Report, strangely interesting, shows the distress of neurologists
in the presence of a disorder of the central nervous system, which
does not fit the frame foreseen by Jean-Marie CHARCOT.
Is the post-concussionnal syndrome of head injuries, subjective? objective? organic? functional? sinistrosic? All these hypotheses are evoked on tip toes and finally conclusions are put off indefinitely!...
The only consensus, that arises - and it is already quite a lot - bases on the intersubjectivity of patients recognition by neurologists of a certain objectivity of the subjective syndrome of head injuries.
Of this distress the fault does not fall on Jean-Marie CHARCOT but on Anatomy, which reduces the structure of man to a topology and forgets its fourth dimension, chronological. The temporal series of chained events of a function imposes its structure to the neurones network.
REVUE NEUROLOGIQUE Tome XXIX Numéro 4-5. Avril Mai 1916
The SOCIETY OF NEUROLOGY OF PARIS held, on Thursday
the sixth of April 1916, an exceptional meeting dedicated to the
War neurology, under the presidency of Mr. Justin GODART, Sous-Secrétaire
d'État du Service de Santé, with the co-operation
of the representatives of the MILITARY NEUROLOGICAL CENTRES of
the war zone and the Regions of the Home, as well as the MILITARY
NEUROLOGICAL SERVICES OF THE ALLIED COUNTRIES. Besides regular
members and national correspondents of the Society of Neurology
of Paris, numerous military and scientific notabilities took part
in this meeting: Messrs general medical inspector FÉVRIER,
President of the medical advisory committee; the medical inspector
SIEUR, Director of the health service of the entrenched camp of
Paris; MESSRS. TEISSIER, REGAUD, MONOD, attached to the sub-secretariat
of State of Health service; the doctor AMODRU, deputy, regional
delegate for the Red Cross; doctor LAFFORGUE; Mr. BRIAND, main
doctor, Head of the psychiatric department at the Val-de-Grâce
hospital, Mr. DUMAS, professor at the Sorbonne; the professors
GRASSET (from Montpelier); CLOWNS (from Bordeaux); CESTAN (from
Toulouse); the lieutenant-colonels W.A. TURNER, PERCY SARGENT,
GORDON HOLMES, neurologists delegated by the health service of
the English armies; doctor HENRY HEAD, from London; ARTHUR MORSELLI,
from the neurological service of the 1st army of Italy, delegated
by the health service of the Italian armies; the doctor BOVERI,
from the neurological department of the military hospital of Alexandria;
doctor MAC-DONALD, from Otago's university, New Zealand; colonel
doctor SOUBBOVITCH, from the Serbian army, etc.
Three sessions took place: the first, on Thursday the sixth of April, from 9 to 12 a.m., rue de Seine, chaired by Mr. Justin Godart, Sous-Secrétaire d'État du Service de Santé; the second in the afternoon from 15 p.m., at the practical School of the Faculty of Medicine, room Cornil, under the presidency of the professors Grasset (from Montpelier) and Pitres (from Bordeaux); the third, on Friday the seventh of April, form 9 a.m., same room, chaired by Mr Huet, president of the Society of Neurology of Paris.
Four questions were discussed. For each of them a reporter had been charged to present a program of discussion, diffused before the session.
1° How to manage after-effects of the wounds of the skull. - Reporter: Mr. PIERRE MARIE.
2° On the value of clinical signs allowing recognising among the wounds of peripheral nerves: A. The complete section of the nerve; B. The degree of functional restoration. - Reporter: Mr. PITRES.
3° Characteristics of the so-called "functional" motor disorders (paralyses, spasms, etc.) and how to manage them. - Reporter: Mr. BABINSKI.
4 ° nervous accidents consecutive to explosions. - Reporter: Mr. C. VINCENT.
Address of Mr Huet
President of the Society of Neurology of Paris.
Mr Sous-Secrétaire d'État du Service de Santé is kind enough being interested in the works of our Society and agreeing to come to chair our current meeting, specially allocated to questions of war neurology. On my colleagues behalf I express to you our deep gratitude, and I thank you for having made summon to this session our colleagues scattered on all sides in neurological centres either home or in the neuro-psychiatric departments of the armies.
I do not need to remind you the favourable reception that received the conclusions of a previous meeting, held in last October, chaired by the professor Ballet with his usual authority and mastery. We were far from suspecting then the grave disease with which our eminent colleague was threatened. Stopped soon in his works, being made, he stopped attending our meetings, and, quite recently, was taken away from the affection of his family, of which we share regrets and pain deeply.
You know what was the work of the military Health Service to organise the War neurology. We owe to it the creation of the military neurological centres of the Home regions, direction of which was confided to our colleagues and to our particularly competent colleagues, we owe to it as well the creation of the neuro-psychiatric centres of army intended to receive from the beginning and near the front those of our brave soldiers or of our glorious wounded whose state requires specially qualified care. Due to this last creation a big number of soldiers affected by neuropathic accidents, which tend to become chronic when they are not fought at once, was able to be quickly cured and to resume their place in the armies.
During a recent meeting, at Doullens, questions concerning insane and epileptics persons were envisaged, about which important practical decisions were taken already. Today, on the program of our meeting, we wrote four questions, about which it seemed to us that the numerous facts that were subjected to our observation could bring some light and it would be important that a common agreement becomes established between neurologists about decisions to set either from the military or from the medical point of view. We thank our colleagues MESSRS. Pitres, Pierre Marie, Babinski and Vincent for having agreed to draw us in brief statements the principal points that we have to discuss.
Today the program engages us to confine to medical neurological questions; but we know the considerable place taken by surgery in the treatment of the wounds of nervous system. But we envisaged as being able to be very fruitful a meeting where surgeons and neurologists, uniting their mutual experience, could in common discuss opportunity, nature and results of interventions on the brain, the spinal cord and the nerves. They welcomed this idea, which we subjected to our colleagues of the Society of Surgery, very favourably. So we can hope that, for the next period, it will be realised for the biggest profit of our nervous wounded persons.
We see, with pleasure, among us some of our psychiatrists colleagues. The fields of investigation of the psychiatry and the neurology not only are often joining, but often still they are penetrated mutually; collaboration between us can only give the happiest results. We still congratulate ourselves on seeing several representatives of the military neurological services of the allied countries. I am anxious to thank our colleagues of England and Italy quite particularly, delegated officially to participate in our meeting, they were kind enough to make long journeys to bring us some help with their competence. Their presence is a brilliant testimony of the firm union that exists among all the allies on the scientific and medical ground, as on every others; this union will be very fertile certainly, not only today, but also in the future. Finally I have to greet the high personalities of the Health service of our country who attending this session honour us, and to ask Mr. Medical general inspector Février, president of the medical advisory committee, Mr. medical inspector Sieur, from the Health service of the entrenched camp of Paris, to take place at our Desk. Once again agreement and collaboration between administrative and medical bodies are stated, they exist with the aim of measures to be taken and of the most effective treatments to be applied to our patients and to our wounded persons. This agreement and collaboration are not new; they did not stop showing themselves for long months; they will become even narrower in the future. It can only result the happiest consequences from the medical, humanitarian and patriotic points of view.
Mr. Justin GODART, Sous-Secrétaire d'État du Service de Santé, wants to rend homage to the activity of the neurologists who put their science and their dedication to the service of the wounded persons: in the name of these last ones, I express recognition to them. Following the works of neurologists closely, he tries to collect ideas that can contribute to improve the lot of the "nervous wounded persons", and he will continue to envisage in the most favourable way the fruitful collaboration of the Health service with the Society of Neurology of Paris and with the representatives of military Neurological Centres.
How to manage after-effects of the wounds of the skull.
Reporter: Mr. Pierre Marie
The wounded persons of the skull have to cross three stages. Each of them can come along with more or less grave accidents. They are:
A. Immediate accidents, arising immediately after the wound (loss of consciousness, paralyses, confusions of the word, visual confusions, etc.).
