Part 47

The scalp movements were quick, affecting the fronto-occipitalis muscles as well as the auricular muscles. The displacement was from behind forward, and then from before backward, with slight oscillations of the ear; and at the same time, the forehead wrinkled or became smooth. The movement was involuntary and more convulsive than the somewhat similar movements that many persons can execute with scalp and ears. The phenomenon appeared after the shock for the first time. He had not noticed it himself but the physician at the ambulance had called his attention to it. The soldier was not disturbed by the matter, either at that time or later.

The diagnostician would consider, on the one hand, tic, and on the other, spasm. According to Meige, the man was a victim of tic. No case of such limited spasm appears to have been observed previously. However, the sudden development of these movements without previous history of tic renders the diagnosis somewhat doubtful. There was also a complete anesthesia to pin-prick in the present case over the whole right side of the scalp, face, and neck, even passing below to involve the chest, shoulder, back, and upper part of the right arm, with hypesthesia decreasing toward the nipple and the elbow. The soldier was quite ignorant of this sensory disorder and had never before been examined for sensations. The examination was made with due precautions to avoid suggestion. The question of anastomosis between the facial nerve and the auriculo-temporal branch of the trigeminus and the auricular branch of the cervical plexus, and of their relations to the anesthesia and tic of this case, is raised.

_Re_ pathological movements such as tremors, tics, and choreiform movements, Roussy and Lhermitte divide the tremors (see also under Case 337) into typical and atypical.

The atypical ones are either limited, or more usually generalized when they are merely parts of the Shell-shock syndrome. Sometimes the tremors are paroxysmal, aggravated by noises. Now and then, a condition of tremophobia appears (see Case 225). As for the typical tremors, see classifications under Case 337.

_Re_ tics, the tonic or postural tic is, according to Roussy and Lhermitte, much less common than clonic or spasmodic movements, which are Shell-shock phenomena like tremors and usually yield to psychotherapy if treated early. These tics are usually observed in and about the head, involving the sternomastoid, trapezius, and platysma muscles to produce clonic contractions of the neck. Other tics involve coarser head movements, nodding, eyelid and facial spasms, bilateral or unilateral, and shoulder movements. Babinski has suggested that some of the tremors are possibly due to organic disease, in view of the fact that they are not readily influenced by psychotherapy. Meige has suggested that some of the tics may also be in some sense organic. As for the differential diagnosis of tremor and tic, according to Roussy and Lhermitte, the Shell-shock onset may be an indicator. The non-rhythmic and irregular nature of the tic movements, and their exaggeration on voluntary movement, may be of some importance. Most of the tremors appear to be attended by a certain degree of permanent contraction of the muscle groups concerned. Tremors cease when these contractions disappear.

A point in treatment is that complete muscular relaxation should be obtained by having the patient open his mouth and breathe deeply.

_Re_ diagnosis of neurasthenia in this case, it may be inquired whether the term is properly used, and whether there is not some confusion here betwixt neurasthenia and hysteria.

_Re_ hyperalgesia, Myers states that about 25 per cent of his Shell-shock cases have shown a variety of disorders of the skin sense. Hyperesthesia and over-reaction is one phenomenon in the list, but is far less common than hyperesthesia. According to Myers, the hyperesthesia was more relative than absolute, and was probably due to increased affective response.

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

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

August, 1915, between Ypres and Flamentières, a Jack Johnson exploded one day about three o’clock in the morning near an experienced gunner, who had been on service in the R. F. A. for 15 years, and in France during the present war 10 months. He came to in the military hospital at Chatham, two weeks later, and was told he was lucky to be there at all as the shell had killed many comrades. He was transferred to Colchester, and thence to the Fourth London General Hospital.

Sitting in a chair, the man showed continuous rhythmic movements of legs, hands, and jaw, exaggerated when he was spoken to. The tremor was almost a clonic spasm. Every now and then, the patient would start and look sidewise and upwards, as if a shell were about to drop. Hyperacusis was such that the firing of the guns as far off as Woolwich alarmed him. In telling his story, he would repeat the same words over and over. He dreamt of shells bursting. His sleep was disturbed with groaning and moaning. The face was flushed, and the palms sweating. Because of the constant tremor, he could not stand or walk without assistance, and it was difficult to test reflexes. The tremor somewhat resembled the intention tremor of multiple sclerosis. He was unable to feel the prick of the needle on legs, left arm, or hand. He could not feel vibrations of the tuning-fork on feet, legs, or hands, though he could on the forehead. The fork was heard quite well six inches from the ears. There was some difficulty in recognizing colors. Bitter fluids could be tasted, but vinegar, salt, and various fluids, could not be recognized. He could not recognize tincture of assafetida, attar of roses, or oil of cloves, though nitrite of amyl, ammonia and glacial acetic acid were recognized.

