Part 33

September 22 there was found a slight laxity of the patella tendon, as well marked on the left side as on the right. The right side was more cyanotic, due to the inactivity of the limb. There was no edema. Tendon and skin reflexes were normal. The lack of power was diagnosticated as purely functional, and the report was rendered that the soldier could begin to walk as soon as he desired. The two knee-jerks were noted to be stronger and polykinetic, and the right knee-jerk appeared a little stronger.

The patient was chloroformed, October 25, 1915. Almost immediately, the knee-jerks, Achilles jerks, plantar, and cremasteric reflexes disappeared. During the first period of anesthesia, there was no accentuation of the reflexes, but at the beginning of recovery the anticipated reappearance of the _right_ knee-jerk was observed. This knee-jerk was already sharply defined at a moment when the left knee-jerk was still abolished. In a later phase of recovery, the right knee-jerk was very markedly exaggerated and a patellar clonus was demonstrable on the right side. Even percussion of the _left_ patellar tendon brought about a contraction of the _right_ adductors. There was a true clonic and tonic spasm of these muscles. On the other hand, percussion of the right patellar tendon was able to provoke no contraction of either right or left adductors. Nor was there at any time any ankle clonus.

Hysterical lameness (bullet wound of calf) cured, but the associated “reflex” disorder (in the sense of Babinski and Froment) NOT cured.

=Case 277.= (VINCENT, April, 1916.)

A corporal was wounded by a bullet in the calf, September 8, 1914. At the end of July, 1915, his lameness continued and he disliked to lean on his left leg which bent under him. There was a slight atrophy of the left calf. The lower leg could not be extended upon the thigh if the foot was in dorsal flexion, and the dorsal flexion of the foot was itself limited. There were no reflex, vasomotor or electrical disorders. The man was given the usual treatment by Vincent and soon learned to carry his body on either foot, and, being well disposed, speedily abandoned his lameness, acquiring such skill in movements that he became monitor over the other soldiers, watching over them in his capacity as corporal.

For about a year he thus served as monitor, and when fully dressed did not seem abnormal or look as if he were walking lame. However, after walking, say 6 kilometers, rapidly, he dragged his leg; nor was extension of the lower leg upon the thigh absolutely complete in habitual walking, though he was able to extend perfectly if requested. Dorsal flexion of the foot was also still somewhat limited, and the measurements of the two lower extremities at both calf and thigh showed a persistent slight atrophy on the left side. He was then sent into the auxiliary service and did good work as draughtsman. In the winter the left foot got cold rather easily.

This case is instanced by Vincent to support the contentions of Babinski and Froment that the truly “physiopathic” or “reflex” disorders do not completely clear up in the recovery from the associated hysterical disorders. That limb, which is the seat of physiopathic disorder, is not in a state of meiopragia.

Foot trauma: Pains and dysbasia, hysterical; slight atrophy of calf, physiopathic. Differential disappearance of hysterical symptoms; increase of physiopathic symptoms.

=Case 278.= (VINCENT, April, 1917.)

Clovis Vincent examined a man who had been wounded in the foot but without injury to the bones. He was first examined in July, 1915, when he complained of foot pains and was walking with crutches. The left calf was smaller than the right (4 cm.). The tendon reflexes were normal. There was no abnormality of electrical reaction. There was no proportionality between the trouble with walking and the organic status. A large part of the trouble appeared to be hysterical. In fact, upon treatment, the man was soon able to abandon the crutches and to walk, though lamely. He was put into the auxiliary military service.

However, the pains grew more marked and the lameness increased. Incapable of working, the patient was sent to the neurological center at Montpellier, whence he came to the neurological center at Tours in September, 1916. He had never been confined to bed, and had never ceased his daily walking, aided by a cane. The walking disorder was very pronounced. The patient said he was still suffering much. The difference between the two calves was now 8 cm. and the thigh was atrophied, though the atrophy had been absent in July, 1915. There was hyperexcitability of leg muscles. The right foot was colder than the left. The hysterical phenomena, so pronounced in July, 1915, were now absent, yet the reflex phenomena were sufficient to invalid the man.