B. Secondary accidents, which arise some days later (acute meningo-encephalite, brain abscess, Jacksonian crises, etc.).
C. The late consequences, after surgical recovery.
Immediate and secondary accidents are managed in infirmaries of the front. Till now, they were the object of surgical studies especially. Due to the creation of a growing number of neurological centres in the war zone, one can hope that they will be subjected more regularly to examination of neurologists.
The late consequences, on the contrary, are almost the only consequences of the wounds of the skull, which neurologists from Home regions are called to pronounce about.
However, none of us can lose interest in the first two stages crossed by the wounded persons of the skull and notably the surgical operations of which we have to appreciate consequences. But, giving a sprain to the chronological order, I propose that we approach these questions only secondly.
I estimate that it is more urgent at first to concern our discussion about the after-effects of the wounds of the skull, the least known, the most difficult to interpret and however the most frequent. It is important, indeed , to adopt as soon as possible a uniform way of managing them.
To restrict the field of our discussion, I shall leave aside all the accidents very well know from neurologists, such as hemiplegias, monoplegias, different confusions of language, etc. They are, it is true, the most striking complications of the wounds of the skull, but each of us knows how to diagnose them and can, as possible, pronounce on their future.
It is not at all the same with some disorders, less grave at first glance, but about which however all or almost all the wounded persons of the skull complain, and which are called to prove, either an indefinite stay in the hospitals of the rear, or repeated renewal of leaves for convalescence.
These disorders are of purely subjective. I shall remind briefly the main.
Subjective Disorders consecutive to the Wounds of the Skull.
I - Headache,
Almost all the wounded persons of the skull complain about headaches: heaviness in the head, squeezing, beatings, either in all the head, or at the level of the forehead or of the back of the head, sometimes behind eyes; this headache is often dominant at the level of the cranial wound, of which the touch, even light, can ache.
This Headache either is almost permanent, or - and it is the most frequent case - arises particularly at certain hours, for example on waking, on going to bed (then often it determines sleeplessness), or even before or after meals.
Several factors can cause it or irritate it: for example, bending to put his shoes. Acts coming along with an effort: sneezing, coughing, etc. Heat, cold may have the same effect. Fatigue also exercises a pejorative influence, - fatigue from walking, mental fatigue, reading, writing, prolonged conversations, which may become mostly impossible or very painful.
Shocks, as contact of the heel on the pavement, going down a stair, jolts in a car, in a railway and in a subway. This last way of transporting is particularly unbearable in a great number of wounded persons of the skull, very affected by the heat, the noise, the shocks that wait for them there.
Noise, notably that of cars that of the hammer blows.
Bright light, such as that of the sun or the arc lamps - or still the vision of an object in movement such as the wheels of a car, or the too much prolonged gazing upon a squaring or a checkerboard.
II - DAZZLEMENTS.
Beyond these painful phenomena, there is another one that most of the wounded persons of the skull complain about; they name it vertigo.
Characteristics of this so-called vertigo are the following: Suddenly the patient feels a sort of dazzle, as if a more or less thick fog extended in front of his eyes and hid him part of the objects that surround him. Sometimes it is a pure and simple obscuring of vision, sometimes this fog is animated with sparks, with lights, with turning lights, with small very numerous bright circles, white and bright butterflies, etc...
During this dazzle, which, generally, does not last any longer than one to three or four minutes, the patient feels a painful sensation; it is not sure any more of his balance and is afraid of falling (although in fact he never falls). If he is in the street, he rests on a wall or on a tree; if he is in a house, he sits down or goes to bed, until the disappearance of the phenomenon. Once it is ended, the wounded person resumes his walk; in some cases however he feels tired and as depressed.
So happen things generally; it is rare that buzzing in the ears accompany dazzle.
It is advisable to separate these facts sharply from true vertiginous disorders, in which usually exists a gyrating sensation, which is lacking here, the patient does not feel any movement either of himself or of surrounding objects.
Moreover this dazzle, common among wounded persons of the skull, should not be confused with the scintillating scotoma, which can also be observed, but very rarely, and sometimes accompanied by epilepsy.
This common dazzle must also be distinguished from labyrinthine disorders, which are more manifestly vertiginous, and come along with modifications of the galvanic reaction (voltaic dizziness), whereas the common wounded persons of the skull do not show any of it or at the most a very light one, according to milliamperes used to obtain reaction.
It should not be believed that this dazzle constitutes a permanent or even frequent disorder. Most of the patients do not suffer from dazzle every day, mostly three or four times a week, sometimes only one a week, sometimes three or four in the same day. Their number and their intensity seem to decrease with time.
Is there a correlation between the place of the cranial wound and the intensity or the modalities of dazzles? - We were not able to put any correlation in evidence.
Is there a correlation between dimensions and depth of the cranial wound and intensity of dazzles? - How surprising can it appear, it is necessary to answer this question negatively.
Indeed, when one observes a big number of wounds of the skull, one notices that subjects of which only the scalp was affected complain exactly about the same dazzles, about the same headache as those that present a wide cranial breach beatings and with impulse to the cough. One can notice however that these dazzles are less frequent among officers than among soldiers, and less frequent also among the wounded persons of the skull that present a big infirmity, such as hemiplegia, paraplegia, etc.
For all these subjects, descriptions of the disorders that they feel are absolutely identical and made with the same expressions; but obviously that cannot be a learnt lesson.
III. - THE OTHER SUBJECTIVE DISORDERS.
In addition to headache and dazzles, the wounded persons of the skull rather often present other nervous disorders less dramatic than the precedents, but which are not unimportant: Changes of humour: sadness, torpor, sometimes irritability. - extreme emotionalism; one of our officers told us that attending a representation of Esther he wept copiously, - another hearing a military music did the same. - State of anxiety. Tendency to height vertigo for individuals that before their wound were exempt from it.
Incapacity to intellectual or even manual works.
Memory disorders, especially of the fixation memory, and for the recent acts.
Vasomotor disorders: hot flushes. Abrupt perspirations, sometimes epistaxis.
Several very important questions arise about the subjective symptoms that the biggest number of wounded persons of the skull complains about.
1° What is the nature of these subjective disorders?
2° What is their degree of gravity?
3° How to manage these wounded persons, once healing of their wound finished?
Have we to reform them? - To indefinitely prolong their convalescence leaves? - to send them to sedentary departments? - to send them back to their depot? And what is to be done at the depot if the serviceman goes on complaining about the same disorders?
Such are the points that seem convenient to be discussed first.
Then we shall have to examine the wounds of the skull from an objective point of view.
First I shall remind you some observations:
The wound itself can show the following variety:
- superficial Wound interesting only mild parts;
- Simple osseous groove on the outer table;
- Simple osseous Breach with or without spontaneous beatings;
- - - - - - - - - with or without impulse to the cough;
- Osseous Breach with opening of the dura;
- - - - - - - - with hernia and loss of substance of the brain;
- - - - - - - - with presence of a projectile in the brain.
These wounds gave place to different therapeutic interventions, following cases, there:
- simple Bandage;
- Cleaning of the wound after crucial section;
- - - - - - - - - - - - - - - - - - - - - - in fragment;
- Trepanation, trully said.
The scar can be:
- net and resistant;
- Anfractuous, especially after the crucial sections;
- Fistulous or at least slightly weeping;
- Thin with tendency to brain hernia.
Without encroaching on the strictly surgical and operating domain, perhaps neurologists could be authorised, by their already well-based experience, to emit an opinion on some of the following questions:
4 ° What is to be thought about current ideas on the frequency of splinters from the internal table, even when the external table was only incompletely hurt?
5 ° What is the gravity of the presence of aseptic foreign body in the brain: splinters of bone from the internal table, missiles?
6 ° Which connections can be established between Jacksonian or global epilepsy and the kind or the seat of head injury? How soon does it arise after the wound? - Which is the influence of surgical operation? - What is the prognosis? - Which measures have to be taken from the military point of view?
7 ° Do we need trepanning all the wounds of the skull systematically?
8 ° When is trepanning necessary?
9 ° In which sanitary structures?
10 ° Each time there is an osseous breach, crucial sections must be banned and large flap process recommended, at least we think so.