Major Mott felt that, though this prolonged severe disease in a long-service man might possibly be related to some organic change in the brain, he might well treat him by suggestion. Major Mott told him that the careful examination just made showed that there was no organic disease, and made it certain that he would recover. In a fortnight, he sat in a chair without tremors and with a profound belief in Major Mott.

Hysteria as appendix to traumata.

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

A private, 25, something of a liar and of rather a low personality, had enlisted in the regular army in 1911, but deserted to become a football player. He reënlisted, and went to France in September, 1914, enjoying the first six months. He broke his ankles by falling into a deep dug-out, and got frost-bite. After three or four months in England, he found that he did not wish to go back to France. He was two months in barracks, and then went up the line in a good deal of a panic. Soon after, he was wounded in the thigh and was able to remain in hospital a fortnight, exposed, however, to shell-fire and given to starting at noise and occasional war dreams. Sent to his base, he remained jumpy and was now permanently afraid of the line. After three weeks in the trenches, he again got wounds, spent five months in England, came back to France in May, and fought till September, 1916. He tried to convince the medical officer that he had appendicitis and trench fever.

About the middle of September he saw with horror a man crushed by a tank, and thereafter was markedly affected by the sight of blood. Another slight wound sent him to a rest camp for two weeks, whence he was again thrown into the line, suffering acutely from fear and horror of blood. In three days he fractured his left collarbone and wrist. He gave a pint and a half of blood for transfusion purposes, and in turn was shipped to England. On removal of the splint, he found “probably not without satisfaction” that the arm was paralyzed. It remained paralyzed for five months, until treatment in a special hospital eventually cured the arm; but upon cure of the arm, nightmares developed,--an indication, according to MacCurdy, of the strong resistance he felt to the idea of returning to the front.

Neurasthenic hyperalgesia after peripheral nerve injury.

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

A German volunteer, a sportsman, was under heavy shell fire after the middle of October, 1914, and was wounded in the upper arm in November, with an injury to the median nerve that occasioned severe pain. These strictly localized pains increased upon any sort of physical or mental strain. If he walked down steps he kept thinking he might have an accident, and then the pains set in with greater force. He became apathetic so that he did not eat, drink or urinate. If his head were touched he felt pain as if from an electric shock. He also felt the pain when he saw anybody approaching a door to close it, through apprehension of the noise. Meantime, the wound was well healed. The pulse was accelerated. The visual fields were only slightly contracted. The patient wanted to get well and go back to the service.

Weygandt regards this hyperalgesia after peripheral nerve injuries as neurasthenic.

Military training: Peripheral neuritis in lead workers.

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

Among fourteen cases of lead poisoning, members of the territorial forces, largely from North Staffordshire, was a patient suffering from peripheral neuritis. He had been in the dipping-house. Two years before going into the service he had been suspended for lead poisoning by the factory surgeon. Giving up his work at the pottery, he became a general laborer in a non-lead process factory.

Three weeks after enlistment, the man began to complain of pains, tenderness in the arms, weakness of the wrists, headache, giddiness, nausea, and constipation. The bowels were opened by a large dose of epsom salts. On blood examination the hemoglobin was found diminished 40 per cent; cells with basophilic granules were found to the number of 500 per cu. mm. The face was characteristically pasty. There was albuminuria. Alcohol could be excluded. The man had to be discharged.

All Shufflebotham’s cases occurred from three to seven weeks after mobilization, nor have any cases ever been reported in territorials after their annual training. Constipation was invariable. In two cases returned to service, there was a recurrent attack. An epidemic could be excluded. Shufflebotham suggests that the altered conditions of life, especially the marching and drilling, caused increased metabolism, setting free lead compounds from the muscles and organs of the body. It is true that a glost placer always works very hard with his muscles, but not with the muscles used by the soldier.

“Peripheral neuritis” cured by faradism.

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

A Naval Service man, 20, was thought to have peripheral neuritis. A long history of pain and numbness in arms and legs, a well-marked analgesia and anesthesia over the anterior aspects of forearms and legs, and an anesthetic band across the front of the chest, seemed consistent with the diagnosis. The calf muscles tightly squeezed yielded no pain. Pins could be thrust without pain into the anesthetic areas. When told to say _yes_ when the pin was felt, and _no_ when it was not felt, the man persistently said _no_ when the areas noted above were touched. The deep reflexes were normal. Faradism by wire brush at two sittings yielded a complete cure. It seems that once this man, after seeing his sister fall in a fit on returning from a funeral, retired to the garden and had a similar fit himself.

Cargill found in 1052 sailors fifteen cases of total absence of one or both ankle-jerks; seven of the fifteen were probably cases of tabes.

