Part 7

A soldier in the Territorial Infantry, 42, a gardener who went to taverns, as he said, “like everybody else,” a widower with two children, a good worker though irascible, had had syphilis as a youth. He was called to the colors at the outbreak of the war and got on well despite tremendous strain. March 9, 1915, he was in a bayonet charge with his regiment and was bowled over by a shell of which a fragment wounded him above the knee and several fragments in the thorax. All these fragments were extracted at a temporary hospital, March 11. The man now became strange, refused to obey orders and did a number of peculiar things so that he was sent to Orléans temporary hospital whence he was evacuated to Fleury Asylum, March 19. He refused to give up his things because he was the master. He did not want to go to bed and wanted to keep on walking constantly. He was without sense of shame, satisfied with himself, grandiose as to his millions in bank and the thirty-six decorations he believed had been awarded him. He mistook the identity of the landscape and of the people about him.

Tongue tremulous; pupils unequal; knee-jerks exaggerated; dysarthria; gaps in memory. In May occurred a number of violent reactions.

In June, however, there was a remission; the ideas of grandeur disappeared first, then the tremors and reflex disorder and finally the speech disorder. There was a slight seizure at this point and the man said he had had another such just before he came to the army. July 20 he was invalided out much improved.

In this case of general paresis there is, besides the syphilis, also alcoholism to consider, so that it is not entirely plain that the exertions of campaign liberated the paresis.

_Re_ wounds and paresis, see also Case 5 (Beaton), in which neurosyphilis advanced rapidly from the time of a trivial injury.

Shell-explosion: Syphilitic ocular palsy.

=Case 19.= (SCHUSTER, November, 1915.)

Schuster notes briefly a curious result of the explosion of a shell, which caused the patient in question to lose consciousness. Shortly after the explosion, the patient came to his senses again, but a surprising paresis of the eye muscles had developed. This paresis looked precisely like a syphilitic paresis clinically.

Examination of the blood serum yielded a strongly positive Wassermann reaction.

According to Schuster, the explosion of the shell had brought about hemorrhage in vessels supplying the region of the eye muscle nerves or nuclei. The reason for the selection of these vessels for rupture due to shell explosion is, according to Schuster, that the vessels were probably already syphilitically diseased.

_Re_ hemorrhages in the neighborhood of the oculomotor nuclei, the phenomena of polioencephalitis may be recalled. In that disease, the predisposition to hemorrhage is presumed to be alcoholic, as the cases of ophthalmoplegia of this group almost always appear in alcoholics. However, the first case of hemorrhagic superior polioencephalitis was a non-alcoholic one of Gayet (1875), in which the symptoms followed three days after a boiler explosion.

A tabetic lieutenant “shell-shocked” into paresis?

=Case 20.= (DONATH, July, 1915.)

An apparently competent German professor in an intermediate school, a lieutenant of infantry reserves, 33 years old, on the 17th August, 1914, was stunned for a while by the shock of a cannon-firing 25 feet away. Urination became difficult. Headaches and limb pains ensued, with paralysis of fingers, gastric troubles, forgetfulness, especially for names, insomnia, and general scattering of mental faculties.

Neurologically, the pupils were irregular, left larger than right; Argyll-Robertson reaction. Right knee-jerk livelier than left. Achilles reactions absent. Slow and dissociated pain reactions in feet, lower thighs and lower quarter of upper thighs, with hypalgesia or analgesia. Station good; gait steady. Mentally depressed, slow of thought. Speech poor and of indistinct construction (mild dementia). Calculation ability poor. No pleasure in work.

Wassermann reaction of serum weakly positive.

It seems that for a year the patient had been subject to spells of anger. He was irritated by his wife who had been nervous since an earthquake.

_On the occasion of the earthquake_, 1911, the patient himself had had a spell of _difficulty with urination_. The spell had lasted two or three months. The patient had had a chancre in 1902, “cured” in four or five weeks with xeroform. In 1908, when about to marry, he had had six mercurial inunctions.