11 ° When a wounded person of the skull must be evacuated to the rear?
a) If he was not operated;
b) If he was not subjected to an operation.
12 ° Could not we react against the abuse, in the hospital sheets and certificates, of the term "trepanning", employed for the removing of the least splinter or even for a simple cleaning of the wound?
13 ° When a wounded person of the skull presents a wide osseous breach, which mode of protection it is advisable to adopt after healing: either stiff skullcap placed on the scalp, or insertion of a metal patch in the cranial breach, or osseous or cartilaginous osteoplasty?
14 ° Can a wounded person refuse a cranioplasty?
15 ° As for the protective value of the helmet, it does not seem that neurologists can emit a peremptory opinion on this subject; they lack a lot of elements to establish statistics. It is difficult to say if the higher frequency of head injury during the last six months is due either to the bearing of the helmet - a higher number of wounded persons survive - or to the fighting methods.
Mr Maurice VILLARET, assistant head
doctor of the Neurology Center of the 16th district (Montpellier).
- Together with Messrs Rives, Maystre, Mignard and Faure-Beaulieu,
assistants at the Neurology Center of the 16th district, I have
had the opportunity, since I collaborate with professor Grasset
in managing this Center, to examine thoroughly a hundred men affected
by cranio-cerebral lesions due to war traumatisms, and to consult
156 observations written on the same subject by the assistants
of the Neurology Center. This important statistic of over 256
cases has allowed us to make the following comments:
With the exception of the events when such traumatisms lead to serious and incurable disabilities, therefore justifying immediate discharge n°1 because of the wounded man's incapacity to serve and provide for his needs, emphasis has to be put on those numerous observations in which the usual disorders, hemiplegic or other, disappear sooner or later, so much so that after a few months the subjects appear perfectly normal and fit again for service.
In this majority of subjects, not only do the paralyses, the spasms and the language disorders eventually vanish, but the subtler manifestations of lesion or excitation of the pyramidal fascicle, such as the alteration of tendinous or cutaneous reflexes, especially the sign of Babinski, disappear. Some symptoms keep continuing, notably the sign of combined flexion that generally remains at the extension of the toe, but they also end up vanishing.
Still, when those subjects are thoroughly examined, it is unusual not to observe the continuance of some very subtle after-effects that have to be stressed because they often escape notice by experts.
I. THE VISUAL AFTER-EFFECTS are, among such after-effects, those we have to speak of first. They are, so to say, always consecutive to occipital lesions.
We have observed them fourty-one times. There have been four cases of transitory blindness, three cases of double vision, sixteen cases of more or less important narrowing of one or two fields of vision, three cases of complete definitive homonymous hemianopsia, one case of incomplete hemianopsia, one case of homonymous hemianopsia in inferior quadrant, one case of homonymous hemianopsia in superior quadrant, two cases of hemiopic notch even less prominent than the quadrant, and finally one case of transitory hemianopsia. Moreover, there have been nine cases of pupilary inequality or other eye disorders.
I have had the opportunity to publish part of those observations with Mr Rives, and we will have the opportunity, with Mr Faure-Beaulieu, to insist on the frequency of the narrowings of the field of vision. As for Mr Pierre Marie, he has drawn the attention to the frequency of those visual after-effects.
II. UNILATERAL ASTEREOGNOSIA represents another after-effect we have to be acquainted with. It can occur following frontal and occipital traumatisms. But it has mostly been observed in parietal lesions.
On the numerous cases of parietal traumatisms observed with my assistant Mr Maystre, it appeared twenty seven times, whether coinciding with the simple broadening of the circles of Weber, or associated to the loss of the sense of attitudes (syndrom of Déjerine), or just combined with bone anaesthesia, or, finally, associated at various degrees to the different disorders of superficial or deep sensitivity, on the side opposite the parietal lesion.
It seems that astereognosia is the most persistent after-effect of the more or less pronounced alterations of sensitivity immediately following cranial traumatisms, and which soon start to lessen little by little. Sometimes the astereognosia diminishes even more, until it disappears, and keeps limited to part of the fingers or of the hand. Mr Faure-Beaulieu and I have several observations on that most curious symptom on which Mr Pierre Marie recently called attention.
III. THE EPILEPTIC EQUIVALENTS represent after-effects sometimes even harder to demonstrate.
With the exception of the typical jacksonian epilepsy, which appears fifty-three times in our observations, we often notice, in cases of cranial traumatism, the only lesional symptom of sensitive equivalents consisting of pins and needles at the extremities - our subjects have spontaneously pointed them out twenty-five times.
Some audition disorders (transitory deafness, buzzing in the ears) and vision disorders (scintillating scotoma, transitory blindness) belong to the same category of sensitive equivalents.
Also to be considered are the psychic equivalents that Messrs Faure-Beaulieu, Mignard and I have observed four times.
Fits of vertigo are even more frequent - they start out suddenly and without any cause, often in any position, last a few minutes, are not combined to a loss of consciousness, but sometimes compel the patient to sit or even lie down. We have observed them thirty-seven times.
Finally, all intermediary states can occur between vertigo equivalents and fits of vertigo induced by position changes, especially by the bending forward of the trunk. Those are so frequent (146 cases in our statistic) that we can consider them as nearly constant, even in the absence of any other lesional manifestation - they are fairly often associated with alterations of the various kinds of vertigo induced.
The clinical value of those epileptic equivalents is great indeed. They appear following not only occipital but also parietal and frontal traumatisms. They often escape notice. They will have to be searched systematically and several times before one can conclude that there are no traumatic after-effects. Quite often indeed they lead, sooner or longer, to more serious accidents, notably typical epileptic fits.
IV. MENTAL AFTER-EFFECTS particularly have to be pointed out as they are often difficult to search for and usually escape notice, however frequent (127 cases in our statistic).
Without considering typical mental symptoms, through which we will not go here, and independently of the shock syndrom, we have, Mr Mignard and I, frequently found, in cases of cranio-cerebral traumatisms, small transitory disorders, intermittent or cyclical, from which it is possible to isolate various clinical forms (form of mental inertia, neurasthenic form, general pseudo-paralysis form, euphoric form, puerile form, amnesic form requiring the use of a notebook, calculation disorders, form of irritability of personnality, etc.).
It is therefore convenient, in our opinion, not to take any decision about a patient with a cranial traumatism prior to his being examined thoroughly and several times by a psychiatrist.
Those mental disorders are not exclusively linked, as one could believe, to traumatisms of the frontal region. We have indeed observed them much more frequently following wounds in the parietal area (more than half the cases) than occipital and frontal lesions.
V. Such considerations lead to PRACTICAL CONCLUSIONS.
1. First of all, one must not hurry in taking a final decision concerning cases of cranial traumatism, even when the subjects are free of all lesional manifestation, and one must certainly not send them back to the war zone, at least prior to a very long observation.
Together with Mr Faure-Beaulieu, we have had the opportunity to study around twenty cases of accidents that occurred in the very long term to trepaned subjects whose clinical picture looked completely normal. We notably happened to see men with cranial traumatisms who had returned several times to the front because no nervous symptom had been observed, and their euphoria induced them to claim an absence of functional disorders, however existing. Now, after six to twelve months only, such subjects had an epileptic fit - a clear sign of a lesion apparently latent until then.
Consequently, it is desirable that concerning trepaned subjects, even with no serious disorders, the following decisions are made: either temporary discharge if there is any clear after-effect of the initial cranial traumatism, or transfer to the auxiliary services if those after-effects are very minor, or unfitness for campaign, with prolonged medical surveillance, if the latter symptoms fail to appear.
2. A second conclusion derives from our observations - and it is that cranial traumatised subjects need X-ray and surgical examination.
Very often, indeed, even in the absence of any apparent loss of osseous tissue, X-rays have revealed the existence of cracks, splinters or foreign bodies which, by their persistence, can lead to accidents in the long term. Moreover, radiography allows us to check on the assertions of the subjects, who, in the all too frequent case of an absence of documents, claim to have been trepaned whereas they have not.
