Part 43

October 9, the clouding of consciousness was less marked. The headaches and amnesia were constantly complained of; the reflexes were normal. October 12, there was less headache. October 25, another lumbar puncture showed but 14 or 15 lymphocytes per cm. and hyperalbuminosis. There was now no longer any clouding of consciousness. The amnesia, retrograde and anterograde back to May 9, 1914 (date of his daughter’s birth), and up to September 25, 1915, persisted. The man did not remember the declaration of war, or the mobilization, or his regiment, and the like. Meantime, the man’s judgment and reasoning powers were normal.

If there had been no early spinal fluid examination of this patient, he might well have been considered an hysteric or even a simulator.

Meningeal and intraspinal hemorrhage: Lumbar puncture.

=Case 372.= (GUILLAIN, May, 1915.)

A gunner from Morocco, who lost consciousness for an hour March 28, 1915, upon the explosion of a large-calibre shell in his trench, was carried to the ambulance. He complained of headache and generalized pains. His status was scarcely modified during five weeks, and a generalized contracture of the body developed whenever movements were attempted. In horizontal decubitus, the muscles of the limbs and neck were of a normal tonicity, but the head went into hyperflexion if the patient was asked to sit. The eyes turned upward, and Kernig’s sign developed. The patient could walk only with short steps, with legs apart and arms held away from the body, the head in a sort of tetanoid dorsal hyperflexion. There was a right-sided hemiparesis with trepidation and the Babinski sign.

Lumbar puncture assured the diagnosis of something organic. The fluid contained blood cells and a marked lymphocytosis. The symptoms evidently depended upon hemorrhages in the meninges and the nervous system, affecting particularly the right pyramidal tract.

_Re_ hypothesis of organic changes in hysterical cases, Roussy and Lhermitte remark in comment upon albuminosis in the cerebrospinal fluid that the albumin is perhaps due (in cases of camptocormia) to the effect upon venous and lymphatic circulation of the spinal curvature. It was Sicard’s claim that camptocormia, or bent back, was due possibly to anatomical changes in the spinal column, that is, that camptocormia was in one sense a spondylitis. In other cases the camptocormia might be due to a ligamentous or muscular change; that is, to a syndesmitis or a psoitis. His idea was that the curvature was in a sense antalgic; that is, a response having the purpose of avoiding pain.

Slight hyperalbuminosis.

=Case 373.= (RAVAUT, August, 1915.)

A farmer, 32, in the 66th Infantry, was lying in a dug-out March 5, 1915, when a bomb threw him on the ground and covered him with earth. He was picked up unconscious, and remained so for an hour. In the ambulance it was found that he could hardly stand, could not speak, and appeared to be completely confused. There was no sign of wound. The next day he recovered consciousness and complained of a violent headache. He was completely deaf in the left ear, and vision was also a little impaired on that side. The puncture fluid was clear, and there was a very slight excess of albumin by the heat test. The next day the headache had entirely disappeared, the left ear was absolutely deaf, but the patient complained of buzzing. Lumbar puncture the following day showed a normal amount of albumin.

March 16 the patient was evacuated to the rear presenting no abnormal symptom except deafness.

_Re_ the spinal fluid, Armstrong-Jones considers that a shock directly sustained by the spinal apparatus through sudden impact to the surrounding cerebrospinal fluid, ought to be felt more by the anterior horn cells than by the spinal root ganglia, since the latter are shielded by the sheath in the intervertebral spaces. Motor symptoms would, naturally, then be more frequent than sensory symptoms. He also believes that the controlling neurones in the intermedio-lateral tracts that have to do with the sympathetic system, would be affected just as anterior horn cells are. Accordingly, the dilated pupils, rapid heart, dyspnoea, and a variety of precordial pains and disorder of the viscera would ensue. The jar would thus be communicated to the neuronic cells of origin of two types: spinomuscular and preganglionic, leaving the gangliospinal neurones relatively intact.

Paraplegia, organic: Lumbar puncture.

=Case 374.= (JOUBERT, October, 1915.)

