of Roubinowitch.
The soldier escaped with a comrade and eventually reached Val-de-GrÂce where the diagnosis of hysterical amaurosis was again made. Examinations several times showed that there was nothing abnormal about the eyes except that the eyelids presented habitual fibrillary movements (antebellum).
The eyelids passively opened, would remain open for a few minutes and then close. There was no winking of the eye to a light, yet the pupil preserved its reflex power.
Vision was abolished, however, the soldier said. He was without any other motor or sensory disorder. Much sympathy was given to the poor blind soldier. People were much astonished when the chief of the ophthalmological service had the man isolated in a dark room. Three weeks later the man had begun to see the light a little. A week later
Re amaurosis, Parsons explains the blindness which may remain after consciousness returns following Shell-shock, as a condition in which the lower visual paths are carrying on their functions normally. For example, the pupillary reactions are preserved. The condition is not unlike that found in amaurosis of uremia, and Parsons has found it in children with posterior basic meningitis. For Parsons, therefore, the block occurs in the higher centers above the thalamus, possibly in the synapses of the optic radiation fibers. Ormond states that the true cases of concussion blindness invariably pass through phases of great discomfort; whereas the malingerers are without such discomfort. Medical suggestion, also, has a powerful effect here, and may actually retard recovery.
A newspaper cure.
Case 462. (Sicard, October, 1915.)
Sicard read in a French newspaper a story to the effect that, at two o’clock in the afternoon, a soldier had fallen on the sidewalk between Nos. 40 and 42 Boulevard de LibertÉ, in a nervous crisis. The people ran and picked him up. When he came to, he was very joyful, perceiving that the shock had given him back his speech, which he had lost the August previous. This soldier, the newspaper continued, became deafmute through the explosion of a bomb in a fight in Upper Alsace. “The brave soldier is most happy over the unexpected result.” The newspaper went on, “We congratulate him sincerely, as well as the people who assisted him.” He was the more contented that he had gotten well because, the soldier said, he would now be able to go back among his comrades to fight with the Boches!
Now, in point of fact, Sicard had dealt with this soldier the morning of the day in question. He had been simulating mutism for ten months, and finally told Sicard that he would like to leave that afternoon as he felt cure coming. Sometime after, he wrote a letter of profuse thanks for the benefits received, and said he did not deserve to avoid court-martial. He also said that he was going to do everything he could to justify himself. Incidentally, he kept his word and an officer in his regiment later gave him an enthusiastic recommendation.
Re malingering, see discussion concerning simulateurs de crÉation and simulateurs de fixation under Case 453.
Deafmutism: Explained by patient as malingering.
Case 463. (Myers, September, 1916.)
A pure malingerer, of set purpose, initiates a quasipathological condition which he will discard when he has gained his end or when he is assured that he is unobserved. Malingering in the field of speech is rare. A private, 26, one year in service, three months in France, entered a base hospital, deafmute for nine weeks. He wrote: “I should be very happy if you can do anything for me. I cannot give a very clear account of what happened, as it is sometime since. I remember retiring from Hill —— with some more to some trenches, and in the open we were shelled and I lost touch with our chaps or else they were killed. I remember a great concussion and finding myself on the ground, and a soldier dragged me up and we ran for the trench. I was very thirsty and I ran down the trench to get some water. I met one of our chaps and tried to ask him for some, and I could not make him understand. He only smiled at me. The man who picked me up took me to an officer who was sitting on the edge of the trench and tried to make me understand, and then he sent me with this man to a dressing station, and from there I have been to different places, the names of which I do not know, except the last place, No. — Convalescent Camp. I have been there about two months——”
He seemed anxious to get well. He could not understand what was said. Induced anesthesia caused no phase of excitement, and the patient failed to regain his speech. He was evacuated to England. Three months later the patient thence wrote the following confidential letter from a Convalescent Home.