Shell-shock paraplegia may AFTER TWENTY MONTHS develop vasomotor and secretory disorders: The whole to vanish on treatment.

=Case 279.= (ROUSSY, April, 1917.)

A foot chasseur, 22, a farmer in civil life, sustained shell-shock _à distance_, June 2, 1915. He had no wound, but lost consciousness. He was evacuated for “contusion of back” to a hospital June 4 to 12; for “contusion of back and _commotio cerebri_” to Portarlier, to July 21; for “internal contusions and _commotio cerebri_” to Besançon, where he was in three hospitals up to May 31, 1916, and the diagnosis “hysteria, old _commotio cerebri_ and trepidant astasia-abasia” was rendered and psychotherapy tried. The man was then evacuated to Saint Ferréol and the diagnosis “hysterical paraplegia” rendered. He finally reached Veil-Picard in February, 1917, still victim of paraplegia.

Up to this point there had been no signs suggestive of organic lesion of the spinal cord or any hysteroörganic intimation whatever. But in February, 1917, besides the motor disorder there was a hypothermia of several degrees, with cyanosis and hyperidrosis of both feet, with a marked diminution (and absence on one side) of the plantar cutaneous reflexes. The man was also victim of “hysterical pregnancy.” The cyanosis, hypothermia and hyperidrosis lasted six weeks.

March 23 the man was given treatment and for the first time in 21 months was able to stand and walk. The foot now turned from blue to red, and instead of cold became warm, even hot. In about a week the hyperthermia diminished, and, with the other troubles, disappeared. There remained only a slight swelling of the foot and ankle joints, due to the painful exercises given the patient.

It would seem, then, that a hysterical paraplegia of long duration may finally associate itself with marked vasomotor and secretory disorders and that these may be altered with extreme rapidity on the very day in which the hysterical phenomena are removed, and quite disappear in a fortnight.

Tetanus clinically cured: Phenomena in part reproduced UNDER CHLOROFORM ANESTHESIA five weeks afterward.

=Case 280.= (MONIER-VINARD, July, 1917.)

An infantryman, wounded at Notre Dame de Lorette, May 9, 1915, by a shell fragment in the right popliteal space, was given a preventive injection of 5 c.c. of antitetanic serum, evacuated to a hospital, May 12, and developed signs of tetanus August 1, with trismus and pains and spasms in the right leg.

The disease progressed with dysphagia, stiffness and paroxysmal hypertonia of the legs, especially of the right leg, fixed orthotonus of the trunk, neck hyperextended, arms stiff but able to move. Antitetanic serum was given daily. At the end of eight days there was a marked improvement and the whole course ran to approximate recovery in 25 days from the onset of tetanic symptoms, at which time the man was able to get up and walk on a crutch. The external popliteal nerve had been sectioned, and the foot was in a marked equinovarus.

Chloroform was administered for the purpose of straightening the foot, September 2, that is, about five weeks after the apparent end of the tetanus. The first stage of the anesthesia lasted about two minutes, but at this point the trunk and leg muscles passed into a state of diffuse contracture. In fact, a _tetanic syndrome_ took place _in the midst of the anesthesia_. At a time when the corneal reflex was completely abolished, it was still impossible, with the exertion of the greatest strength, to flex the segments of the lower extremities. Moreover, the trunk was stiffly extended and the jaws were in trismus. Tonic and clonic contractions were produced by the efforts made to straighten the foot, and these contractions passed from the right side to the left. The chloroform was now increased and a transient resolution of the muscles was obtained, lasting hardly more than a half minute. As all efforts to reduce the pedal deformity failed, anesthesia was stopped. The contractures and paroxysms lasted a few minutes. The knee-jerks were extremely exaggerated and there was a bilateral ankle clonus. After a brief phase of excitement, the patient emerged from anesthesia, began to talk with his comrades, and ate his usual meal without inconvenience. The chloroform anesthesia had lasted twenty minutes, and 60 grams had been administered.

