Part 32

A seaman from the _Derfflinger_ was brought into a naval hospital with loss of voice, December 22, 1914, able to speak only in a whisper. As a child he had had diphtheria, but recovered without complication. He had always had a very well-controlled voice. Early in December he had had a cold owing to sentry deck duty in bad weather. Two days after the shelling of Scarboro,--December 16,--while in the munition chamber of the big guns, he suddenly lost his voice. He had been greatly upset during the firing of the guns. In two weeks he recovered speech.

February 12, 1915, he returned to the hospital with a complete aphonia. This was immediately after the naval engagement in the North Sea. Three days later he was treated with electricity directly applied to the vocal cords. March 20 he was discharged with speech completely recovered. As soon as he went on leave, however, his voice was lost for the third time, and he was still aphonic at time of report.

Shell-shock MUTES observed, then DREAMED OF: MUTISM developed the SECOND NIGHT after shell explosion.

=Case 265.= (MANN, June, 1915.)

A volunteer of 20 was made unconscious for a short time by a shell explosion, but was still fully able to speak when brought to the field hospital.

In the second night after the explosion, however, he dreamed that he had lost his speech. In the ward, meantime, he had seen a number of shell-shock mutes. Following this dream of aphasia, came several weeks of mutism, which then cleared up. According to Mann, this is experimental proof of the psychogenic origin of a mutism.

Mortar explosion: Hysterical deafness.

=Case 266.= (LATTES and GORIA, March, 1917.)

A young soldier, a peasant, fell down unconscious when a mortar exploded killing several men. He regained consciousness a few hours later but was deaf on both sides. He looked dazed and did not spontaneously move, having to be called for meals. Communicating by writing, he could tell all the details of the accident.

The laryngeal and corneal reflexes were absent and there was a hyperesthesia and hypalgesia of the right side of the body. No anatomical basis for the deafness could be determined.

Shell explosion: Onomatopoeic noises in ears.

=Case 267.= (BALLET, 1914.)

A Zouave was with his squad at Tracy-les-Val Church, October, 1914, when the roof was burst in by a shell which wounded four men. The Zouave felt a strange emotion with trembling, and whistling in his ears. However, he helped his comrades into a neighboring car. From that time forward, he was very emotional, and felt noises in his ear, sometimes humming, sometimes whistling. At Compiègne Hospital a lumbar puncture was made, perhaps with a therapeutic purpose, but this gave no results. The noises were heard as a whistling _pseeee_ followed by a _boom_,--an onomatopoeia recalling the whistling and bursting of the bomb. There was, in short, no labyrinthine lesion, but merely an obsessive mental phenomenon. There were no ear lesions objectively. The man developed a stuttering some time after the humming and whistling in the ear.

Injury of eyes by gravel from shell-burst: Photophobia, blepharospasm, facial anesthesia, pains.

=Case 268.= (GINESTOUS, January, 1916.)

A soldier of the Ninth Engineers, 28, a Beaux-Arts student, was wounded, December 19, 1915, by stones and gravel thrown in his eyes by a shell-burst. The eyelids swelled and the eyes filled with tears. He was treated at the relief station and then evacuated to Verdun. The edema disappeared in five weeks, but it was impossible for him to look at light. February 2 he was evacuated to Nice, where he received the diagnosis of traumatic keratalgia, blepharospasm, and photophobia. After eight days’ leave he went back to his corps; but the eye troubles persisted and he was sent to the ophthalmological center at Angers, May 18, 1915.

Both his father, 67, and his mother, 58, were irritable and odd. Three brothers and three sisters were also more or less neuropathic, and one of the sisters had been in a hospital for the insane with a persecutory mania. The patient had a daughter, fourteen months, well.