3. A third conclusion has to be drawn: a search for visual after-effects, disorders of the stereognostic sense, vertiginous and mental epileptic equivalents, even minor and incomplete, isolated or associated to other manifestations, has to be carried out systematically, every time one has to confirm finally the retrospective diagnosis and the remote prognosis of cranio-cerebral traumatisms that occurred several months before.
Indeed, their discovery is likely to change significantly the expert's opinion, as a superficial examination could otherwise lead to the wrong conclusion that pathological nervous after-effects are inexistant.
MR HENRI CLAUDE, head of the Neurology Center of the 8th district (Bourges). - The various subjective disorders mentioned in Mr Pierre Marie's report can be observed with a remarkable regularity in subjects wounded in the skull. In over four hundred cases I have had the opportunity to study at the Neurology Center of the 8th district, where four thousand three hundred nervously wounded or ill persons have already been attended, I have observed more or less pronounced, more or less permanent headache, combined or not with pains either localised or spreading to the skull, the face. Fits of dizziness, instability and insecurity in walking and standing up are very frequent and, together with headache, become more accute when the subject stoops down, bends his head or has to make an effort. The other subjective symptoms are more variable: hyperacousia, buzzing in the ears, declining memory, especially concerning recent facts, attention disorders, declining work capacity and intellectual value, headache fits with migraine-like vomiting, etc.. I wish to underline the painful reactions induced in such subjects by explosions: I have seen several cranial wounded men be evacuated from the front as they could not endure the detonations because of the nervous shock and the headache exacerbation they caused them. I myself have been able to observe how much those traumatised subjects suffered from noise and explosions because, my hospital standing close to the shooting range, artillery shots often sound very violently.
The degree of gravity of such disorders is not at all proportional to the extent of the cranial lesions. I have even noticed that the trepaned subjects who have suffered quite an important loss of osseous tissue are often less affected than some subjects who have just a slight bone depression or a mere crack. Lesions in the temporal region seem more difficult to endure. Long linear breaches of the external table combined with a slight bone depression and without any loss of tissue, are often the cause of accute disorders.
The origin of those subjective disorders has to be looked for in an organic alteration, which varies from one case to another. Indeed, there are in some subjects circumscribed lesions of the meninges or of the cerebral matter that do not give birth to any sign, but nevertheless are still a cause of general symptoms. In the absence of location signs, it is difficult to appreciate those lesions, but the study of the cephalo-rachidian liquid shows, however, the existence of appreciable alterations. Indeed, I have often noticed, parallely to the increase of albumin in that liquid, the pressure increase measured with a manometer, and several times the exacerbation of the symptoms (headaches, fits of dizziness, vomitings) coincided with states of hypertension also detected by alterations of the papillary venous circulation. The pressure increase generally does not exceed 50 cubic centimeters of water. Besides, there is no constant parallelism between the pressure increase and the intensity of the subjective symptoms. The pressure increase does not follow the albumin increase, which never reaches a high proportion.
The existence of functional and general disorders in cranial wounded subjects being acknowledged, and explained by biological observations, what is the decision to take regarding those men? First of all we have to say that there cannot be any univocal regulation: for each case the subject's value has to be determined, each specific case has to be taken into account and it would be antimedical to regulate the situation of those wounded men. In general, with the exception of the individuals who show signs of organic lesion or epileptic fits, I usually propose for discharge #1 those trepaned men whose loss of osseous tissue measures around 4 centimeters and shows the encephalic pulsations. Indeed, despite the protection plates, those men are incapable of any physical effort and frequently psychonevropathic worries worsen their state whenever they are serving. Other wounded men whose losses of tissue are less important will be discharged temporarily with reward or transfered to the auxiliary service depending on the importance of the functional disorders or the existence of added organic lesions. The same goes for some wounded men who have simple bone depressions or who have suffered losses of tissue now filled up. Concerning the latter, their activity in the auxiliary service and even at certain posts of the armed service is often possible and scarcely are those wounded men sent back to me by the deports because of an inadequacy of their work capacity. It seems to me rather difficult to pass judgement in general on the intellectual and moral value of those cranial wounded men, even more so regarding the officers or non-commissioned officers who wish to stay in the army. On the whole, they have better be employed in interior services and not be sent to the front - most importantly, they should not be entrusted, in the armies, charges of unit commanders as qualities of initiative and self-control are required.
MR J.-A. SICARD, head of the Neurology Center of the 15th district (Marseilles) - My assistant, doctor Cantaloube, and I have mainly devoted ourselves to examine the cephalo-rachidian liquid of subjects with a cranial crack, whether or not trepaned. We have mostly set our minds to the study of rachidian albuminosis in those subjects.
In slightly more than one third of the cases, on around a hundred cranial wounded men examined, we have observed an increase in the rate of albumin, varying between 30 and 60 centigrams approximately.
That dosage was carried out thanks to a new method - a measuring tube with precipitation of the albumin under the influence of trichloracetic acid at one third. Thanks to that method, any error due to personal equation is eliminated. As it is used comparatively, it gives more regularly faithful information than the method of weighing, more precise at first sight but subject to numerous errors when it is not performed by totally competent chemists.
In order to establish the medical situation of those cranial wounded men, we have not merely studied the cephalo-rachidian liquid, but we systematically have them examined by ophtalmologist and aurist specialists.
As most of our colleagues in Neurology Centers, we have noticed the frequent existence of hemianopsia disorders in lesions of the occipital region and much more rarely abnormal reactions of the fundus oculi. An audition examination is also part of the rules we apply. In cranial wounded men, the auditive sphere is less frequently affected than the visual sphere.
These subjects who have a cranial crack, whatever the topographic situation of the wound, seem to us in a great majority of cases, even in the absence of any motor or sensitive reaction of the members, totally unfit for active service. They either have to be affected to the auxiliary service or proposed for temporary discharge.
We consider the latter proposition for temporary discharge, as a rule regarding cranial wounded men with a permanent after-effect of rachidian hyperalbuminosis.
MR JUMENTIE (Neurology Center of the 16th district, Montpellier) - I will merely support my master Professor Grasset's proposition to reserve prognosis concerning cranio-cerebral wounded men who at some point have shown organic signs and to oppose their return to the front: I will give a summary of the anatomic observation of a man wounded in the parietal region. Immediately following his wound he showed hemiplegia and aphasia, and was discharged six months later. He was admitted again in the hospital for headache and fits of vertigo. We observed him during two months and, apart from his trepanning opening and his vertigo disorders, did not find more than a very light mumbling and slightly quicker tendinous reflexes. The lumbar punction did not show anything abnormal.
Suddenly, in four days, more than ten months after his being wounded, the man died showing signs of meningitis. The autopsy revealed a purulent meningitis of the base with ventricular flood. An horizontal section performed in the superior part of the left hemisphere showed right in the oval center, 3 centimeters down the cortex in the superior rolandic area, the presence of two splinters. One of them was 2 centimeters long and at the center of a softening zone that spread up to the lateral ventricle. That was not a cerebral abscess, but a sore probably infected by the splinters that had become encysted there. Let me pass round some drawings that will tell more than any description. I intended to talk longer about this case, concerning the seriousness of the prognosis on splinters in the internal table - but as I do not know if I will be able to attend that debate, I put this observation forward right now.
MR P. SOLLIER, head of the Neurology Center of the 14th district (Lyons) - Whereas the reality of subjective disorders associated to cranial wounds is not questionable whenever they are associated to more or less intense objective disorders, it is suspiscious when they exist independently and late after the traumatism. One could wonder if the subject does not keep complaining about disorders he has been affected by but that have since disappeared.
I have therefore devoted myself to find out, in the subjects now only showing or never having shown anything but subjective disorders, if one could not also detect some objective disorder that the subject would ignore as it would not be painful.
Now, I was struck, in a great number of similar subjects, by the existence of the mydriasis, either unilateral, or bilateral. Since the moment when I systematically searched for it, I found it 52 times out of 79 cases, that is in 2/3rds of the cases.
If we consider it relatively to the affected areas, we observe that it appears mostly in frontal lesions (14 times out of 16), then in temporal ones (11 times out of 15), then the parietal ones (24 cases out of 40), and quite far behind, the occipital ones (3 cases out of 8).