Re hysteria explained by the patient as malingering, Chavigny discusses what he calls sursimulation. The physician must not fall into a permanent state of suspicion, and especially must not reveal his suspicions to the accused or to the bystanders. Chavigny quotes a French soldier whose letter to his wife was intercepted, stating that he was going to feign deafmutism to secure his discharge. Before he had succeeded in doing so, however, he suffered Shell-shock, and got a true hysterical deafmutism, which showed no signs of malingering whatever.
Deafmutism: Appearance of malingering.
Case 464. (Myers, September, 1916.)
A stretcher bearer was seen by Lt.-Col. Myers two days after admission to a base hospital. Stolid looking and mute, he had nevertheless talked in his sleep, had written a few words about “shells coming over,” and understood what was said to him. Lt.-Col. Myers’ notes run, “He puts out his tongue and closes his eyes and holds out one hand when I ask him to do so, but gets stupid (as if sulky) when I ask for the other hand. He will not hear any more. Next day quite deaf, and the following day light anesthesia with ether caused a return of hearing and of speech, with repetition of syllables to request on the way to deeper anesthesia. On awaking he cried as he was induced to resume his speech, and complained of pains in the head.
“Two days later, he seemed normal and said that he could have spoken on the second day, but that his eyes and ears had begun to swim, that he had felt dizzy, and was afraid to talk. He did not want to be sent back to the trenches. There had been severe shelling. He had lost consciousness until he awoke in a hospital at Y—. He recalled, little by little, how he had been taken back by a corporal to a cellar. He said he wanted to go back, but wanted a rest first. He went back to his unit and was reported as having done well for four months.”
There was a certain suggestion of malingering about the admission of the lad that he could have spoken before he was induced to do so. According to Lt.-Col. Myers, a number of patients upon recovery of speech are apt falsely to believe that they have been malingering. Functional disorders may simulate malingering.
Lannois and Chavanne warn against the suggestions given to malingerers and to hysterics by the statements on the tickets of admission borne by the patients for transfer, e.g. “incurable deafness.” These authors found 11 per cent malingerers amongst 262 cases of labyrinthine shock.
Simulation of deafmutism.
Case 465. (Gradenigo, March, 1917.)
A soldier in the mountain artillery acted like a deafmute. He was unable to read or write. It was reported that he had been wounded, but no evidence of wound could be found. The man had a low forehead and a furtive glance, his whole impression being that of a criminal.
The only evidence of disease found was inflammation with perforation of the tympanic membrane of the left ear. Deep in the left auditory meatus was found a grain of crushed oats! The man’s speech difficulty was of a stuttering nature, but he stuttered in a different way at every test. He was unwilling to be narcotized. Finally by a process of scolding and cajoling, the man was made to confess that he could both hear and speak well. The peculiar stuttering early led to the diagnosis of simulation, but the fact that the tympanic membrane was not anesthetic, and that there was no anesthetic zone in the body strengthened the suspicion—to say nothing of the refusal of narcosis and the general behavior of the somewhat criminal-looking soldier.
A lame rascal.
Case 466. (Gilles, April, 1917.)
An infantryman, 28, had an equinovarus, for which he was evacuated, hospitalized, given treatment, sent home for convalescence, and declared unfit for service. He was, however, sent back to the front, and on arrival, went lame; whereupon the regimental surgeon sent him to a nerve center. The equinovarus was there but it was nothing but a simple contracture without pain, atrophy, sensory, reflex, electrical, or X-ray disorders.
The abductor muscles were stimulated by electricity and the foot straightened. He was kept under observation for a time, was lame no longer, and was sent back to his regiment.
However, sometime later he was evacuated again to the same neurological center, stating that he did not know why. There was no longer any varus or anything abnormal. The rascal had enjoyed the game of going lame and had prevailed upon his officers to evacuate him. He then saw that he was found out and pretended that he had been forcibly evacuated.
Mother love and jaundice.
Case 467. (Briand and Haury, January, 1916.)