A gunner, 23, was thrown to the ground, according to his story, by the explosion of a large-calibre shell, at eight o’clock in the morning of September 10, 1914. He could not get up but thought he had not lost consciousness. September 13, he arrived at hospital, looking like a man with dorsolumbar fracture of the spine. There was, however, no external injury. There was a marked paresis of the right upper extremity, with diminished sensibility, weakened reflexes, numbness, formication. The right lower extremity was subject to complete flaccid paralysis, with lost reflexes, and anesthesia in all respects reached to the belt level, and stopped sharply at the median line of the abdomen. The left leg, also, was paretic but the muscles could be contracted weakly; the knee-jerk was exaggerated; there was a tendency to epileptoid trepidation, and the sensations were only slightly diminished. There was a Babinski reflex on the right side; the abdominal reflex was absent on the left side; both cremasteric reflexes were present. The feet at times gave formication. Rectal, bladder, and sphincter paralysis. Dark albuminous urine, with a few blood cells, was obtained on catheterization. There was an early sacral decubitus; consciousness was somewhat clouded. The man made no requests except for something to drink, and seemed apathetic.

Lumbar puncture, September 14, yielded hemorrhagic fluid. Three days later, the upper extremity regained its powers and sensations, but the paraplegia had become complete, with abolition of reflexes on both sides, and absolute anesthesia. The feet yielded formication at times, however. Sacral decubitus increased and healed not. The temperature varied between 38 and 39. The patient died September 24, in coma, with anuria and Cheyne-Stokes breathing.

Gunshot wound of spinal column; no penetration or injury of dura mater: At first quadriplegia; later cerebellospasmodic type of disorder.

=Case 375.= (CLAUDE and LHERMITTE, July, 1917.)

A soldier, 22, sustained a gunshot wound in the neck about the level of the fourth cervical vertebra. He immediately became quadriplegic. He recovered arm motion in two months and some weeks later ability to stand and walk.

Three months after the injury, station was difficult, better on a broad base. Rombergism, even with eyes open. Cerebellospasmodic gait. There was no weakness of leg muscles, but there was a certain degree of weakness of the upper extremities, especially in finger flexion. There was hypertonia of the muscles of all the extremities and the hands showed the signs of Raimiste, of Klippel and Weil, and of Dejerine. Static equilibrium was preserved to the will, but the kinetic balance was affected, and as much in the upper as in the lower extremities. Ataxia, tremors, dysmetria, adiadocho-kinesia, and disorder of combined movements in thigh and trunk flexion were all in evidence. Meantime, there was no disorder of sensation whatever except that the ulnar border of the right hand showed a hypobaresthesia, and there was a disturbance of tactile discrimination and absolute astereognosis in the hands. The deep reflexes were everywhere increased, and ankle and patellar clonus were easy to excite, especially on the right side. Bilateral defense reflexes. Bilateral Babinski sign. The hypertonia and ataxia ebbed away during the following three months. Walking became normal, and there was little sign of difficulty except astereognosis of both hands, combined with slight disturbance of deep sensibility and poor response to compass test in palm.

We here deal with a case of spinal column injury without injury to the dura mater. This cerebellospasmodic form of the superior cervical type of spinal concussion is less frequent than a quadriplegic form with Brown-Séquard syndrome. It is striking that both types of concussion may recover.

Spinal column trauma, with local signs: Later, hysterical anesthesia and contracture of back muscles homolateral with the trauma.

=Case 376.= (OPPENHEIM, July, 1915.)

A musketeer, wounded August 20, 1914, by a shell splinter in right side of vertebral column, fell unconscious, but was able afterward to crawl on all-fours out of the firing line. Severe vomiting and epistaxis followed. August 23, there was pain in the small of the back; the last two ribs were painful on right side; and the muscles were slightly swollen up to the iliac crest. August 30, a slight rise of temperature (at first it had been above 38) still persisted, but the muscular swelling was diminished. Treatment by aspirin and baths. No further rise of temperature after early in September.

On October 9, patient was permitted to get up, whereupon he showed a peculiar curved attitude of the body, reduced almost completely by passive straightening. Swelling of the longitudinal muscles. Radiograph negative, except that one picture showed a change in left twelfth rib, near the transverse process. Pains in left lumbar region.