_Re_ tabes, Lépine shows that tabetics are numerous. They are numerous among officers and also in the auxiliary service, in which latter tabetics are maintained on desk duty. Perhaps they had been admitted to such work as unable to march or fight, on the basis of having had so-called “rheumatism.”

Shell-explosion may precipitate neurosyphilis in the form of tabes dorsalis.

=Case 21.= (LOGRE, March, 1917.)

An artilleryman, 38, had a large calibre shell explode very near him and afterward could not hear the whistle of a shell without falling down in a generalized tremor, sweating profusely, urinating involuntarily, in a mental state approaching stupidity. Here was a case that might be regarded as one of morbid cowardice in a psychopath, following violent emotion.

The artilleryman proved to be a victim of tabes and of general paresis. The incontinence of urine under the influence of emotion was nothing but an effect of tabetic sphincter disorder. The crisis of cowardice proved nothing but an initial symptom of general paresis.

Shell-explosion; burial: Tabes dorsalis incipiens.

=Case 22.= (DUCO and BLUM, 1917.)

A French soldier was buried by effects of shell explosion September 8, 1914. He sustained no wound or fracture.

Incontinence of urine developed. Anesthesia of penis and scrotum. Reflexes absent; pupils sluggish. Wassermann reactions suspicious.

The diagnosis =tabes dorsalis incipiens= was made (hematomyelia of conus terminalis eliminated).

The patient was estimated to be “40% incapacitated,” according to the French “_échelle de gravité_” of conditions. A full pension would not be justified in the opinion of the French authors.

SHELL-SHOCK PSEUDOTABES (non-syphilitic, serum W. R. positive). Improvement.

=Case 23.= (PITRES and MARCHAND, November, 1916.)

Innkeeper B., 36, a shell-shock and burial victim June 20, 1915, was looked on by a number of physicians as a case of genuine tabes.

Even eight months after the episode, he still showed (when observed by Pitres and Marchand, February 3, 1916) absence of knee-jerks and Achilles jerks, a slight swaying in the Romberg position, pupils sluggish to light, incoördination, delayed sensations. There was also a history of pains in the legs, compared by the patient to those of sciatica. These pains came in crises, the longest of which had lasted 30 hours.

It seems that this soldier’s troubles began the day after his shock with a feeling of swollen feet and of cotton wool under them. He stayed on service, however, walking with increasing difficulty.

At the time of his evacuation, July 10, he could walk with great difficulty. “Strips of lead were between his legs.” He could hardly control movements in the dark, or descend stairs. Often his legs would bend under him. Vesical function sluggish.

After a few months the patient could walk better. In February, 1916, he walked thrusting his legs forward trembling, and dragging toes a little. He could not support himself on either leg. Jerkiness and incoördination in extension or flexion of leg on thigh.

The muscular weakness was decidedly against tabes or at all events a pure tabes. The incoördination proved to be due, not to loss of position sense (which was intact) but to unsteady muscular contractions. Deep sensibility was intact.

There were no mental symptoms. There was a slight hesitation in speech and doubling of syllables, but nothing demonstrable with test phrases.

The serum W. R. was positive.

Shell explosion; unconsciousness: Neurosyphilis.

=Case 24.= (HURST, April, 1917.)

A private, 31, was in the retreat from Mons, was blown up by a shell and buried in May, 1915, went back to the front after two months leave, was knocked unconscious by a shell December, 1916. He came to himself two days later in the hospital, but remained confused and lethargic. In England, December 21, his legs were still weak and walking was unsteady. The right pupil reacted neither to light nor to accommodation and was irregular, eccentric, and dilated. The left pupil showed the Argyll-Robertson reaction. There was early primary optic atrophy. The right knee-jerk was slightly exaggerated. The vibration sense was reduced over sacrum and malleoli. At this time the man’s mental condition was practically normal.

The Wassermann reaction of the serum and spinal fluid proved positive. Improvement followed rest, iodide, mercury, and seven injections of salvarsan. By the middle of February he was able to walk well. The right pupil regained its power to react to accommodation, but remained inactive to light. Meanwhile, the left pupil had regained a slight power to react to light.