It was double in more than half the cases, 3/7th exactly, and predominantly on the side opposite the lesion in 1/9th of the cases only.
On the contrary, when unilateral, it was situated opposite the lesion in 3/5th of the cases.
In one case, I observed a variability in the aperture of the pupil, that changed sides from one moment to the other with the closing and the opening of the eyes.
What causes that mydriasis? I first tried and searched in the circulation variations, but no disorder of the kind came to support that hypothesis. I rather think it is an irritation, or maybe more simply a meningeal irritability and an excitation of the sympathetic nervous system.
That phenomenon would then manifest the reality of isolate subjective disorders observed in a great number of cases, and would make understandable why the subjects affected by them are incapable of sustained work, attention, etc..
It is difficult to tell, right now, what the prognosis for such disorders is. What seems sure is their long persistence. And, as Mr Marie points out, they bear no apparent link to the depth or topographic situation of the lesions, but it seems to me they frequently showed in the frontal ones.
On a practical point of view, I ask for the wounded man affected by them - when the loss of osseous tissue is not too important - his transfer to a sedentary auxiliary service, and if he is not even fit for it, his temporary discharge or a long term leave.
MR J. BABINSKI - What comes from my observations is that cranial wounds, especially in the case of a fracture, often lead to vertigo sensations showing the subjective and the objective features of the labyrinthine vertigo. It is not even necessary for the rock itself to have been affected, and vertigo sensations can derive from fractures situated in the various regions of the skull.
I have had the opportunity to notice in such occurrences the different alterations of voltaic vertigo I have previously described (see: Report of the scientific works. Masson et Cie, editors, p. 167 and following): increase of the resistance to the excitation induced by voltaic current, head moving backward and forward instead of bending and rotating, cephalic nystagmus, unilateral bending, unilateral rotating, sometimes bending and rotating performed on the same only side, sometimes unilateral bending on one side with unilateral rotating on the other side, sometimes circumducting movement of the head.
Those are signs that should be known and searched for because their presence allows us to dismiss the hypothesis of suggestion or malingering and to assert that vertigo sensations are induced by a labyrintine disorder. That is all the more interesting as such an observation bears a therapeutic sanction. Indeed I formerly showed - and my observations have been confirmed everywhere in France and abroad - that lumbar punction often has a positive action on labyrinthine vertigo: it generally lessens it and sometimes even gets rid of it. In cranial fractures, we have to admit that the efficiency of rachicentesis usually is less important than when vertigo sensations have another origin and are, for instance, induced by simple concussions. However, even in such a case, the punction is sometimes followed by an appreciable lessening of vertigo sensations.
Apart from some exceptions, I consider that the subjects wounded in the skull are unfit for campaign. A great number among them has to be discharged at least temporarily. A few others, however, could be employed in the auxiliary service.
MR J. FROMENT - I have had the opportunity to study in my master Mr Babinski's service a fairly important number of cranial wounded men with a fracture in the left parietal region. I have observed, whereas the language disorders themselves had already completely retroceded, the presence of residual disorders of the intellectual faculties revealed through calculation, drawing, describing some images that the subjects had to examine, and more seriously, through the very diminution of professional abilities. Such facts, which we have already thoroughly studied (The prognosis of traumatic aphasia following firearms wounds in the skull, Lyon chirurgical, may 1916), are interesting on a doctrinal point of view insofar as they ascertain that intellectual disorders indeed belong, as Mr P. Marie upheld, to the series of symptoms of aphasia. But they also have a practical implication: they demonstrate that a throrough examination of the intellectual faculties is compulsory concerning skull fractures and especially when the left parietal region has been affected. That examination, judging by the subjects we have been able to study, will often manifest the unfitness of such wounded men for the front, for active service and sometimes even for any military service.
MR CESTAN, head doctor of the Neurology Center of the 17th district (Toulouse) - As early as January 1915, carrying out a parallel study of simple cerebrally concussed subjects and trepaned subjects, we had acknowledged that two categories could be distinguished in the signs showed by cranial wounded men who had undergone a trepanation, and hence describe, on the one hand, the syndrome shared by any trepaned subject, and on the other hand, the situation syndrome depending on the lesion of one or another part of the encephalon.
We do not wish in this session to give you the results of the researches carried out with our collaborators Messrs Descomps, Euzière and Sauvage on the shared syndrome, as those researches already date back one year.
That syndrome includes the signs named subjective by professor Marie. We will show, however, that some balancing disorders are objective indeed: that is why we prefer the name of shared syndrome. Besides some other subjective disorders can come under the situation syndrome. That syndrome includes: 1. headaches, 2. psychic disorders, 3. balancing disorders, 4. some alterations of the general state (asthenia, emaciation, etc.). We have already expounded, in our monthly reports at the Neurology Center, some of those facts, and in the following reports we will expound all our researches, but we are too limited in time here.
However, we wish to draw attention especially to balancing disorders, because of their frequency and their particular intensity which alone can justify discharge #1. Their characteristics are: 1. subjective signs, such as vertigo sensations, anxiety, fog before the eyes, buzzing in the ears, headaches; 2. objective signs, such as the subject's falling, disorders of the voltaic vertigo (either alteration of the labyrinthine voltaic resistance, or situation of the falling, always on the same lateral, posterior, anterior side, or early appearance of the voltaic, etc.), disorders of the caloric nystagmus (we are currently studying the possible connections existing between the last two categories of signs), walking disorders under certain conditions (blindfold following Babinski's method with or without rotatory or voltaic excitation of the labyrinth), disorders of the attitudes of the big segments of the members, etc..
In general the shared syndrome, the major characteristics of which we have now pointed out, exists, whether the lesion affects the frontal lobe, the parietal lobe or the occipital lobe, whether the subject has undergone a small trepanation or a big trepanation. Better still, it is present with the same accuteness in subjects cerebrally concussed by shell explosion. Therefore it seems that it depends as much on the mecanic shock by lesion of the brainpan as on the concussion caused by shell explosions, the mechanism of which we have tried and analysed in our monthly reports. Trepanation did not better them, time is the only important factor from that point of view - some better little by little, others continue with furthermore signs, such as headaches and psychic disorders most probably increased by an important factor of traumatic neurasthenia even including war pessimism.
On a practical point of view, some trepaned men only show the shared syndrome. Sometimes that syndrome will be so intense as to justify a temporary reform, sometimes on the contrary it will be minor enough to allow the cranial wounded man to be fit again for service.
As for ourselves, we have considered fit again 34 trepaned men out of 106, that is 14 frontal subjects out of 28 (50%), 15 parietal subjects out of 66 (24%), 5 occipital subjects out of 12 (40%). The reasons for the others' temporary discharge belonged to such factors as vertigo sensations, visual disorders, convulsive disorders, important osseous crack, etc.. Among those 34 trepaned men fit again for service, half of them had an osseous foundation in the trepanation zone, the other half had a maximum loss of tissue of 2 centimeters in diameter.
In our opinion, subjects with a small trepanation and who are fit again could normally be transfered in the auxiliary service and not temporarily discharged.
The return to the front can be dangerous, but we have had the experience of three cases only of worsening of the balancing disorders due to successive concussions by shell explosions.
On a practical point of view it is therefore necessary to be absolutely sure that the subject does not have convulsive disorders and certainly not balancing disorders, before sending him back to the front.
This last possibility, even if we consider it as exceptional, may occur. Those are specific cases mostly judged by the sole appreciation of subjective disorders (headaches, psychic disorders, vertigo sensations) on which the pessimism factor can have various influences.
Thus appears the practical interest of our researches on the means to test the labyrinth, which will allow us to check objectively on subjective disorders and to set rules allowing us to give medical conclusions and military decisions.
Even considering the employement of trepaned men, we would like the subjects transfered in the auxiliary service to be affected to an easy service. In order to achieve that, the simplest solution would be to send them in sanitary units where the doctor, being more qualified than anyone else, would find them a function in adequacy with their output capacities that, we fear, will always be low due to the war pessimism factor.
