Case 370. (Buscaino and Coppola, 1916.)

An infantryman, 22 (father and mother quite normal; patient showed slight convulsions, attributed to worms, from which he actually suffered; was malarial from 9 to 15; had otitis media and lost hearing completely at 11; had suffered from 9 onwards with joint pains; as an adult had no convulsions), was called to arms August, 1914, and sent to the front May 2, 1915. About the end of August, in a water-filled trench by Monte San Michele, he was covered with mud from a shell explosion, lost consciousness, and in some way got back to the second line. He was told that blood had flowed from the right ear, and on recovery he found himself unable to hear with that ear, although it was the left in which he had had otitis. There were continual noises in the ear. He was, however, sent back to the front line. By mistake, one day, he got with companions in the midst of the enemy’s barbed wire, saw sparks from the guns, heard no shots, saw comrades fall, and threw himself instinctively into the wire network. Leaving the food kettles, he finally got back to the trenches. He was sent to the hospital at Legnano for his ear pains, and was treated by leeches, which he could not feel. He began to hear a little more. Flies walked on the left cheek without being felt. This anesthesia had begun a few days after the shell explosion. He was transferred to a military hospital at Florence.

One day he wedged a toothpick in cotton into his left ear and was charged with simulation, though he had been absolutely deaf in his left ear since childhood. From the moment the military surgeon told him he would be denounced for simulation, he lost his memory. Reports indicate that he had headache and delirious dreams (October 30), and suddenly he became furious (October 31), about three hours later going into severe collapse, for which camphor injections were given.

November 1 he had battle dreams and lumbar puncture had to be given up as he was in the midst of an attack. A hypodermic injection was interpreted by the patient as a wound, and he cried as if he were being abandoned on the battle-field. At one point he woke up from his hallucination and asked where he was and shortly relapsed into stupor. November 2, the patient was slightly bewildered and felt pains where the lumbar puncture needle had been tried the previous day. November 5, he was disoriented, thinking himself still at Legnano. The pupils were throughout dilated. November 6, confused and dreamy; November 7, he soiled his bed, was somewhat disoriented, immediately corrected himself; oculo-cardiac reflex 64 full compression, 62 during compression. November 11, headache; November 12, a slight bewilderment reappeared; November 13, remembered for the first time having been stunned by shell explosion, and this day got up and wrote home. November 14, complained of pains in muscles and weariness. Pupils still dilated. November 16, pulse 86; a gradual increase from 50 to 60 during previous days. November 17, patient had begun to remember facts that preceded the dream syndrome. November 18, pulse standing 88; November 20, pulse standing 120. This day cried when he remembered having been suspected of simulation. November 22 and 23, aches in joints and intense otalgia; pulse 86. November 24, diarrhea; deafness somewhat diminished; 26, diarrhea; looked as if he were about to have a new hallucinatory episode. This, however, did not come about until December 1, when he heard cannonading and knew the regiment was near. Next day he had forgotten the cannonading. December 14, the patient had become entirely tranquil and lucid and was able to give his entire history. December 16 and 17 he was given a systematic neurological examination, which showed on the left side complete anesthesia, hyperesthesia to pressure, thermanesthesia, analgesia, loss of bone, tendon, and muscle sensation. Vision was diminished more on the right side than on the left, and the visual fields on this side were more contracted. During examination, the fields became still more tubular. There was complete deafness, anosmia, and ageusia on the left side. On the right side there was a slight diminution of hearing. The pharyngeal reflex was abolished; the cremasteric reflex was somewhat less on the left than the right; and the defensor reflexes of the left leg were less marked than those of the right. There was no clonus or Babinski. The dynamometer grasp on the right was 37; on the left 18; and on this side there was a limitation of voluntary movements.

C. THE DIAGNOSIS OF SHELL-SHOCK

In the course of our study of psychoses incidental in the war (Section A) and especially of Shell-shock’s nature and causes (Section B), we have naturally met most if not all of the major diagnostic difficulties. In the present Section we shall study cases for the light they may throw on the more technical troubles of the diagnostician. Who would à priori have felt that such diseases as tetanus, rabies, malaria, would produce practical difficulties in clinical diagnosis in the field of Shell-shock?

Mayhap there was no need to emphasize further the values of lumbar puncture fluid examination. Yet the admixture of “functional” and “organic” symptoms in numerous puzzling cases can hardly be over-emphasized.

But the interpolation, through the ingenious inquiries of Babinski, of a new or but vaguely suspected series of “reflex” (“physiopathic”) troubles between the organic neuropathic disorders on the one hand and the hysterical psychopathic disorders on the other—the result of these observations, sampled only in Section B, is given more in detail in the present Section. What a split in therapeutic method a recognition of this new group of “physiopathic” disorders might entail is seen also in further cases in the Section that follows this (Section D on Treatment and Results).

A number of simulation cases has been added.