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

_Re_ differential diagnosis between peripheral neuritis and reflex (physiopathic) paralysis, Babinski and Froment offer the following table:

_Peripheral Neuritis._ _Reflex Paralysis and Contracture._

1. Motor disorder, degenerative 1. More or less segmentary amyotrophy, and sensory disorder topography. corresponding topographically to anatomical distribution of nerve (neuritic) topography.

2. Amyotrophy very pronounced, 2. Amyotrophy variable; regardless of localization. ordinarily well-marked but not so severe as that of neuritis.

3. Reaction of degeneration, especially 3. Reaction of degeneration weakening or abolition of faradic absent, never marked excitability of muscles. weakening of faradic excitability, which is often normal and may even be exaggerated.

4. Tendon reflexes, corresponding to 4. If reflexes are altered, the muscular territory of the they are as a rule nerve, weakened or abolished. exaggerated and never abolished.

Multiple wounds; signs of late tetanus 7-8 weeks later: Pain and contracture of neck, tetanic, 14 weeks after trauma. Dysentery. Recovery.

=Case 419.= (BOUQUET, 1916.)

A soldier invalided for endocarditis July 8, 1908, went back to the colors on his own request August 8, 1914. He was wounded at noon September 6, 1914, in the attack at Abbaye Woods. He lay in the woods, with several comrades as badly wounded as himself, until September 10, eating berries and drinking rain water. He had five wounds in all; in left lower leg, thigh, left external malleolus, right calf, and left forearm. Moreover, he had dysentery.

He was picked up by the Germans September 10 and carried by them to the ambulance at Saint André, where he was given belated first dressing. When the enemy retreated September 12 he was left behind and finally carried back September 13 into the French lines by a French physician who had been a prisoner likewise. A second dressing was given September 14 at Rambluzin. He was then carried in a sanitary train to Bar-sur-Aube, where, September 15, injection of antitetanic serum was given. He left Bar-sur-Aube on December 18, 1914, practically cured, though one of the wounds still needed care. The dysentery was still present and walking was difficult. He was then cared for at Auxiliary Hospital No. 102 in Paris.

It seems that about six weeks after his entrance in the hospital at Bar-sur-Aube he had had some difficulty in opening his jaws, with acute pains at the temporomaxillary joint. Similar pains appeared a few days later in the neck, with a sensation of stiffening. The jaws still opened easily enough December 18, yet the man got pains in his jaws as soon as he began to speak. The pain and contracture in the neck region were sharp and permanent. Sometimes the contracture got more marked, and the board-like muscles could be felt stiffening under the examining finger. During such crises the patient had to lie or sit down. Sometimes the pains descended below the shoulders along the vertebral column. The crises occurred more often in the night, in bed.

The diagnosis of late tetanus was made, and alcohol rubs were given. The phenomena gradually disappeared. The dysentery also had not yielded to therapeutics until eight or ten days before the patient left the hospital. There was still, at the time of report, a certain difficulty in walking, with a tendency to use the external border of the left foot rather than the sole.

Shell-shock: Spasmodic neurosis and neurasthenia. Treatment without great success.

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

August 19, 1914, a shell exploded very close to a soldier, whose bread bag, cartridge container, and field flask were pulled away from him, but who was not himself wounded. He fell down. Shortly developed headache, vertigo, palpitation. In running he fell down repeatedly. Spasms soon appeared in the legs. He had previously suffered from gastric disturbances, and heavy food did not agree with him.

At the time of admission to hospital he complained of great irritability, nervous twitching, formication in his limbs, war dreams, tachycardia. The heart boundaries were normal. The muscles of lower extremities were attacked by tonic spasms, and felt board-like. This tonic spasm occurred on each attempt at motion, very gradually disappearing when at rest. Passive movements also had the same effect. Fibrillary tremor affected the left quadriceps. On each attempt at motion, pains were felt in the legs. At first the cramps were so severe that all locomotion or even standing was impossible.

Treatment: Cold-water pack (Priessnitz), hyoscin injections, magnesium sulphate injections (5 to 10 c.c. of ten per cent solution), perineural injections, lumbar spinal analgesia,--all without success. Fibrillary tremors persisted in the quadriceps and in the extensors of the toes. The tonic spasms on increased attempts at motion became combined with clonic twitchings. From the end of November on the patient made attempts to walk with straddling legs, and under considerable vibratory tremor. Picture of severe crampus-neurosis, combined with neurasthenia gravis.

CHART 13

SHELL CONCUSSION

CAUSE PHYSICAL FROM EXPLOSIVES--AMNESIA FOR SHELL EPISODE AND FOR A SUBSEQUENT PERIOD--FOLLOWED BY TRAUMATIC NEUROSIS

SHELL HYSTERIA

SHELL HEARD--VICTIMS ALREADY UNSTABLE--RUM ISSUE PREPARATORY?--OVEREMOTIONALISM--SENSORY AND MOTOR DISORDER

SHELL NEURASTHENIA

HEADACHE, DIZZINESS, INSOMNIA, ANOREXIA, VISCERAL PAIN--VICTIMS, OLDER MEN

After H. P. Wright

(_a_) Bullet-wound of forearm: Combination of hysterical (brachial) monoplegia, and reflex (physiopathic) disorders. (_b_) Refrigeration: Combination of hysterical paraplegia and reflex (physiopathic) disorders.