The man was a nervous, impressionable person, who wept at the slightest emotion. With an effort of will he could open his eyes, but if one tried to open them passively there was stout resistance. In the dark the occlusion was not so complete. Both eyelids were wrinkled and folded and made jerky, fibrillary movements. The conjunctiva and cornea were normal (fluorescein test), but the palpebral conjunctiva was red and injected. The patient said he had subcutaneous pains recurring at irregular intervals above and below the left orbit, brought out or exaggerated by pressure; but such pressure had no effect upon the lid movements. Visual acuity was normal, but the use of ophthalmometer was impossible, as was measurement of the visual field. There seemed to be no disorder of chromatic sense. The reflexes could not be fully examined; knee-jerks preserved. There was a zone of anesthesia to pin prick, less marked to heat, on the whole left side of the face. W. R. negative.

Shell-shock; burial; blow on occiput: Blindness.

=Case 269.= (GREENLEES, February, 1916.)

A man in the third Wiltshire regiment was buried in a shell explosion and struck by a large mass of earth on the back of the head. When dug out, he was found blind. It was thought at the time that the severe blow at the back of the head had “concussed” the occipital cells for sight.

Some months later the man was sent to Mr. Pearson’s home for blind soldiers in London; but two months later was returned to Weymouth, under Greenlees’ charge. He thought himself worse, since now he could not see light at all. He had trained himself to take care of himself and steered confidently aside from obstacles in walking about. He was able even to learn the various colors by the sense of touch, according to Greenlees; thus, blue was diagnosticated against red: according to the patient, a piece of colored card always had a rougher feel if it was blue than if it was red. In fact, his work consisted of making colored net bags.

As to the possible interpretation of such a case, see Case No. 433 (man who could see large letters sometimes).

_Re_ blindness, H. Campbell states that the number of cases of hysterical blindness appears to be decreasing as the war continues. The blindness he finds to be rarely an absolute one. As a rule, the vision is merely blurred or there is a contraction of the visual fields. The condition is much less frequent than that of deafmutism.

_Re_ hysterical blindness, Dieufaloy is cited by Crouzon as describing a triad of conditions characteristic of hysterical blindness, namely, (_a_) sudden onset, (_b_) preservation of pupillary reflexes, and (_c_) normal fundus.

Shell-shock amblyopia (composite data).

=Case 270.= (PARSONS, May, 1915.)

Parsons describes a typical case of shell explosion amblyopia. After more or less prolonged fatigue from marching and trench exposure, the soldier is knocked down or blown into the air, and more or less severely injured or wounded by concussion, fracture, bullets, or shell splinters, losing consciousness, but perhaps not enough to prevent automatic walking in a dazed state to the dressing station. Memory of this phase is lost. The man is instantaneously stricken blind, possibly also deaf; and possibly smell and taste are also lost. Blepharospasm is intense; there is lacrimation; the lids are opened with such difficulty that examination of the eyes is almost impossible (nor, according to Parsons, have the pupils yet been examined at this stage).

In a week or two the blepharospasm diminishes, and the fundi, which are found to be absolutely normal, can be examined. The eyes may be found to be quite normal, the pupils reactive to light though perhaps sluggishly and perhaps unequally. Sight is now somewhat restored, light can be perceived, and large objects distinguished. The patient can grope about and usually does not stumble against obstacles. The fields of vision are markedly contracted, and more so than the avoidance of obstacles in walking would suggest.

Vision is eventually recovered completely. The right eye (the shooting eye) is often more deeply affected and recovers more slowly. Perhaps a central scotoma may persist. Sometimes on manipulation of lenses the full vision can be produced for the types. Parsons seeks to explain the psychology of traumatic amblyopia in the light of deductions of Lloyd Morgan, Mark Baldwin and McDougall.

Shell-shock amblyopia (excitement, blinding flashes, fear, disgust, fatigue).

=Case 271.= (PEMBERTON, May, 1915.)

Pemberton calls attention to the following factors in a case of amblyopia: First, excitement during a prolonged and somewhat critical attack; second, overstimulation of eyes and ears due to brilliant flashes, night firing from many batteries close together (the gunners are always subject to temporary deafness from this firing); third, natural fear from close bursting of shells; fourth, disgust at decapitated and disemboweled soldiers; fifth, fatigue from twelve hours’ work.

The artillery sergeant worked under heavy shell fire at Gun No. 1. A direct hit killed three men serving No. 2 gun. The sergeant became somewhat excited but worked his gun until the following dawn, when he collapsed across one of the disemboweled corpses. He thus had been at work for about twelve hours. The battery had fired 400 or 500 rounds.