It was now determined to section the tendo Achilles and the tibialis posticus. September 8 the man was chloroformed again and the same phenomena were exactly reproduced. Sixty grams of chloroform was again administered. The tendon resections permitted placing the foot in the proper attitude. Next day the patient was examined neurologically. The skin reflexes were found normal. The Achilles and knee-jerks were somewhat exaggerated, but equal on the two sides. There was no ankle clonus. Sensations proved normal. There was a mechanical hyperexcitability of the muscles of the anterior aspect of the thighs and of the calf.

In another case chloroformed 17 months after recovery from tetanus no such phenomena appeared. It would seem that the impregnation with tetanic virus or toxin must last in the nervous system a good deal longer than the apparent disease clinically lasts, but that this belated and concealed intoxication eventually passes.

The phenomena are perhaps _analogous to_ those of _Babinski and Froment’s_ so-called post-traumatic physiopathic or _reflex phenomena_. It was following the special work of Babinski and Froment upon the use of chloroform anesthesia in detecting physiopathic conditions that Monier-Vinard made his observations in cases of tetanus.

Shell-shock from falling of shell at a distance: Hysterical hemiplegia, terminating in brachial monoplegia. Case to show that the reflex or physiopathic disorders of Babinski and Froment may occur without mechanical injury in the region involved.

=Case 281.= (FERRAND, June, 1917.)

A soldier of the class of 1917 who never went to the front, while in training at Belfort, felt violent emotion on the occasion of the falling of a big shell in the town of Belfort. The explosion was a good distance from him. He lost consciousness a few moments, February 23, 1917, and almost at once found himself unable to move his left side. He was hemiplegic three months, but his leg shortly regained power. December 23 he entered a neurological center with his arm flaccid and a paralysis affecting the shoulder also. There was an almost complete anesthesia of the arm terminating in segmentary fashion about the shoulder, and the whole of the left side was slightly hypesthetic, although there was no disorder of motion except in the arm. The tendon reflexes of the left arm were exaggerated, and there was even contracture upon percussion of the muscles themselves. Percussion of the thenar and hypothenar eminences produced movements of the hand. There were several vasomotor disorders. Percussion led to large vasomotor plaques, and rubbing of the skin produced a reddening which passed away slowly. The hand was red and cold. Slight electrical hyperexcitability of flexors with feeble galvanic current; excitation of the extensors not associated with any contractions of the antagonist muscles. Threshold lower for flexors on the affected side in the forearm. Half centimeter atrophy of the biceps. The forearm and hand were possibly slightly increased in volume from a blue edema of the dorsal surfaces. The man was very timid, complained little, and accepted all treatment, which, however, was not very effective. This is presented by Ferrand as a case with physiopathic disorder in the sense of Babinski and Froment, though it does not present any sign of organic lesion whatever.

Shell fire: Delayed shell-shock symptoms, sub-lethal, appearing in England.

=Case 282.= (MCWALTER, April, 1916.)

A soldier was picked up insensible in the public street and brought to hospital by ambulance, unconscious, breathing stertorously, pupils dilated, lips parched, unresponsive to stimuli, but without signs of injury or alcoholism.

The pulse grew slower, the respirations more sighing, the heart-beat more diffused and labored; but towards evening, about eight hours after admission, he began to move the eyelids and lips, and muttered a response to the request for his name. After ten more hours, respiration grew better, and Croton oil led to a movement of the bowels. Natural sleep intervened, and 18 hours after the onset of unconsciousness, the man woke up, and in the course of a few days became fairly well though still dazed and confused.

This soldier had never received any definite injury in his war service, but McWalter attributes his break-down to the effects of the constant shocks from the bursting of shells, and the scattering of shrapnel.