_Re_ treatment of syphilis, both Thibierge and Lépine give warning of some bad results with arsenobenzol treatment, though Thibierge states that the number of serious accidents and especially of deaths has diminished more and more now that no arsenobenzol (drug No. 914) is given. Encephalitis is the gravest of the untoward results of injection, sometimes appearing in young and vigorous subjects. Hemorrhagic encephalitis appears to occur more frequently after the second injection than after the first, and according to Thibierge may be especially suspected in subjects who after the first injection present much fever, congestion of face, and cutaneous eruptions. Treatment in these cases should be suspended or given in moderate doses.

Shell-explosion: Neurosyphilis. Fit for light duty.

=Case 25.= (HURST, April, 1917.)

A corporal, 26, blown up by a shell December 7, 1916, was admitted to the hospital on the 13th, dazed and with symptoms of a left-sided hemiplegia of organic origin. The right pupil was larger than the left. There was a bruise of the scalp in the right parietal region. The man had had syphilis at 16. The Wassermann reaction of the serum was strongly positive. Rest, salvarsan, mercury, and iodides were given, and the general symptoms and hemiplegia gradually disappeared, until on December 12 there was only a moderate weakness of the left side, with knee-jerks in excess, abdominal reflexes absent, and the Babinski reaction.

The Wassermann reaction was still strongly positive. Salvarsan, mercury, and iodide were continued. January 6, 1917, the plantar reflex had become flexor. The abdominal reflex returned. Babinski’s second sign (combined flexion of thigh and pelvis) was now the only evidence of organic disease. Further antisyphilitic treatment removed this sign also. February 28, the man was discharged fit for light duty, with unequal pupils and positive Wassermann reaction, and a complete amnesia for the four weeks following his blowing up in the trenches.

_Re_ fitness for light duty, see remarks on Case 20 concerning desk duty for certain tabetics.

_Re_ the premature or unexpectedly early appearance of neurosyphilis under war conditions, the early claims of some authors have not been maintained. In the above instance, the infection was at 16 and the shell explosion occurred at 26, namely, at about the right interval for the development of neurosyphilitic signs. Gerver states that military service brings out the lesions of paresis earlier than they would otherwise come. Bonhoeffer has been unable to show that cerebrospinal syphilis is favored in its development by the exhaustion factor.

SHELL-SHOCK PSEUDOPARESIS (non-syphilitic). Recovery.

=Case 26.= (PITRES and MARCHAND, November, 1916.)

June 19, 1915, a shell exploded some distance from Lieutenant R. He remembers the gaseous smell, the bursting of several shells nearby and a sensation of being lifted into the air. When he recovered consciousness, he was in hospital at Paris-Plage, covered with bruises and scratches. They told him he had been delirious and had vomited and spat blood.

June 24, his wife came to see him, but this visit he could not remember. Nor could his wife at first recognize him, he was so thin. He roused a few moments and recognized his wife, but relapsed into torpor again. Speech was difficult and ideas confused.

A few days later he was able to rise; but his mental status grew worse, especially as to speech and writing, the latter quite illegible. There was insomnia, or, if he slept, war dreams.

August 7, he began a period of five months’ convalescence passed with his family, depressed, given to spells of weeping, confined to bed or couch, unable to “find words,” conscious of his state and troubled about it, speaking of nothing but the war, and afraid to go out for fear of ambuscade. There was at first a slight lameness of the right leg. Although he could walk, he felt pain in the knee on flexing the right leg on the thigh. He walked holding this leg in extension.

On going back to the colors, he was immediately evacuated to the _Centre Neurologique_ at Bordeaux, January 20, 1916.

Examination found a bored, impatient, irritated man, vexed that a man who was not sick should be sent up “_comme fou_.”

Omitting negative details, neurological examination showed slight lameness as above, body stiff and movements jerky, difficult, unsteady gait. The lieutenant could stand for some time on either leg. Tongue and face tremulous during speech. Limbs moderately tremulous, especially in the performance of test movements.

Knee-jerks and Achilles jerks absent. Other reflexes, including pupillary, normal. Segmentary hypalgesia of right leg, especially about knee. Tremulous speech and writing. Patient would stop short in speaking for lack of words.