November 19, on examination, pulse 112. November 23, after massage, vomiting. Temporary use of plaster corset.

On admission to the nerve hospital December 22, the musketeer was unable to extend the trunk, and the long muscles of the back were on the stretch, often as hard as wood, especially those of the left (longissimus dorsi). Patient lay on right half of pelvis. Hemianesthesia and hemianalgesia, left side. Tachycardia. Formerly the patient had done hard work, especially carrying heavy bags. He declined to be examined under general anesthesia. He seemed to be of unreliable character, and his trouble did not prevent him from returning from leave of absence, on one occasion, drunk.

Mine explosion: Combined hysterical and lesional effects.

=Case 377.= (DUPOUY, September, 1915.)

A lieutenant, 23, was in a mine explosion June 23, coming out in complete torpor, with mutism and retention of urine. He was brought to hospital June 26, with jactitation, irregular pulse, markedly exaggerated tendon reflexes, absent skin reflexes, sluggish, dilated pupils, especially right, and general anesthesia. The spinal fluid contained an excess of albumin, altered blood cells and many lymphocytes.

Several hours after puncture he suddenly demanded where he was, thought it was the year 1911 when he was in the Dragoons, talked about his camp, and was confused, irritable and stereotyped in questions. There was no verbal amnesia. Speech was hesitant, explosive and scanning, suggestive of multiple sclerosis. Next day there was still retrograde amnesia. He clung to the belief that it was July, 1911, and asked wearisome, stereotyped questions. The words, “German house” caused a jactitation, stiffening and relapse into a _second état_, out of which he came with hiccoughs and sighs, and amnestic for this conversation. There was general hypesthesia and muscular weakness especially of legs. The reflexes were as before.

The morning of June 28, he heard the hum of an airplane, whereupon his memory returned. It seems that he had himself once ascended. The memory gap was now limited to the time immediately preceding the mine explosion and the days following, up to the time of hearing the airplane. He told about his military life and also about incidents immediately preceding his blowing up. He complained of malaise and of pains in the vertebral column and limbs.

There was a quadriparesis, more marked, however, on the left; walking with falls to the left; astasia with left foot; double facial paresis; inability to whistle and to close eyes completely; intestinal and bladder paralysis; nocturnal emissions non-pleasurable; partial anesthesia of right leg, of arm and of hand, with hyperesthesia of thigh, of forearm and of the posterior aspect of the upper arm; anesthesia of the left side, including thorax and abdomen, excepting that the arm was hypesthetic only. Face hyperesthetic. Complete anesthesia of nipple and testis; hypesthesia of neck; anesthesia of tongue, nose and vertex; plantar, cremasteric, abdominal reflexes absent; exaggerated tendon reflexes; pupil reflexes normal; painful heat flashes and profuse sweating on the slightest movement; vertigo and tendencies to syncope after effort; explosive, scanning speech; intermittent convulsive movements of the arms. Palpation and X-ray show separation of the spinous processes of the third cervical vertebra.

Improvement was marked and progressive in motor, sensory and reflex fields. At the time of report three months later, there was a definite paresis of the left leg, with anesthesia and absent plantar reflexes, and slight paresis of the orbicularis palpebrarum, scanning speech and syncopal tendencies. Here, then, due to diffuse, non-systematic lesions, with superadded hysterical manifestations, were probably some effects of a permanent nature due to destructive processes.

_Re_ combination of functional and lesional effects, Sollier and Chartier state that in Shell-shock hysteria, physical causes and conditions are the chief factors; that in the so-called hystero-traumatism of Charcot, the psychic and physical factors are of virtually equal importance, and that in ordinary cases of hysteria, the psychic is the chief genetic factor.

Shell explosion: Hysterical and organic symptoms.

=Case 378.= (HURST, 1917.)