A soldier, 19½, entered the central psychiatric service at Val-de-GrÂce, having been evacuated from a hospital in Paris, suspect of having brought about a picric acid jaundice. He had been undergoing treatment in this hospital, when the physician who had isolated him found that he was getting picric acid in packages secreted in his kÉpi.
It seems that the soldier lived with his mother, and enlisted when he was not yet 18. He proved to be as good a soldier as he was workman, and came through the campaign without wound or disease. Accordingly, in December, 1915, he got a six-day leave. His mother, who loved him well, and of whom he was the sole support, had much regretted his enlisting. She was sick with some stomach disease and, after he enlisted, she told everybody that she was going to die and that it was his fault. So, when he came on leave the next day, she asked him to take a powder so he might stay a fortnight. She did not tell him the name of the drug; only told him how to take it in a small paper, swallowing it with a little water. She said he would become yellow and that he would get a supplementary leave. Three days after his return to the front, the boy took three of the ten powders; took the same number three or four days later; and the others five or six days later. He soon had jaundice with colic and diarrhea, and apparently was exempted from service for a few days. He had returned to the front hardly a month when his mother died and the boy got another six-day leave for the funeral. He took ten fresh doses of picric acid while at Paris, and was put into hospital by a physician without suspicion. His relatives thought he was suffering from a recurrent jaundice. When the story was told, the boy confessed to the family, and said that he had taken the drug in the first place only to please his mother. It is harder to explain the second trial, since he talked about the compassion and sense of obedience he felt to his dead mother. It is probable that he simply wanted a prolonged leave at Paris.
Re malingering, Blum speaks of fictitious jaundice as having received the name of La Carotte (the carrot) from the soldiers. Blum gives a partial list of instances of simulation as follows:
SIMULATION
(Blum, December, 1916)
False angina, from irritating solution.
Gastric disorder. Oil and tobacco (with tachycardia or jaundice) (use ipecac).
Diarrhea. (Isolate.)
Diarrheal stools imitated by a mixture of urine and water.
Dysenteric stools imitated by the addition of fat pork and bits of raw meat.
Appendicitis. Complaint of pain at the well-known McBurney point.
Tape worm. Carriers supply others.
Jaundice. (Smoke mixture of antipyrin and tobacco; drink tobacco juice. Ingest picric acid.)
Hemoptysis. Irritation of throat surfaces with a needle.
Albuminuria. Eat kitchen salt to excess in a bowl of milk. Edema and albumin disappear on surveillance. Albumin injected into bladder.
Diabetes. Phloridzin, or oxalate of ammonia. Glucose added to urine.
Incontinence. (Difficult to prove fraudulent. True incontinence in middle of night. Simulated, just before waking.)
Skin diseases:
Erythema. Herbs.
Eruptions. Mercury, arsenic, iodine, bromide.
Herpes. Euphorbiacae.
Eczema. Rubbing with slightly warmed thapsia. Rubbing excoriated skin with acids, Croton oil, bark of garou, sulphur, oil of cade, mercurial pomade.
Impetigo. With cantharides plaster and pomade stibiÉe.
Intertrigo. (In the infantry.)
Hyperidrosis of feet. Prolonged hot baths. Hot foot baths with excoriation, followed by scratching and covering with linen soaked in urine.
Edema of legs. Constriction.
(In Lombardy, cases due to introduction of equisetum arvense, an astringent herb, by fingers and toes, followed by energetic rubbing.)
Recurrent wounds. (Cover with wax sealed bandages.)
Abscesses. Introduction of septic material. A thread soiled with tartar from teeth is drawn through the skin. Characteristic odor of resulting abscess.
Phlegmons. Subcutaneous introduction of turpentine or petrol.
Paraffine tumors. (Apply heat.)
Sprain. A stopper is put under the heel; or compress the leg with bandages to stop circulation and knock below repeatedly and forcibly. Edema and ecchymosis follow.
Conjunctivitis. Ipecac, pepper, septic or fecal materials. Pupillary dilatation has been produced by introduction of a belladonna grain under the eyelid daily.