A few hours later, the man was conscious but very feeble and much shaken. There was amblyopia and contraction of the fields of vision to rough tests, but no change in color vision. Taste sense was blunted, and salt could hardly be told from powdered quinin tablets. Smell also was practically absent, although he had never been able to smell accurately. Hearing was not more affected than that of other men in the battery, and there were no tympanic fractures. Both thighs, from about the apex of Scarpa’s triangle to the knee, showed partial anesthesia, such that a pin prick that should have been painful was felt only as a tactile sensation, whereas lighter stimulation caused no sensation whatever. The patient himself complained of numbness in these areas. The gait was slow and spastic. The knee-jerks were brisk. Sent back to the wagon lines for a week, the patient lost his sensory disturbance, but the symptoms of mental distress increased. He walked weakly and stiffly; he continually thought of the dead men at the next gun, one of whom was a friend. He was finally sent to a hospital in England.

Shell-shock amblyopia.

=Case 272.= (MYERS, February, 1915.)

A private, 20, lay in the booking-hall of a station, October 28-29, not securing much sleep; motored in a bus next day to another place at 7.30 p.m.; went into billets at 8 p.m.; mounted guard 10-11.30 p.m. and 1.45 to 3.45 a.m.; and went to the firing-line for the first time at 11 a.m. October 31. The platoon advanced through two sets of trenches, which were full, and had to retire. About 1.30 p.m. they were found by the German artillery.

This man had been rather enjoying it and was in the best of spirits until the shells began to burst. The platoon was retiring over open ground. He was kneeling on both knees, trying to creep under wire entanglements, when two or three shells burst near by. Three more shells burst behind and one in front. The escape was described by an eye-witness as a miracle. He managed to get back under the entanglements and into the trench, and shortly, as the fire slackened, rejoined his company.

His sight had become blurred immediately after the shell burst. Opening his eyes hurt him, and the eyes burned when closed. The right eye “caught it” more than the left. At the same time, he was seized with shivering, and cold sweat broke out, especially about the loins. He thought the shell behind caused the greater shock, like a punch on the head without pain. The shell that burst in front had cut his haversack away, bruised his side, and burned his little finger. This shell he thought caused his blindness.

He was led to the dressing station by two comrades, opening his eyes to see where he was going but finding everything blurred except immediately after opening his eyes. There was no diplopia. Objects seemed to dissolve. He was weeping and worrying about becoming blind. The horse ambulance took him to a hospital and thence to another hospital, and thence he went by motor ambulance at night to the starting point, where he arrived five days after he had entered the field. He could remember nothing about the ambulance trips. There was a slight deafness which soon passed off. In hospital he shivered almost incessantly in bed, and he kept thinking about his experience and the shell bursting. The shivering ceased November 3. No micturition from the afternoon of October 30 until the afternoon of November 2. No movements of bowels from October 30 to November 5.

It seems that this soldier had been for two months in the Aisne district, sleeping badly on account of lumbar pains and toothache. There had been albuminuria, and the patient said he had failed to pass a medical examination. The fields of vision were found to be distinctly contracted. There was difficulty in taste and smell, which the patient said he had lost since the shell-burst.

Hypnosis was tried but the patient “insisted on resisting.” The suggestions were offered during the concentration period. November 13 taste and smell began to return and the fields of vision were less contracted. He was transferred to England for further treatment, and by November 27 had become much improved and not so “nervy.” February 1 he had begun to attend hospital as an out-patient.

SHELL WINDAGE (NO EXPLOSION): Multiple affection of cranial nerves.

=Case 273.= (PACHANTONI, April, 1917.)