Malnutrition. Appetite good, but a bursting feeling after meals.

Skin dry, scaly on legs, fissured on fingers.

Serum W. R. negative. Fluid not examined.

=Mental examination.= Conscious and complaining of his troubles, Lieutenant R. claimed persistently that he was not sick. Memory for recent events was in general poor. Errands easily forgotten. Lost in the street. Complaint of corpse odors round him. Everybody is looking at him and making fun of him. He was apt to insult bystanders. He was afraid of German spies. Things in shops angered him as they seemed to him to be of German manufacture.

There were frequent periods of depression, with pallor and no spontaneous speech for some hours to a half-day. Headaches coming on and stopping suddenly.

As to diagnosis, the first impression, say Pitres and Marchand, was that of general paresis. The progress of symptoms after the shock was consistent with this diagnosis. The mental state and the physical findings seemed consistent, although the pupils were normal. His partial insight into his symptoms was not inconsistent with the diagnosis. He had a characteristic self-confidence. There had been four stillbirths (two twins); two children are alive, 11 and 13. Typhoid fever at 30. Syphilis denied. No mental disease in the family.

The patient had never done military duty, having been invalided for “right apex.” But he had volunteered and been accepted in September, 1914.

How was Lieutenant R. cured? Apparently by rest in the _Centre Neurologique_. Pitres and Marchand do not speak of the subtle relation between mental state and the idea of non-return to military service. This motive might still work even if Lieutenant R. kept protesting sincerely that he wanted to go back into military service.

War strain; shell explosion; unconsciousness. Sensory and motor disorders. Subject an old syphilitic.

=Case 27.= (KARPLUS, February, 1915.)

A captain, 34, was under much stress and strain in the field and gave himself over to excesses of alcohol and tobacco. August 25, 1914, at the Krasnik battle he suddenly saw at his right a gleam of fire and was afterward able to remember very distinctly the words of a lieutenant standing near by, “The man is dead.” Three or four hours later he came to himself at a relief post, vomited and bled a good deal from nose and mouth. He heard later that he had been thrown on his back.

Manual tremors and general pains developed in the next few days. Two weeks after the accident a slight nystagmus on looking to the left appeared, but there was otherwise no disorder of head or extremities. He was able to sit up, supported by his arms, and he was able to contract his abdominal muscles normally. As for his legs, active movements were limited and weak. He could not lift his legs. The paralysis was more marked distally. He could walk with the support of two persons, but was unable to lift his feet from the ground. The right upper abdominal reflex was elicited, and both patellar reflexes were tolerably active. Cremasteric and plantar reflexes were absent. Neither of the Achilles jerks could be produced. There was hypesthesia and hypalgesia of the lower extremities, and of the back up to a horizontal line corresponding with the ninth dorsal segment; thermo-hyperesthesia and disorder of vibration sense in the lower legs. Both the motor and the sensory disorders were more marked on the right than the left. Insomnia and battle dreams.

The gait disorder and paresis gradually improved. There was no alimentary glycosuria and adrenalin produced no mydriasis. In the course of several weeks the patient gained seven kilograms, began to sleep well and showed gradual improvement in his gait and in the execution of various movements with his feet. The abdominal reflexes were now both present, but there were no plantar reflexes and the Achilles were still both absent. The sensory disorder remained unchanged, so far as the skin was concerned, but the deep sensibility improved. Both legs from the knee down were somewhat cold.

This man had had syphilis at twenty-two, had gone through an inunction cure, and repeated W. R.’s came through negative. He had suffered from vomiting spells and anxiety feelings for a number of years which had been diagnosed by physicians as cardiac neurosis. Yet for a year before going into the war he had felt absolutely well.

Shell-explosion: Amnesia; syphilitic hemiplegia. Recovery except for amnesia as to brief period and loss of occupational skill.

=Case 28.= (MAIRET and PIÉRON, July, 1915.)

A man of 40 underwent shell shock June 15, 1915, and had no remembrance of what happened up to July, 1915, when in hospital at Tunis he felt “born again.”