=Case 421.= (BABINSKI, 1916.)

The forearm of a soldier was pierced in its lower part by a bullet, which produced no lesion of large nerve trunks or blood vessels. A complete brachial monoplegia followed. Every movement of the different segments of the arm was abolished. The hand and forearm were slightly atrophied, and were of a reddish salmon color. The temperature of the affected hand and forearm was about three or four degrees lower than that on the other side. The sphygmometric oscillations of the forearm were twice as small in the paralyzed limb as in the healthy limb, but the systolic blood pressure was normal. There was a mechanical over-excitability of the muscles, and a slight exaggeration of the bone and tendon reflexes. The paralysis was in part of reflex (physiopathic) nature. On account however, of the completeness of the monoplegia, and the fact that the reflex paralyses as a rule affect only the distal portion of the limb, the diagnosis of hysteria had to be made in addition to the diagnosis of reflex disorder.

As a result of freezing, this patient had also a complete crural paraplegia. He showed vasomotor disorders and hypothermia of both feet, together with mechanical over-excitability of the muscles; and these latter disorders appeared to be of a reflex nature. The paraplegia, however, was of a hysterical nature.

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

Differential diagnosis of organic (central) monoplegia and reflex (physiopathic) contracture and paralysis. (Babinski-Froment.)

_Organic Monoplegia_ _Reflex Contracture and Paralysis_

1. Paralysis often affects the 1. Paralysis almost always partial. whole extremity, either arm In arm paralysis, affects as a or leg. rule fingers and hand. The leg is often affected at its origin, and then only partially.

2. After several weeks of flaccid 2. Paralysis may remain flaccid for paralysis, as a rule contracture a long time, and frequently occurs. coexists with contracture, hypertonicity and hypotonicity of different muscular groups.

3. The upper extremity shows flexion 3. The upper extremity in with clawhand. The lower hypertonic cases often shows the extremity shows contracture of _main d’accoucheur_, the _main extensors. The patient walks en bénitier_ (holy-water vessel throwing his leg sidewise hand), the _doigts en tuile_ (_Démarche helicopode_). (crowded fingers). The lower extremity does not exhibit the sidewise movements.

4. Tendon reflexes, a few weeks 4. Reflex status variable. after paralysis begins, Hyperreflexia often absent even exaggerated. in hypertonic forms.

5. Babinski sign in crural 5. Babinski sign absent. The skin monoplegia. reflex may be abolished but may be reproduced on warming the foot.

Slight bullet wound of hand: Flaccid paralysis with vasomotor and thermic disorder. A case “non-organic” in the ordinary sense and non-hysterical, _i.e._, reflex or physiopathic.

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

Struck by his observations upon the persistence of tendon reflexes in narcosis in a wounded soldier, Babinski continued observations in the same general direction in a case which may be termed briefly one of hypotonia of the extensors of the hand following the passage of a bullet through the arm without nerve trunk lesion.

This patient had flaccid paralysis of hand and fingers following wound in second dorsal interosseous space and vasomotor disorder and local hypothermia in the hand. There was a slight diffuse atrophy of the muscles of the hand, forearm, and arm; but this atrophy was not systematized, and there was no R. D. The tendon reflexes of the extremity were preserved. There were no signs of organic disease of the central or peripheral nervous system; that is, in the ordinary sense of these terms.

Was it a question of hysteria or of simulation?

Babinski was struck by the following symptoms:

First, the remarkably intense hypotonia, especially noteworthy in the thumb, a hypotonia quite equal if not superior to that observed in paralysis following marked nerve lesions;

Second, mechanical over-excitability of high degree in the muscles of the hand and forearm, with retardation of the muscular response; and

Third, electric over-excitability of the muscles, with what Babinski calls “anticipated fusion” of the faradic reactions.

It appears that this patient had been wounded in September, 1914, and that the paralysis had developed five months later. Before the development of this paralysis, there had been simply a meiopragic state.

Without perforating the hand, the bullet had remained in the wound, being excised therefrom three months after the trauma.

In January, 1916,--that is, some sixteen months after the injury and eleven months after the recovery of the paralysis,--the vasomotor disorder and the hypothermia, and the faradic, voltaic and mechanical over-excitability of the hand and forearm muscles, were in evidence. Hypotonia was marked, permitting an overflexion of the hand upon the forearm. If the patient moved his forearm, the affected hand would hang and oscillate inertly; likewise in walking, seeming to obey only the laws of physics.