August 22, 1914, a French officer was leading his company to an attack and carried on, though wounded in the side by a bullet. Suddenly he felt as if he had received a terrible blow with a hammer on the left cheek and eye and as if his arm had been torn off. He fell to his knees without losing consciousness. _There had been no explosion_, and none of his soldiers had been hit. He felt of his arm and carried his hand to his head to make sure of the wounds. There were none, but he was bleeding from the nose and the mouth. His left eye was closed and his left cheek drawn “by an invisible hand.” His tongue had swollen until it had to be pushed out of his mouth. He was breathing hard. He fell upon his side without losing consciousness and he was carried by his men to shelter in a trench. Placed on his back he felt that he could not lift his head as “it had become too heavy.” His voice was lost. He could neither cough nor spit. In order to get air he had to remove bloody saliva from his mouth with his finger. The left side of the head was swollen. On opening his eyes he could no longer see with the left eye. His cheek was covered with ecchymoses but without wound. A few hours later he was made prisoner by the Germans. For two months he had an increase of temperature every evening and for three months he lost his voice. Six months later there was still visual impairment. He was anesthetic in the left cheek, unable to chew, paralyzed in the left facialis region. There was alteration of taste, with atrophy of the left side of the tongue deviating to the paralyzed side, and nasal regurgitation. There was continual drooling and convulsive coughing. In dorsal decubitus the head could be lifted with difficulty. There was a kind of paresis of the esophagus, as he felt the bolus stop at the level of the third ribs so that with each mouthful he had to swallow a little water. Apparently he had a paralytic state of the following nerves: optic, oculomotor, trigeminal, glossopharyngeal, pneumogastric, spinal accessory and hypoglossal. There was evidence of a slight old tuberculosis at apices. The man was slightly pale. There was an atrophy of the optic nerve and some retinal swelling. No pupillary reactions to light on the left side; but the accommodation reflex and sensory reaction were preserved. Divergent strabismus of the left eye. The taste on the left side and on the anterior part of the tongue was slightly diminished. Diminution of galvanic and faradic excitability on the left side of the face. No reaction of degeneration. Bitter, salt and sweet tastes altered. Left-sided atrophy of the tongue. No reaction of degeneration in the tongue and thyroid muscles although there was a marked diminution in faradic excitability.

The author records this case of multiple lesions of cranial nerves as due to shell windage. Thirty-one months after the onset of the paralysis the cranial nerves, although manifestly regenerated, had not regained conductivity. The officer was examined by Pachantoni at Louèche-les-Bains in Switzerland.

_Re_ windage, see remarks under Case 201.

Wound of thigh: Claudication, vasomotor disorder, hypothermia, but no exaggeration of tendon reflexes. Under CHLOROFORM, ELECTIVE EXAGGERATION OF REFLEXES, _i.e._, in this case, hyperreflexia of affected thigh, including patellar clonus, after other reflexes (including conjunctival) had become extinct. The case described led to the new formula of THE PHYSIOPATHIC SYNDROME (BABINSKI).

=Case 274.= (BABINSKI AND FROMENT, 1917.)

Babinski examined in August, 1915, at the Pitié, a soldier who had been wounded in the upper and outer part of the thigh. He showed a most marked claudication with outward rotation of the foot. There was a muscular atrophy of the thigh but no appreciable disorder of the electrical reactions. There was a slight limitation in the movements of the hip, namely, the movements of flexion and internal rotation of the thigh upon the pelvis; yet this limitation of movements did not seem to be in proportion to the rest of the motor disorder. The X-ray showed no joint lesion. The right knee-jerk was a bit stronger than the left, though this was controversial. Achilles reflexes were normal and equal; epileptoid trepidation of the foot, and clonus of the patella absent; the limb showed marked and permanent vasomotor disorders and local hypothermia; both phenomena were of a sharp and definite nature.