Examined in January, 1916, it was found that he had a left hemiplegia (in fact, he had a syphilitic hemiplegia on that side, several years before, which had disappeared under antisyphilitic treatment). This hemiplegia passed, but he then had crises of depression due to his despair at not being able to know who he was and what he was doing. He could speak French and Spanish, and knew from the hospital ticket that he was born in Spain; but he had no idea what had happened to his relatives or what he was doing in France. He had, however, a very correct idea of what happened during six months after July, 1915.

One morning in April, 1916, his old memories came back all of a sudden on waking. The gap was filled up to the moment of the shock. There was no gap left except for a period of about 25 days following the shock. He now found that he knew a little English but that he had lost his stenography as well as his professional skill at typewriting.

_Re_ French statistics for the occurrence of general paresis, Lautier found 27 cases in 426. Early in the war, Boucherot at Fleury received four cases of paresis among 107 cases; the majority of these, however, had not left the interior. Consiglio in Italy received two cases out of 270.

_Re_ hemiplegia in this case, it may be inquired whether the hemiplegia which developed after the shell explosion on the same side of the body on which the patient had a true syphilitic hemiplegia, was really syphilitic or not. Was it not, perhaps, in some sense psychogenic? A similar question may be raised concerning cases in which the _locus minoris resistentiae_ becomes the site of symptoms. See Cases 409-414.

Shell-shock: Hysterical blindness. Signs of cerebrospinal syphilis: Nevertheless, amaurosis functional.

=Case 29.= (LAIGNEL-LAVASTINE and COURBON, March, 1916.)

A soldier of the class of 1906 underwent shell-shock August 13, 1914, regaining consciousness 20 days later, but blind. The light of the shellburst, he said, was the last thing he had seen.

For sixteen months, he was transferred from hospital to hospital, looked on sometimes as blinded; sometimes as feigning. Finally, on the isolation service of Maison-Blanche, December 15, 1915, he received an ophthalmologist’s diagnosis namely, hysterical amaurosis. At this time there were found: stereotyped winking, with slight lachrymation, a slight left external strabismus, limitation in movement of all the extrinsic muscles of both eyes, especially to the right and in convergence and elevation; pupils slightly smaller than normal--and the general impression of a genuinely blinded or amblyopic subject. He seemed to be able to distinguish faint whitish spots, without contour or color, in objects brought to a distance of at least 40 cm.

He also complained of bad feelings inside his head on the left side, and he proved to have a left-sided hemianesthesia of hysterical nature. There were no other sensory disorders and no reflex disorders.

The nasolabial fold on the left side was flattened out, and there was also on the same side a slight diminution in the lower abdominal skin reflexes, and no response to plantar stimulation. Examination of the mouth showed leucoplakia, and the history showed that the man’s fifth child was born before term and died at two months. Lumbar puncture yielded lymphocytosis (55 cells) and an excess of albumin. The fundus examination showed a slight papillary disorder, suggesting a retrobulbar affection of the optic nerves.

However, the preservation of the pupil reflexes seemed to indicate that nine-tenths, at least, of the amaurosis was functional. After mercurial treatment the headache grew less and the man was able to see somewhat better with his right eye.

Laignel-Lavastine and Courbon suggest that there was a dynamic disorder in this case, bearing the same relation to vision as mental confusion bears to the process of ideation. Analogous phenomena have been found in the sense of hearing, in such wise that the victims can, as it were, passively hear but do not listen.

_Re_ functional eye cases, see below, especially Cases 432-437.

Shell shock (functional) phenomena in a syphilitic.

=Case 30.= (BABONNEIX and DAVID, June, 1917.)

A marine, 26, on land service March, 1916, was buried by the explosion of a large calibre shell which killed most of his comrades. He remained for a time in a sort of lethargy. Coming to, he found himself victim of a right hemiplegia and deafmutism, which phenomena vanished under electricity.

In July, however, he had to be sent to a hospital on account of his sufferings, which received the diagnoses _commotio cerebri_, disorder of consciousness, disorientation, delirium, amnesia, over-emotionality. He was sent back to the front in December, 1916, but promptly reported sick, with headaches and insomnia.