Ears. Running at the ears produced by placing urine or chemical product in the ear.
Emaciation and pallor. Ingestion of a large amount of vinegar. Abuse of strong tobacco.
Muscular weakness. Arsenious acid in eggs. Voluntary lead and mercurial intoxications.
Epilepsy. Absence of pupillary reflex to light and pupillary dilatation, insensibility of nasal mucosa and modifications of pulse persistent after the attack is over cannot be imitated.
Fever. Striking elbows against walls to elevate the mercury in the thermometer. Take temperature by rectum.
Bites. One simulator had a fork with twisted teeth to produce the effect.
Intra-abdominal projectiles. Bullet swallowed.
Swelling of hand and forearm, seven months.
Case 468. (LÉri and Roger, September, 1915.)
A soldier was wounded September 22, 1914, at Charleroi by a bullet in the forearm. He came under observation May 14, 1915, with a huge edema of forearm and hand, suddenly stopping at the elbow, an elastic edema, especially marked in the palm, which was restored to its smooth contour very quickly after being compressed by the fingers, and very like an elephantiasis. The hand was in a position of moderate extension on the forearm, with fist clenched. There was a linear ecchymotic line at the upper edge of the zone of edema, especially on the antero-internal face.
According to the soldier’s own story, the swelling had begun a fortnight after the injury. He said that a very tight moist dressing had been applied during the first few days.
The patient was cared for by massage, and then by local baths. He was anesthetized in December and several drains were inserted; no result. In January he was chloroformed again and two long incisions were made along the internal border of the supinator longus and along the ulnar border of the forearm. He was better for two weeks after this second operation, but then grew worse.
The diagnosis of syringomyelia was now made, based upon the appearance of the arm and upon some ill-defined hypesthesia. This diagnosis was not entertained by LÉri and Roger who, when they obtained the patient, put him into a plaster cast up to the shoulder. The edema went down rapidly to normal. In short, it was here a question of a simulator, who was even willing to undergo surgical operations with general anesthesia.
Re evading service, Gleboff’s classification is as follows: 1. False assertion of disease of (a) internal organs, (b) vision, (c) hearing, (d) joints. 2. Simulation of temporary disease of organs. 3. Mutilation of limbs.
Re swelling of hand and forearm, see remarks on hysterical edema under Cases 407 and 456.
A German shell-shy.
Case 469. (Gaupp, April, 1915.)
Gaupp’s simulator had not been under shell fire. He said to his captain that he wanted to see his badly wounded brother (he had in fact no brother), and got a furlough on this ground. He then fled as far as possible from the front, into the interior, roved about for some days, falsely asserting that he was under dentist’s treatment.
He was brought to TÜbingen on the ground of mental derangement, on a hospital train, and was delivered to the clinic as a case of Shell-shock. This man’s state of excitement soon ended. As Gaupp could not make out his case clinically, he applied to the regiment and received in return court-martial papers. The man confessed that he had made false statements and fled because he was afraid of shells. Reproached with simulation, he preserved a shameful silence.
A fair exchange no robbery: France gets a simulator in an exchange with Germany of prisoners “unfit for service.”
Case 470. (Marie, April, 1915.)
A French soldier arrived in France from Germany in a reciprocal exchange of prisoners supposed to be incapable of bearing arms. The man showed a paraplegia with clonic movements of exaggerated degree. He was rapidly “cured” after being placed in a military hospital, and disciplined. He proved to be a vulgar simulator.
It was clear that the German physicians had made a gross error in diagnosis; but what, asks Marie, should be done with such a man, since he evidently should not be given a convalescent leave or a retirement? Should he be sent back to his dÉpÔt?
If a year’s treatment yields no results, Grasset suggests discharge with suitable gratuity.
SIMULATION: Question of Quincke’s disease.
Case 471. (Lewitus, May, 1915.)
An infantryman was brought to the eye department of the Wieden Hospital early in May, 1915, with a diagnosis (from the internists) of Quincke’s disease.
