Bombardment; shell explosion nearby: Mania; death in 24 hours. The AUTOPSY showed superficial punctate hemorrhages of brain and congestion of pia mater. CAUSE OF DEATH—small bulbar hemorrhage, congestion of veins, and nerve-cell changes of a local and differential nature (chromatolysis of vago-accessorius nucleus). SHELL-SHOCK SYMPTOMS due to capillary anemia and chromatolysis of various regions.
Case 197. (Mott, November, 1917.)
A soldier became rather nervous at the Somme, and later underwent intense bombardment for some four hours, February 22, 4 to 8 P.M. Although he said he “could not stand it much longer” he carried on for twelve hours more when perhaps six shells went over, February 23. One of the shells burst about ten feet away, just behind the dugout. The first day of the bombardment he was tremulous and depressed; later coarsely tremulous in the limbs. February 23 there was crying and inability to walk or do any sort of work. Questions were not answered. The pupils were dilated. The evening of February 23 the man was admitted to the field ambulance in acute mania, shouting: “Keep them back! Keep them back!” He was quieted with morphine and chloroform and slept well during the night. There were at least two hypodermic injections of morphine in the ambulance. He woke up the morning of February 24 apparently well, but suddenly died.
The autopsy showed small scratches on the anterior chest wall, but otherwise no sign of external violence. Both lungs were edematous; the left lower lobe showed a considerable hemorrhage. The heart was enlarged and the right side dilated. The liver was somewhat congested. The kidneys were small, but otherwise showed no gross change (urine without sugar or albumin).
Chart 7
EFFECTS OF HIGH EXPLOSIVE SHELLS
- EMOTIONAL
- COMMOTIONAL
- LESIONAL
After Vincent and others
Chart 8
The scalp showed a slight frontal bruise. The brain was extremely congested. On each side of every superficial vessel there was an ecchymosis. A number of minute punctate hemorrhages was found on the surface of the brain in connection with very small vessels. The brain substance was soft, but not markedly edematous. The cerebrospinal fluid was tinged with blood. On each side of the great sinuses of the skull there was considerable ecchymosis. This examination was made by Capt. A. Stokes, R.A.M.C., in the mobile laboratory. There were no areas of large hemorrhage anywhere in the brain substance and no smaller petechiae, except the superficial ones above noted.
Microscopically Mott confirmed the pial congestion and macroscopic subpial hemorrhages described in the gross. He found besides congestion also actual hemorrhage in the vascular sheaths of the corpus callosum, internal capsule, pons and bulb. Now and then blood corpuscles were found extravasated into the nervous tissue.
The microscopic examination showed a generalized early chromatolysis in the nerve cells of varying intensity, especially affecting the small cells. The Nissl granules of the larger cells were also somewhat abnormal, being smaller and packed rather loosely together.
The small cells of the bulb and pons were slightly swollen and their nuclei large and clear. As to the larger cells of the bulb and pons, there was less evidence of this swelling and nuclear change.
According to Mott, this chromatolysis may perhaps be regarded as a sign of loss of biochemical neuropotential. The chromatolysis indicates a relative degree of exhaustion of the kinetoplasm. Mott assumes that the cells of this victim of shell-shock are in a state of beginning nervous exhaustion. He remarks that the cells of the vago-accessorius nucleus show more signs of this nervous exhaustion than others. With respect to cerebellar findings Mott remarks that the changes found are very similar to those described by Crile in the case of an exhausted and wounded soldier. Mott correlates the mania shown on the evening of February 23 with the venous congestion of the cortex, the small subpial hemorrhages and evidence of scattered arterio-capillary collapse.
HISTOPATHOLOGY OF CASE OF SHELL-SHOCK, BURIAL, GAS POISONING? (F. W. MOTT)
Punctate hæmorrhages in corpus callosum from a case of shell-shock and burial; very probably accompanied by gas poisoning while lying unconscious and buried. Observe the small white area in the centre of the hæmorrhage, in the middle of which is a small vessel which, under a higher magnification, will be seen to contain a hyaline thrombus. (× 20.)
Hyaline thrombus of vessel in centre of a punctate hæmorrhage. The thrombus was stained brown by dissolved pigment. Around the blocked vessel is a white area of brown substance containing numbers of leucocytes; outside this is the hæmorrhage, not very distinctly seen. The specimen was prepared from the subcortical white matter of the frontal lobe. (× 345.)
Leash of small perforating optostriate arteries filled with pigment granules. Two of the arterioles show miliary aneurisms. (× 350.)
Three punctate hæmorrhages showing optostriate arterioles filled with pigment granules. (× 30.)
HISTOPATHOLOGY OF SHELL-SHOCK (F. W. MOTT)
NOTE THAT THE CHANGES IN CELLS OF FIG. 3 ARE DIFFERENTIAL FOR NUCLEUS AMBIGUUS: CELLS NEARBY PROVED NORMAL
Fig. 1.—Photomicrograph of section of corpus callosum from case of shell-shock showing the capillary punctate hæmorrhages. In several a small white area is seen of brain tissue in the centre of which is a small artery or vein. (Magnification 20 diameters.)
Fig. 2.—Section of medulla oblongata from case of gas poisoning, stained by Nissl method, showing the swollen cells of the nucleus ambiguus. Observe the enlarged, clear, eccentric nucleus; the surrounding cytoplasm shows an absence of Nissl granules. In not a single cell is the nucleus seen in the centre as it should be. (Magnification 450.)
Fig. 3.—Section of medulla oblongata from case of shell-shock with burial, stained by Nissl method, showing the swollen cells of the nucleus ambiguus. Observe the enlarged, clear, eccentric nucleus; the surrounding cytoplasm shows an absence of Nissl granules. In not a single cell is the nucleus seen in the centre as it should be. (Magnification 450.)
Fig. 4.—Section of third cervical segment of spinal cord from case of concussion, stained by Nissl method, showing the medium group of anterior horn cells corresponding to the nucleus diaphragmaticus. They show certain amount of perinuclear chromatolysis. But all the cells exhibit the Nissl granules. Even at the seat of concussion, the fourth segment, an external group of cells remains showing Nissl granules. Concussion therefore does not destroy the Nissl granules. Probably the cells of the nucleus diaphragmaticus show a certain amount of chromatolysis because they were continually discharging impulses along the phrenic nerves, and the few cells that were left of the nucleus had therefore much more work to do. (Magnification 300.)
Mott suggests that the sudden death of the case may be due to a hemorrhage into a sheath of a fair-sized vessel in the median raphe of the bulb; the general venous congestion; and the almost complete chromatolysis of the vago-accessorius nucleus (adjacent hypoglossal nucleus normal).
According to Mott, also, many Shell-shock symptoms, e.g., headache, giddiness, amnesia (anterograde and retrograde), dizzy feelings, lack of power of attention, and fatigue, stupor, inertia, mental confusion, terrifying dreams, are to be explained on the basis of capillary anemia and chromatolytic changes.