Besides, that solution only concerns the present state of war and it is understood that at the end of the war those wounded men could rightly enforce their claims for a reward.
MR ANDRE LERI (head of the neurology service Ambulance 1/2). - The question of those subjective disorders following cranial traumatisms, clearly pointed out by Mr Pierre Marie, has not, so to say, been considered until now. Yet it is one of the most important ones in the nervous pathology of war, because of the extreme frequency of similar disorders, of the nearly systematic complete absence of any objective sign that could justify them, and finally of the serious military decisions that such disorders imply.
The frequency of such disorders can be estimated by figures. Since the receipt of the report, we have had time only to establish a statistic over 100 cranial traumatisms randomly taken - now, out of those 100 observations, 30 times we noticed the syndrome shown by Mr Pierre Marie, that is headaches or continuing pseudo vertigo sensations, with or without other subjective disorders . Considering the fact that we have not specifically and deliberately searched for that syndrome and that we have taken it into account only when it was obvious, we can say that the 30% proportion certainly is a mere minimum.
It seemed to us that it was possible to establish some kind of connection between the situation of the cranial wound and the existence of the subjective syndrome, headaches and vertigo sensations.
Among the 100 cranial traumatisms, 15 were in the frontal region, 20 in the occipital region, 11 in the temporal region, 39 wounds were in the parietal region and 12 amply encroached on that region (5 in the fronto-parietal region, 3 in the occipito-parietal region, 4 in the temporo-parietal region) . In other words, among 100 cases, 51 times the parietal region was affected, exclusively or not.
Now, among the 30 cases when important subjective disorders existed, the wound was situated 9 times in the frontal region, 11 times in the occipital region, 3 times in the temporal region, 3 times only was it in the parietal region and once each in the fronto-parietal region, the occipito-parietal region and the temporo-parietal region. That is to say that the headaches and the continuing vertigo sensations were induced by frontal lesions 9 times out of 15, by occipital lesions 11 times out of 20, by temporal lesions 3 times out of 11. On the contrary those subjective disorders were induced by exclusively parietal wounds only 3 times out of 39 and to lesions more or less affecting that parietal region only 6 times out of 51.
Those figures clearly show (what we thought we noticed in the process of our clinical examinations) that serious continuing subjective disorders, mainly in the form of headaches and pseudo vertigo sensations, are much more frequent when the wound is situated in either the frontal or the occipital regions. They are relatively rare following wounds in the parietal region.
It seemed to us that such disorders did not always have identical features in frontal lesions and occipital lesions.
The headaches are nearly always frontal, either totally or partially, and not only when the wound is in the forehead, but even if it is in the occiput. In the first case, they usually are almost exclusively frontal, and in the last one they frequently are helmet-like, crown-like, often frontal, nearly never exclusively occipital.
As for vertigo sensations, it seemed to us that fairly often in occipital lesions and sometimes in temporal lesions, they showed the features of real vertigo sensations or more precisely some visual features: feeling that the objects or the patient himself are turning round, dimming of the sight, blurred objects, "vanishing" and reappearance of the objects as if by a photographic shutter, etc.. What occurs in frontal lesions is rather a simple and quick clouding of the conscience with a sensation of general faintness, of imminent fall, of "nothing" - a sensation which makes that pseudo vertigo comparable to the epileptic pseudo vertigo.
It seems to us that those differences in frequency as well as the few dissimilarities in symptomatology depending on the regions, support the observations made by Mr Pierre Marie on the fact that, if those subjective disorders may partly come from the subject's moral state, from self-indulgence rather than true exaggeration, they are nontheless real indeed sensations with an organic basis, and in no way the "telling of the same story".
As for the origin and the very nature of such disorders, in a great majority of cases we believe them to be connected to meningeal adherences. We certainly have observed cases when, following a simple violent concussion, the subjects have complained for a long time of headaches and pseudo vertigo sensations - but those cases are exceptional. On the contrary there are very frequent cases when the subjects affected by those subjective disorders show, just where they have a loss of cranial tissue, expansions and tractions of the scar marking an adherence, not only of the scalp to the dura mater, but mostly of the dura mater to the brain . The cause and effect relationship between those adherences and those disorders had appeared so probable to us that together with doctor Bourguignon we had attempted, between the months of september and october, to come to a solution thanks to a method that we found had given good results against sclerosis tissues - that is, ionization with iodide of potassium. We cannot yet give conclusive results from the few attempts that had to be interrupted.
Whatever their cause, similar subjective disorders, headaches, pseudo vertigo sensations, etc., generally seem very persistent: out of the 30 observations we have noted, three times the wound dated back 13 months, twice 12 months, twice 10 months, five times 8 months, four times 7 months, etc.. That long persistence was more or less the same, whether the wound was situated in the forehead, in the occiput or in the temple. That does not mean, however, that in some cases those disorders had not already begun to diminish. Neither does it mean on any account that they cannot diminish and disappear faster - the subjects in which they had disappeared having for that very reason escaped our prolonged observation.
In the perspective of practical decisions, those points of note enhance the need to avoid at the very least three mistakes: 1. One must not consider those subjects as malingerers just because their disorders are only subjective. At the very most, one could sometimes suspect exaggeration or perseverance to some extent. 2. They must not be kept in hospital units as they would uselessly occupy beds without any hope of quick recovery. 3. They must not be discharged definitively because, whereas the disorders are prolonged, they by no means seem immutable and definitive.
Two solutions are left that does not seem mutually exclusive to me, i.e.: 1. Transfer to the auxiliary service whenever the disorders are moderate. 2. Temporary discharge when they are very accute, when the intensity of the disorders would be such as to make the subjects very bad auxiliaries, and when the activity, whatever minor, they would be liable to, could only have a bad effect on the evolution of their disorders.
MR FR. MOUTIER (2nd Neurology Sector of the 3rd District, Trouville) - I was struck by the amazing frequency of fits of dizziness and above all of fits of vertigo in cranial traumatised subjects. As I have systematically explored the galvanic vertigo in such subjects, I have been able to identify the existence of labyrintine disorders in a great majority of parietal and occipital wounds. Such disorders often consist of a varying increase of resistance to vertigo (18 to 44 mA and sometimes 20 and 24), more scarcely of a great diminution of that resistance (0.5 to 2 mA). At the same time different anomalies in the way those subjects react to vertigo are noticeable: constant bending on the same side, cephalic oscillations, late or non-appearance of the nystagmus, and above all persistence of the vertigo far beyond the usual delay.
I found the caloric tests less practical, less faithful and less easy to read than the voltaic test so clearly defined by Mr Babinski.
As for the settlement of the military situation of those wounded men, I consider that in most cases (obviously only concerning the subjects whose morbid syndrome prolong their stay at the special Center), they are incapable of any effort, unfit for the slightest work, be it in the deport or in the auxiliary services. I usually consider temporary discharge as the best possible solution.
MR GEORGES GUILLAIN (Neuro-psychiatry Center of the VIth army) - I have had the opportunity to observe a certain number of officers and privates who had come back to the army after having been previously trepaned following skull wounds. These formerly trepaned subjects complained of headaches, vertigo, memory disorders, asthenia, abulia, etc.. I believe that most of those symptoms derive from organic disorders. Sometimes we can detect in those subjects hypertension or hyperalbuminosis of the cephalo-rachidian liquid, sometimes the functions of the labyrinth are not normal, and sometimes, indeed, we cannot put forward any objective sign of lesion or of neuralgic disorder. More serious accidents, occurring without any apparent cause, sometimes happen to those formerly trepaned subjects - I mean epileptic fits, not jacksonian epileptic fits, but serious epileptic fits with fainting, convulsions, biting of the tongue, etc.. I observed those epileptic fits in various officers who, driven by very praiseworthy feelings we can only approve of, had asked to go back to the front shortly after their cranial sore was scared over. Very recently still, in Compiègne, a young lieutenant was under my observation. He had gone back to the front against medical advice and thought he had completely recovered. First in a trench, then while riding, he went through typical epileptic fits. The serious consequences that such accidents can bear when occuring to platoon commanders are obvious enough. Whereas asthenia, abulia, partial amnesia are only of little importance concerning privates, such nervous disorders have to be taken into account when affecting officers, as the latter have to take decisions, to show presence of mind and will. It cannot be denied that after a few weeks many a formerly trepaned subject has restored perfect physical health and mental balance, and is fit again for active service in the army, yet one has to be acquainted with the fact that in other cases nervous disorders can exist in those subjects. I think that formerly trepaned men who complain of headaches, vertigo, sluggishness of mind, have to be kept temporarily, for several months, in rear units. Considering the observations I have made, this guiding principle particularly has to be applied to officers. As for formerly trepaned subjects who have gone through epileptic fits, even scarce and isolated, I consider that they must never be sent back to fighting units.