A champion heavy-weight boxer, 29, was unconscious for two days after being knocked over by the explosion of a shell in December, 1914. He found at first that he could not move the right arm or left leg; and after power had returned to the limbs, he had forcible involuntary movements in the left leg whenever he tried to stand. Examined, April 1, 1915, he answered questions slowly and with slow words; the right arm was weak. When the left hand was clenched, an associated movement took place in the right hand, but not vice versa. There was, however, no diminution in the girth of the muscles. The man was unable to localize light tactile stimuli accurately. Movements of the left leg were somewhat weak, the left knee-jerk was slightly brisker than the right; ankle clonus could be obtained on the left side and Babinski second sign (paralyzed leg rising higher than the normal leg in combined flexion of thigh and pelvis). When the man tried to walk, the left leg moved rapidly from side to side round the point of contact of the toes. When the right leg moved forward, the left dragged behind in irregular movement.

Every effort to cure the patient by means of suggestion during hospital care for a month entirely failed. Although the man was easily hypnotizable, he could not be made to move his leg under the deepest hypnosis. The first whiff of ether hypnotized him, so that the method of etherization could not be used in the endeavor to control the leg movements. Over a year later, July, 1916, the patient had greatly improved mentally but was otherwise in precisely the condition that is above described.

Gunshot wound of buttocks with injury to cauda equina: Urinary disturbance; decubitus; anesthesia. Superimposed paraplegia, regarded as functional and cured by psychotherapy.

=Case 379.= (OPPENHEIM, July, 1915.)

A German grenadier, October 11, 1914, was wounded in the left buttock by a missile that passed out through the right buttock. Pains in the abdomen and legs followed. The man had to be catheterized on the battle-field.

October 23, he suddenly fell down with total paralysis of both legs.

November 3, numerous small furuncles appeared on the buttocks, and bedsores developed. The patient lay helpless in bed, was unable to sit up without support, or to turn from one side to the other, and had areas of anesthesia.

During November and December, there was persistent high temperature, between 38 and 40; but January 3 the temperature stood at 36.6.

January 7 the patient was admitted to a nerve hospital. At this time he was able to pass urine unaided, though with tenesmus and pain, sometimes nausea and a tendency to vomit. He complained of pain in the back and pelvic region; the legs lay as if paralyzed. No active movement whatever was performed. There was a marked increase of tendon reflexes (even including the semi-membranosus). The muscles were relaxed through disuse but there was no atrophy. The patient moved his legs about with his hands. Sensibility was preserved except in the region of the pubis. The plantar reflexes were absent. Electrical reactions normal.

The diagnosis was functional paralysis of the legs (previous gunshot injury of cauda equina).

Treatment with psychotherapy met with prompt results; within a few days, the patient learned to move his legs and to walk with support, though making enormous efforts which threw the pulse up to about 160 and made the face congested. The bladder disturbance and the sacral anesthesia persisted.

Spinal concussion with spinal cord lesion: Thermanesthesia and analgesia of right leg and side.

=Case 380.= (BUZZARD, December, 1916.)

An officer was hit in the back by a shrapnel fragment, fell paralyzed, but after a few minutes was able to walk more than a mile to the dressing station. Eventually arriving in London, he had nothing to complain of except the wound, as the foreign body had been removed in France. The wound healed and the patient went to a convalescent home.

However, when taking a bath he could not feel the temperature of the water with the right leg. Muscular power was perfect; reflexes normal; but the heat, cold and pain sense was lacking in the right leg and the right side of the body from the seventh costal cartilage downwards.

One may make a wrong diagnosis of “Shell-shock.”

=Case 381.= (BUZZARD, December, 1916.)

In August, 1915, an officer was blown many yards by a shell, lay unconscious a while, could find no bruises, and carried on for twenty-four hours. Then, finding legs unreliable, he reported sick and was sent home as “Shell-shock.” He remained “Shell-shock” until February, 1916, then being able to walk five or six miles on smooth ground. Going downstairs he took the step with left foot rather than with right, and the right was apt to turn in. The sense of position and movement in regard to the right foot proved to be faulty. He could not balance himself on the right foot, nor could he appreciate tuning fork vibrations as well on this foot as on the other.

An X-ray examination showed a slight fracture, without deformity, in the left post-Rolandic region near the median line. His helmet had been bashed in at this point, and the bruised brain yielded symptoms even eight months later.

Retention of urine after shell-shock.

=Case 382.= (GUILLAIN and BARRÉ, November, 1917.)