McWalter generalizes that a soldier, in the course of some civil occupation _after_ the war, might develop symptoms, even fatal symptoms, and still the death in the case would be a direct consequence of the war.

Shell-shock symptoms, some initial, with recovery--others late and gradual, with deterioration.

=Case 283.= (SMYLY, April, 1917.)

A soldier became blind, deaf and dumb, as well as paralyzed, as a result of shell explosion. When he arrived at the hospital, he was able to see but had visual hallucinations. In a few days he recovered his hearing. There was a fine tremor of the hands, controllable by suggestion. There was an almost complete amnesia, but the patient remained able to read and write.

The pain persisted several months. The patient was physically well and seemed perfectly intelligent despite his aphasia and amnesia. One night, he sprang out of bed, shouting, “The guns are coming over us!” and from that time forward was able to speak. Amnesia, however, supervened for the months in the Dublin Hospital, and the patient believed that he was still in France. He also became unable to read or write, and was unable to recognize any letters except those he had been taught to speak during his period of dumbness. Still later he got a flaccid paralysis of the legs. From seeming perfectly intelligent, he began to seem markedly deteriorated. Hypnosis with waking suggestions had no power upon him. After a time, intelligence reappeared, but there had not been any recovery of locomotion at the time of report.

Wounds, gas, burial: Collapse on home leave.

=Case 284.= (E. SMITH, June, 1916.)

A non-commissioned officer went through the first eleven months of the war in France and Flanders and was subjected to every kind of strain therein. He was wounded twice, gassed twice, and buried under a house, in each instance being treated in the field ambulance and returning to the trenches. Some time thereafter he was granted five days’ leave.

On reaching home, while waiting for a train, the officer suddenly collapsed and became unconscious. For months thereafter, he was the subject of a severe neurasthenia; “the whole of his trouble seemed to be due to the dread, lest on his return to the front, the added responsibilities which would fall upon his shoulders might be too much for him.” He thought his intelligence had been numbed by his experience. He thought his memory was unreliable, and that he could understand neither complex orders nor even the newspapers.

As to the reason for his maintenance of composure at the front, this may be laid to the excitement, the officer’s sense of responsibility, and the example he felt he should set his men. This kind of case “demands a great deal of patient and sympathetic attention before the real cause is elicited, and then months of daily reëducation to build up anew the man’s confidence in himself.”

Bullet wound of neck: Late sympathetic nerve effect.

=Case 285.= (TUBBY, January, 1915.)

A Belgian was wounded, October 21, 1914, at Dixmude. The bullet wound was just below the right mastoid process. He was admitted to the London General Hospital, October 29. He said that the bullet had passed into the tonsil, lodging there, but that on the third day, while vomiting, he brought up the tonsil with the bullet in it. There was in fact a large ragged wound at the site of the right tonsil. He could swallow fluids only, but articulated clearly. There was a question of injury to the following nerves: facial, glossopharyngeal, vagus, hypoglossal, spinal accessory, and sympathetic. None of these nerves, however, appeared actually to have been injured. The difficulty in swallowing was due probably to the faucial wound, and it is hard to see how the pharynx could have been involved on account of the perfect articulation. November 3 the right sympathetic nerve was slightly affected; the right pupil was smaller than the left although it reacted to light. November 12 the patient left the hospital and nothing further is known of his history. Thus there was a late effect upon the sympathetic nerve thirteen days after the wound.

_Re_ peripheral nerve disorders, see remarks under Case 252 (Tubby).

Fall from horse under shell fire: Crural monoplegia, hysterical. Reminiscence? Autosuggestion?

=Case 286.= (FORSYTH, December, 1915.)

A patient of Forsyth had been exercising a high-spirited horse. Artillery fire close by made the horse leap sidewise, and the rider fell, his back striking the ground. He seemed to be curiously shaken out of proportion to the gravity of the fall. In a day or so, he lost the use of one leg.