MR COLLET - In taking the decision, utmost importance has to be given to the search for accompanying objective disorders: induced nystagmus, pupilary disorders, state of the pulse, of the cephalo-rachidian liquid, etc.
MR MARCEL BRIANT, Head of the Psychoses Service (Val-de-Grâce). - We certainly often observe a disconcerting disproportion between the features of the cranial wound and the subjective disorders claimed by the subject.
I wish to call attention on the frequence of tachycardia in cranial traumatised men. It seemed to me that this tachycardia often increased when touching the scar.
Cranial wounded men who show such subjective disorders have to be treated like excessively pessimistic subjects, victims of work accidents. When all treatment has failed, we shall try and rehabilitate as far as possible for military life those who could be employed at the rear. The unfit, who will generally not recover until after the war is over, will have to be discharged.
MR LORTAT-JACOB, head of the Neurology Center of the 18th District (Bordeaux) - The search for increased resistance to voltaic vertigo proves the organic reality of the disorders subjectively claimed by cranial wounded men. In 85 per cent of the cases, this increased resistance was demonstrated. It is often very high. There is no connection between the importance, the size of the cranial wound and the existence of voltaic vertigo disorders. Apparently very small cranial wounds often induce a strong increase of resistance to voltaic vertigo. The disorders are long lasting.
Subjects wounded in the parietal region often show sensitive disorders with radicular, or striped, topography on the members. Those striped sensitive disorders reveal the organic nature of subjective sensations claimed by the subjects.
As a general rule: those cranio-cerebral wounded men, who show disorders of the voltaic vertigo or sensitive disorders with organic topography, must not be sent back to the army. They have to be temporarily discharged.
MR PITRES, head of the Neurology Center of the 18th district (Bordeaux). - Among the subjective disorders shown by cranial wounded men, some seem to attest a blow to the sympathetic nervous system - for instance the syndrome of Claude Bernard-Horner, signs of rough basedowism, singular cenesthopathies. I also observed several times the loss of the sensation of hunger, the absence of erections.
MR ANGLADE - We observe in those cranial wounded subjects phenomena similar to those shown by subjects concussed without sores. They are purely psychic reactions, of emotional origin - their persistence can be long lasting and they have to be taken into account in the evaluation of subjective disorders.
MR ERNEST DUPRE - It cannot be denied that a cranial traumatism can exaggerate, or even create out of nothing, the emotional constitution with all its chemical manifestations: hyperreflectivity, vasomotor and secretory disorders, etc.. And among those signs of morbid emotionalism, irritability is one that can bear serious consequences as far as military disciplin is concerned.
MR SOUQUES - Subjective disorders following cranial wounds, which I have observed, remind in their general features those so clearly exposed by Mr Pierre Marie.
I observed two kinds of headache: the first one is situated on or near the scar, connected to the situation of the wound and constitutes a sort of hyperesthesia. The other one is general, often localised in the fronto-temporal regions, and bears no relation to where the wound is situated.
I found fits of dizziness much more frequent than vertigo accompanied by a moving sensation. On the ten wounded subjects I currently have in my service, seven show actual fits of dizziness and only one vertigo accompanied by a moving sensation. Two of them never had fits of dizziness or vertigo. By the way, I underline the fact that those two wounded subjects have fits of partial epilepsy and serious hemiplegia - this confirms the observation made by the rapporteur.
Finally, it seemed to me that intellectual disorders were constant, characterised by a weakening of the faculties, especially memory. It is mostly an amnesia of fixation for facts posterior to the wound. Yet I have seen cases of retrograde amnesia. All the wounded men I have examined complain of forgetting quickly the events of the day before or of the day: several men complained that the day after they had forgotten they had written to their parents the day before.
Those various subjective disorders (headache, fits of dizziness or of vertigo, amnesia, weakening of intelligence, etc.) are obstinate and persistent. In most of the wounded men I have observed, they have resisted all therapy and have not bettered until now - in some of them they have been lasting for fifteen and eighteen months that way. They are serious disorders that worsen with movement and intellectual works.
I consider that these wounded men are not fit for service and that they either have to be transfered to a rear service, or even to be proposed for temporary discharge.
MR C. VINCENT (Neurology Center of the 9th district, Tours) - Cranial wounded men, even if they have to go back to the front some day, cannot do it before a very long time - six months, a year.
To send them back earlier is, to my mind, dangerous for them, dangerous for others, all the more so if they are officers.
Concerning officers, prior to their return to the front, they should have to stay a long time at the deport, with compulsory riding, stay in camps or shooting range. Concerning privates, in a great majority of cases, temporary discharge would be advisable.
However there are special cases - cases of small trepanation without lesion of the dura mater (disc of trepanation) - in which the privates or the officers could go back to their service.
MR ROUSSY (Neuro-psychiatry Center of the Xth Army) - I fully subscribe to Mr Guillain's conclusions on formerly trepaned men sent back to the army. These subjects cannot stand violent explosions, they often cannot bear the helmet, and are soon sent back to military neurology services. It would therefore be advisable not to send to the army formerly trepaned men who have not completely recovered.
MR LAIGNEL-LAVASTINE - Concerning the way to act with cranial wounded subjects with subjective disorders limited to headache and some fits of dizziness that have been going on for months, without any other complication, here is what I have been doing for a year:
Privates who do not have any more hyperalbuminosis of the cephalo-rachidian liquid and accute disorders of the voltaic vertigo, are sent back to their deport.
However, officers, who generally ask too early to go back and whose cerebral functions have, in war commanding, much more importance than the same functions in privates, must not be sent back to deport prior to an even greater bettering.
MR CHIRAY (Head of the Neurology Center of the 10th district, Rennes) -
1. Concerning very mild cranio-cerebral wounded men, who have not undergone trepanation and with only superfical scratches of the skullcap, there can be no doubt - those wounded men must be sent back to the front.
2. Concerning cranio-cerebral wounded men whose brainpan and cerebral hemispheres have been severely affected, and who have such after-effects as paralyses, atrophies, spasms, important disorders of the sensorial organs, neither can there be any doubt - those subjects must be discharged.
3. The problem becomes more complicated concerning wounded men with a fairly important cranio-cerebral lesion, followed by trepanation, and who show various functional disorders. Those subjects can be divided into two categories: those who want to go back to the front, and those who do not.
Concerning those who want to go back to the front, there can be no major drawbacks to comply with their wishes if they are privates. However, if they are officers, considering the heavy responsibilities they can be weighed down by at a given moment, and the lapses that have been observed in similar cases, when the situation becomes critical, it is advisable not to comply with their wishes of returning to the front prior to very prolonged and thorough enough examinations.
Concerning those who do not want to return to the front, one must admit that when they show signs of cranio-cerebral lesions and signs of ensuing trepanation, we have to depend on their assertions about the various subjective disorders they complain of and we cannot force them back to the front. For such subjects, the only possible debate is between transfer to the auxiliary service or temporary or definitive discharge. In most cases, the latter measure will have to be adopted, even if we are convinced that those wounded men obviously exaggerate the actual disorders.
MR MAURICE VILLARET - 1. We must not send back to the front area the serious cranial traumatised subjects, even when free of all lesional manifestation, at least prior to a very long observation.