On the basis of the intensity of these vasomotor disorders, Babinski felt that, in accordance with his general ideas, he was not dealing with hysteria, and that he was in fact dealing with the so-called physiopathic syndrome. Lacking for this syndrome was the exaggeration of the tendon reflexes of the affected limb. Might it not be that the improper attitude and muscular stiffness of the limb were based simply on retractions of tendons? The patient was chloroformed. This procedure was the more warrantable as a number of physicians had thought of the patient as an exaggerator or even as a simulator. Under chloroform there was in fact a slight tendon retraction; yet on the whole it was clear that the attitude and stiffness of the limb were largely dependent upon a contracture. When during narcosis all the other tendon reflexes and skin reflexes had become extinct, there was still to be observed on the affected side a hyperreflexia, and even a clonus of the patella; and the clonus lasted an hour after recovery from the anesthetic. This curious phenomenon of elective exaggeration of tendon reflexes in narcosis, Babinski has observed to be not infrequent. It is a valuable diagnostic sign for a sure proof of excess tendon reflexes in cases where doubt prevails under ordinary circumstances. Sometimes the contracture will yield, but only in the deepest sleep, outlasting even the conjunctival reflex and the reactions to pricking of the normal extremities. Moreover, the contracture would return from 20 to 25 minutes before any manifestation of consciousness. If an endeavor was made to reduce the contracture under full anesthesia and in complete unconsciousness, a spasmodic movement was provoked which exaggerated the abnormal attitude of the limb. Sometimes even the leg would be thrown into flexor contracture.

The case above described was the one which led Babinski to his new formula of the PHYSIOPATHIC SYNDROME. This he describes in general terms as follows:

These disorders consist in post-traumatic contractures, paralyses or paretic states, but are not attended by any of the signs of the so-called organic diseases, either of lesions of the central nervous system, or of the peripheral nervous system, or of the great arterial systems. In fact, these disorders somewhat resemble hysterical manifestations. The underlying lesions appear to be sometimes extremely small; in fact, so minimal as to be out of proportion with the functional disorders that they produce. These disorders do not correspond with any known anatomical regions, but they are singularly tenacious, and, unlike truly hysterical (pithiatic) phenomena, they are completely resistant to suggestion. Yet it is not merely in resistance to suggestive therapy that these reflex disorders differ from hysteria; for besides the contracture and the paralysis or paresis found in the different segments of the extremity concerned, the complete Babinski syndrome includes also muscular atrophy, exaggeration of tendon reflexes, alterations of skin reflexes (even amounting to areflexia), hypotonia, mechanical over-excitability of the muscles with retardation of the muscular contraction; quantitative changes in electrical excitability of muscles (excess or diminution without R. D.), mechanical over-excitability, and occasionally electrical over-excitability of the nerves, disturbances in objective and subjective sensibilities (anesthesia and pains), heat regulation disorders (especially hyperthermia), and disorder of the vasomotors (cyanosis, skin redness, oscillometric lowering at the periphery of the extremity in the presence of low temperature), secretory disorders, and various trophic disorders of the bony system, the skin, and the nails.

Despite the permutations and combinations of these symptoms, according to Babinski they amount to a new group of disorders and represent a nosological species: a species of disease phenomena that lies midway between the organic affections and hysterical disorders. Babinski proposes the term _physiopathic_ for these phenomena, a term which excludes the connotation of hysteria and all forms of psychopathia, on the one hand, and seems, on the other, to express the fact of their correspondence to a physical material perturbation in the nervous system of a novel sort.

Bullet wound of ankle: Contracture effect of chloroform.

=Case 275.= (BABINSKI AND FROMENT, 1917.)

A man was wounded, September 1, 1914, by a bullet in the left ankle. Contracture of the foot and of the four outer toes in extension followed, with a flaccid paralysis of the great toe. The left knee-jerk was a little stronger than the right; the left Achilles jerk also appeared weaker but observation was difficult on account of contracture of the foot.

Chloroformed, October 22, 1915: There was no sharply defined asymmetry of the tendon reflexes. The left Achilles reflex appeared a little weaker. In the phase of muscular resolution, the contracture disappeared entirely, but it reappeared a little after the return of the tendon reflexes. The reappearance of the _contracture preceded_ the reappearance of _consciousness_ from twenty to twenty-five minutes.

Post-typhoidal reflex or physiopathic disorder of right leg. Elective exaggeration under chloroform.

=Case 276.= (BABINSKI AND FROMENT, 1917.)

A typhoid patient, October 20, 1914, showed phlebitis and abscess of the right buttock with contracture of pelvic trochanteric muscles. He was sent to the Pitié on medicolegal grounds.