Under the conjunctiva of each globus oculi were countless small air vesicles. There was not the slightest emphysema of the eyelids or of the skin about the eyes. The skin in the neighborhood of the zygoma was thick, red and swollen; but no air could be demonstrated in the subcutaneous tissues on palpation. Next day the skin swelling and the conjunctival emphysema had disappeared. No communication of the orbits with the air spaces of the skull could be demonstrated nor was it possible to push air into the conjunctiva by nose-blowing. The fundi were both normal and vision was normal. Special rhinological examination showed the nose to be normal. It was the skin swelling of the orbital region that had given rise to the diagnosis of Quincke’s disease. The man had been then referred to the internists who could, however, find no evidence of disease whatever.
During the three months’ stay of the patient in the eye department, once more swelling of the left orbital region and air under the conjunctiva of the left globus oculi suddenly appeared one day, but disappeared over night. At this time small subconjunctival ecchymoses were found.
This case must be regarded as one of simulation but produced in a manner unknown.
Bruises of head and back, not severe: “A case of pensionitis, a self-made neurasthenic for medicolegal purposes.”
Case 472. (Collie, May, 1915.)
Sir John Collie remarks that sometimes one has to recommend a pension knowing that what amounts to a fraud is being perpetrated. A seaman, 25, got newspaper notoriety after receiving some not very serious bruises of head and back. Two months later, when seen by Sir John Collie, he was a victim of bent back. He was finally able to remove his clothes and put them on with some alacrity, although at first he declared he could not. Woebegone during examination, he was noted to laugh and gossip with strangers outside. A physician had diagnosticated it as an obscure spinal lesion, but as he was fit to work, he was sent back.
Forty-one days later he put himself on the sick-list again. Pluck and nerve were gone beyond recall, according to his physician. In hospital his appetite was good, he slept well, and he had no troubles except an hysterical loss of sensation. There followed 33 days in hospital, three weeks in a convalescent home, and return to work for a month. Unable to stoop or kneel for pain, he was thought organic.
Sir John found him without desire to get well, hysterical, and suffering “from pensionitis, a self-made neurasthenic for medico-legal purposes.” He was placed for four months in a nerve hospital. On leaving this hospital he was still in the bent-back position, and went into a pantomime display when asked to touch his toes. Four weeks in the convalescent home found the following: The attending physician now suggested locomotor ataxia as the correct diagnosis! Sir John Collie was asked to report finally as to the fitness for work. Well assured that the patient was really a malingerer, Sir John nevertheless certified him as permanently unfit for further service as a case of traumatic neurasthenia, venturing to predict that after receiving the pension, he would be at work within six months. He received the pension (25 s. a
Re malingerers, Glueck remarks that a malingerer, besides being a malingerer, is a worthless sort of person in any event, and calls attention to the fact that special stresses may reduce men to lower cultural levels, to which lying and deceit may be more appropriate. Glueck remarks that the lay mind does not readily appreciate that a man with mental disease may at the same time be a malingerer of additional mental symptoms. It may be added that the professional mind is sometimes equally slow to appreciate the fact.
Chart 14
SHELL-SHOCK
- GROUP I. EXHAUSTION
- (Alcoholism perturbs treatment)
- GROUP II. HEREDITY
- (Certain poor recruits)
- GROUP III. MARTIAL MISFITS
- (Wrong attitude of mind)
After Farquhar Buzzard
Chart 15
NEUROSES AND PSYCHOSES OF WAR
- 1. NEUROSES
- Motor
- Sensory
- 2. NEUROSES
- Special Sensory
- Speech
- 3. NEURASTHENIA
- Hemichorea
- Exophthalmic Goitre
- Trench Spine
- 4. PSYCHOSES
- Minor
- Gun-shy, Insomnia, Dreams, Phobias, Psychasthenia, Hypochondria
- Stupor, Anergia, Acute Dementia
- Psychoses (Civilian Forms)
After A. W. Campbell