2. It is desirable, for trepaned subjects, to declare either prolonged unfitness for campaign with medical surveillance, or transfer to the auxiliary service in a position free from violent efforts and brutal changes in temperature and pressure, if they do not show any apparent nervous disorder, or temporary discharge (second category), if those disorders are not very pronounced (sensitive or visual disorders, fits of vertigo, sensitive or sensorial vertiginous epileptic equivalents, mild mental disorders), or discharge #1 with high renewable reward if classical symptoms of lesion of the nervous centers exist.
MR ANDRE THOMAS - Among the trepaned subjects who do not show any more subjective disorders, one can first identify the following group: trepaned subjects showing or having shown for a while unquestionable signs of organic lesion of the nervous system. This group merges with Professor Grasset's cranio-cerebral traumatised subjects. Those trepaned men must not be sent back to the war zone. Such is the wish that could, to my mind, become a Principle, according to what most of our colleagues have expressed.
MR GRASSET, head of the Neurology Center of the 16th District (Montpellier). - It seems to me that the facts we have observed at the Neurology Center of the 16th District and that have been communicated by Mr Villaret and Mr Jumentié, as well as the facts observed by Mr Guillain and several other colleagues, lead to the following conclusion: that any cranio-cerebral traumatised subject has for that very reason become unfit for armed service at the front for a very long time.
Mr Cestan having asked the definition of the cranio-cerebral traumatism, I accept the criteria proposed by Mr André Thomas: actual or anterior presence of organic cerebral symptoms.
As another of our colleagues suggested, during the period of unfitness, we should plan and demand thorough examinations in a Neurology Center, every six months for instance.
The employement of the unfit man (auxiliary service, deport, temporary discharge) would have to be adapted to each specific case.
MR REBIERRE (Neuro-psychiatry Center, Epinal) - When the decision initially taken concerning a cranio-cerebral traumatised subject who has recovered from accute phenomena, is his employement as unfit in the deport, after six months the doctor of the deport will have to send the subject to the Neuropsychiatry Center of the district in order to define his current state and take a new decision.
MR P. SOLLIER, head of the Neurology Center of the 14th District (Lyons) - In cases of mild subjective disorders and small loss of cranial tissue, we can try the auxiliary service or the deport with unfitness for campaign. When the disorders are more intense, long term leave or temporary discharge seem adequate, given that we do not know how long they will last or what remote consequences can occur later on.
When the subjective disorders are accompanied by more or less pronounced objective disorders, discharge #1 seems the only possible measure.
To sum up the principles that must guide us, I suggest the following method:
As a rule any soldier affected by a cranio-cerebral traumatism having shown at some point, having caused organic disorders, must not be sent back to the front, even if he does not show more than subjective disorders, and must be kept at the rear.
MR JEAN LEPINE (Psychiatry Center of the 14th District, Lyons). - The wounded affected by severe cranio-cerebral lesions are not, as a rule, fit for service at the front anymore. Military doctors' attention will have to be drawn on them, with a view to their examination - if necessary in a Neurology Center - and to their potential employement in interior services.
MR JUSTIN GODART - What seems to emerge from the debate is that, in cranial wounded subjects, it is necessary to search with great care for a number of disorders, the observation of which is important on a prognostical point of view. First, as the rapporteur clearly showed, headaches, fits of dizziness, then, as the other speakers said, vertigo disorders, labyrinthine disorders, alterations of the voltaic vertigo, and also visual disorders. It is also necessary to analyse intellectual disorders, emotional, sympathetic, circulatory, secretory, etc., disorders. Finally the examination of the cephalo-rachidian liquid must not be neglected.
Concerning the guiding principle to follow regarding those wounded men, it seems difficult and not desirable to reach an absolute rule - we always have to take into account specific cases. But the prevailing opinion seems to aim at sending back to the front cranial wounded men in very exceptional cases only. The necessary steps to be taken are mostly either temporary discharge or employement in interior auxiliary services.
We still have to debate on the objective signs listed by the rapporteur, but, in accordance with the latter, we had better defer the debate until later. It will be more profitable in a common meeting between neurologists and surgeons where the ones and the others can bring the results of their experience.
MR P. BOVERI (Military Neurology Service of Alexandria, Italy) - Regarding the late after-effects observed after the surgical healing of cranial wounds, we want to call attention on two facts we find worthy of notice:
1. Visual disorders
2. Intellectual disorders, especially following wounds in the left parietal lobe.
Our master, Professor Pierre Marie, was the first to show the importance of the examination of the visual field in cranial wounded men.
The penetrating sores of the occipital region almost certainly cause disorders of the visual sphere.
It is easily understandable that, following such wounds, all kinds of visual disorders can appear. We do not want to go through serious cases, with blindness, etc., that everyone is familiar with.
On the contrary it is mostly in cases of mild wounds in the occipital region that the examination of the field can give very important pieces of information regarding the unsuspected presence of metallic fragments in the brain, that radiography will later confirm.
In most cases, we have thus observed negative hemianopsic scotomas, which, as they do not cause any black spot, are nearly always ignored by the subject. These cases are very frequent. The subject only complains of a slight eyestrain and of some reading difficulty. The wound is perfectly healed and one could believe in a complete recovery.
The observation of hemianopsic scotomas is a sign that hints at the presence of intracerebral foreign bodies.
The second fact we have observed in cranial wounded men is an intellectual decline that have various manifestations but is striking in wounds in the left parietal lobe. We can say that almost all cranial wounded subjects - those, of course, with a lesion of some importance of the cortex - show psychic disorders, however minor and vague (asthenia, abulia, torpor, extreme emotionality, memory disorders, etc.).
When the lesion is situated in the left parietal lobe, the phenomena are very obvious, and the decline of intelligence makes these patients similar to children. In our neurology service in Alexandria we currently have several very clear such cases.
It seems to us that this fact gives a confirmation of Pierre Marie's theory on aphasia.
MR PIERRE BONNIER - In the debate that followed Mr Pierre Marie's report, a mostly informative and clinical debate, I did not want to ask and give a technical observation. I later regretted it, considering the way most our young colleagues conceive the clinical examination of vertiginous phenomena.
I thoroughly studied vertigo in the past, nearly a quarter of a century ago, at a time when that subject was not on the agenda. I have been able to describe and explain physiologically, define and classify all the modalities of that disorders, isolated from nearly all my colleagues, to which they have been revealed by the war. My definition of the sense of attitudes, which has gradually been accepted in neurologic practice, derives from this work of mine. And when I wrote that the clinical examination of the labyrinthine system and its centers had to be done through oculomotor disorders, and that it was through the study of the nystagmus, of the mydriases, of the deviations, of the tonic and clonic disorders of the musculature of the eye, of its failures and of a full picture of ocular complexes - to which I later added the labyrinthine forms of Ch. Bell's phenomenon -, that we had to explore the vestibular disarrays, I knew indeed that such notions, five, ten, twenty years later, would end up forming part of usual data.
But the old practice of that research, the account given in a series of writings and in my lectures at hospital, confirmed me in my observance of the following principle, often repeated: in order to be well acquainted with the functional disorders of an organ and its capacity, most importantly it must be left in its own physiology, not be spoken a language it does not understand, not be initially taken out of itself by imposed experimental conditions absolutely unfamiliar to the physiology in which it is specialised and organically differenciated. I advised, during the examination of the eye, to submit the ear to physiological stimuli corresponding to the functions of that organ, such as the centripetal pressures of Gellé, inspirations, various movements of the head, the eyes, etc., but I expressly advised against the tests in which one used modifying agents unfamiliar to the organic specialisation of the ear.
One does not benefit much from submitting the full mass of the two ears, the medulla oblongata, the cerebellum and the two hemispheres to a voltaic current, that puts the labyrinth in a situation totally unfamiliar to its legitimous functioning conditions. Similarily, an injection of hot water in the ear will certainly tell us how a subject whose tympanum is strongly irritated will react, but that brutal attack is far from the respect a physiologist ows to the marvel of delicacy our balancing system is.
There are other means to sound the ear deeply. They consist in speaking its own language, and if one wants to achieve that, the splendid chapter of its physiology will have to be studied somehow.