He recalled a rather similar incident: He had taken a hand in a local uprising in a distant quarter of the world. While he was escaping up a mountain track, a rifle-shot from the enemy brought down his horse, which rolled over and threw him violently against a boulder, where the small of the back met the force of the impact. He felt intense pain and lost consciousness. Upon recovery he found he was paralyzed. At the end of several days, in a hiding-place in the rocks, he found himself still unable to move his legs. The friend who had carried him to the hiding-place refused to leave him. He thought of suicide, but then discovered that he could move: at first, the big toes, then the ankles, then the knees, and finally the hips. He was finally able to get into the saddle.

Moreover, years before, he had heard that a man who broke his back was paralyzed in the legs.

_Re_ autosuggestion, Babinski remarks that suggestion may work in hystero-organic cases not precisely as in hysterical cases. Autosuggestion may here replace or accompany the ordinary heterosuggestion. Some temporary disturbance--a slight pain, a trivial injury, or a mere bruise--may start up a complex process of autosuggestion in which it may be difficult to unravel the part played by the patient’s own reflexes, his previous experience and beliefs (in this case, the reminiscences of a similar accident), the solicitude of his friends, and the medical examination itself. Babinski believes that hysterical paraplegia or monoplegia never appears automatically under the influence of emotion; never appears after the manner of sweating, diarrhea, or blushing.

Shell explosion; struck in cave-in: Symptoms in right leg (antebellum experience).

=Case 287.= (MYERS, March, 1916.)

A private, 26 years old, had 11 months’ service and one month’s service in France. He arrived at a base hospital the day after his shock. Concussion had caused the dug-out in which he was standing to collapse. A beam struck him on the left side of the face, and pinned him to the ground on his right side. A piece of iron fell on the left side of his back, and his right leg was pinned by a cross beam on the back of his thigh. He was dazed by the shock; was released and was able to walk, but complained of a pain in the right groin and a giving-way of the right knee. The medical officer arrived about an hour later. A numbness, or state of no feeling, in the right thigh appeared, and increased to the point of total analgesia to the level of the upper margin of the patella save for a narrow strip in the mid-line on the posterior aspect of the leg. The only area of complete anesthesia and algesia was on the outside of the lower half of the leg.

According to the patient, it seems that about three years before, he had been buried four feet deep in a brick yard, beneath a heap of clay. He had felt it most in the right leg, but the thigh had been merely stiff and sore, and not numb. The patient admitted that the present accident immediately reminded him of his previous experience. There were no tremors or sensory disorders in the face, arms, chest, back, or abdomen. There was diminished sensibility to cotton wool of the left buttock (across which a plank had fallen), and there was a degree of hypalgesia of the buttock. The right thigh showed a degree of thermanalgesia and slight loss of vibratory sense. The corneal and conjunctival reflexes were diminished, and the knee-jerk was unobtainable on the right side. Three days later, there was a marked improvement with almost complete return to normal, whereupon the patient was sent to a convalescent camp.

Emotional subject, ALWAYS WEAK IN LEGS; shell explosion; wound of back: PARAPARESIS.

=Case 288.= (DEJERINE, February, 1915.)

A Lieutenant, 25, was wounded at Arras about 10 a.m. October 20, 1914, just as he was leaning on another officer’s shoulder looking at a card in a chateau room. A shell burst in the court yard. A fragment came in the window, struck him in the back and pushed him forward, whereupon he felt pain in the back and a severe dyspnea, due to the gas from the shell. He lost consciousness several times and the dyspnea lasted for about two hours. When he was picked up he could not walk.

He was carried on a stretcher to the ambulance at Avin-le-Compte. During the fortnight there, he was also several times dyspneic. Strength left his legs and he could only get about on crutches. There was now a suppurating wound in the interscapular region where he had been struck by the shell fragment. Evacuated to Paris, he was operated upon on account of a tremendous abscess in the back, and the shell fragment and some bits of cloth were removed. The wound healed; but vague pains in the left thorax remained, especially when the man walked.