An infantryman underwent shell-shock December 19, 1915, from the explosion of a torpedo nearby. He arrived at the ambulance, unable to speak, and next day had a confusional crisis of convulsions with contractures. He had not urinated since the accident, and two liters of clear urine were withdrawn by catheter; after which, the patient rested quietly and gradually regained consciousness. He was catheterized again in the evening and clear urine withdrawn. He remained unable to urinate spontaneously until December 25, and was catheterized accordingly.

There was no motor, sensory, or reflex disorder in this patient. Lumbar puncture yielded a normal fluid; the pupils were normal, and the only appearance was that of a marked asthenia.

Three months after his shell-shock, in March, 1916, the soldier was once more examined and still complained of headache, weakness, and inability to walk more than four or five hundred meters without a certain trembling of the legs. The reflexes remained normal and no further bladder trouble had supervened.

_Re_ anuria, Babinski remarks that, in days of yore, hysteria was supposed to be able to produce anuria as well as albuminuria, and even such organic changes as vesicles of the skin, ulceration, hemorrhages in the skin or of the viscera, fever, and even gangrene. He remarks that of late years no single identifiable case of this sort proved to be hysterical, has been reported. This is aside, of course, from such superficial and quickly passing vasomotor disorders as erythema and dermatographia. Anuria and albuminuria have consequently passed from the textbooks on hysteria, just as Babinski believes that hysterical edema and hysterical exaggeration of the reflexes are bound to pass. Hysteria cannot imitate everything; it cannot reproduce the characteristic phenomena of organic paralysis.

Retention of urine after shell-shock.

=Case 383.= (GUILLAIN and BARRÉ, November 1917.)

An infantryman, 27, underwent shell-shock August 16, 1916, at four o’clock, from the nearby explosion of a big shell. He lost consciousness for a period of ten minutes, was sent to the regimental aid post, and twelve hours later brought to a hospital center, in a state of profound muscular weakness. He could not walk although he could make every movement of the legs. There was a marked diffuse cutaneous hyperesthesia. The reflexes were normal; the pupils were unequal, the right myotic. The lumbar puncture yielded a clear fluid under normal pressure, but with an excess of albumin. For three days, retention of urine was absolute, requiring the catheter. There was neither sugar nor albumin in the urine withdrawn. On the fourth day he was able to urinate spontaneously; the asthenia and other symptoms had disappeared in two or three weeks.

Incontinence of urine after shell-shock and burial.

=Case 384.= (GUILLAIN and BARRÉ, November, 1917.)

An infantryman was subject to shell explosion and burial May 10, 1917. He lost consciousness for a few hours and spat blood for two days. He was carried to an evacuation hospital and thence to the neurological center at Amiens. Incontinence day and night lasted from the period of shock up to May 29, when the patient was transferred again, to another hospital. The man had never, either in childhood or adult life, had incontinence. He showed a slight tendency to latero-pulsion toward the left. Puncture fluid normal.

Guillain and Barré report but 12 cases of sphincter disorder following shell-shock without external wound among hundreds of cases, and among 12 instances of sphincter disorder there were but three of incontinence, of which the above is one example. Incontinence lasted longer in these cases than retention. Guillain and Barré are unable to assign a cause for the findings.

Struck in back by shell splinter: Crural monoplegia; absence of plantar reflex.

=Case 385.= (PAULIAN, February, 1915.)

An infantryman, 20, was struck by a shell fragment in the small of the back while lying in the firing position, about 2 P.M. August 22, 1914, at Eth in Belgium. He felt as if he had been struck by the butt of a gun in the lumbar region. He was unable to get back with his comrades. His sack had been cut. He was without ammunition, and getting to a bridge he was able to jump a distance of about 8 meters. He fell and fainted. On coming to himself, his left side felt bad and he could not move his left leg. He dragged himself to the relief post which was being bombarded just as he arrived, and he got a bullet in the left frontal region.

He was evacuated to another ambulance and decided to go back to France. Supported by his Lieutenant, he walked all night making about 35 kilometers on foot. He arrived at Charancy and got by train to Mont-Midi. On alighting, he could not walk. He said he was bent in two, and shuffled on in this position.