This
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.
SIRS,
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.
FIRST QUESTION
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.
Sleeplessness, nightmares.
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.
Objective signs.
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;
- Esquillectomie;
- 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.