Shell-shock and other neuropsychiatric problems

by Elmer Ernest Southard

This patient was first brought to Jena November 23, 1914. An illegitimate child, a moderately good scholar, he had worked as a mason until he went into the army, in 1912. He worked as a soldier chiefly in the officers’ casino because he got pains in his legs and knees in long drills. At the outset of the campaign, however, he withstood the heavy marching, although with difficulty. He was in his first actual skirmish September 20. A shell struck nearby and threw him several meters; whereupon he became unconscious and was carried away by the hospital corps. When he woke up he could not speak or hear. Ten days later, however, speech returned, and hearing returned in right ear; October, deaf in the left ear, and he could not hear a watch tick on the right side at a distance of 16 centimeters. He was examined at the otological clinic in Jena October 12, where the drum membranes were both found opaque, without reflexes or normal contours; hysterical attack on the caloric test. The next day, on the medical visit, there was a screaming attack. His plight seemed not so much simulation as one of traumatic hysteria.

Again, after his stay at the nerve hospital, another hysterical outburst was produced by a hearing test with vestibular apparatus, in the ear clinic, February 6, 1915. The diagnosis was nervous deafness with involvement of left ear.

The insomnia was successfully treated by sodium bicarbonate. There was a slight improvement in speech. In March body weight had improved, but there was a marked tremor of the right hand. In the next few months there was a progressive improvement in general well-being, in speech disorder, and in tremor. The auditory disorder remained unchanged. The man now works in his father’s garden.

This case appears to show a combination of psychic and mechanical injury. There are severe hysterical auditory and speech disorders. Although the auditory disorder is of mechanical origin, the speech disorder appears to be of psychogenic nature. It is somewhat remarkable that the ear tests almost every time produce hysterical attacks in the form of convulsive crying. Rather unusual is the general cutaneous hyperalgesia, more marked about the ears.

Shell-shock (distant, neither seen nor heard); left tympanum ruptured; semicoma eight days: Cerebellar syndrome and hemianesthesia. Recovery, nine months.

Case 218. (Pitres and Marchand, November, 1916.)

A lieutenant underwent “shell-shock” either at night or in the early morning, September, 1915, the shell bursting at a distance. He neither saw nor heard the shell, lost consciousness and was eight days semicomatose, failing to recognize his wife.

On recovering his senses, he could not get about, as he had lost his memory, having to write down his room number and be warned of meal times. He was led about like a child. He had a continuous headache on the right side and pains in the occiput and along the spinal column, as well as in the right leg as far as the heel. These leg pains were lightning pains. Walking was difficult, staggering, leaning to left. Weakness of right arm and leg; right-sided hemianalgesia. Complete insomnia. During November there were frequent urgent desires to urinate day or night. Evacuated to the oto-rhino-laryngological center in Bordeaux, December 13, for examination of ears. The right ear was found normal, but there was a rupture of the left tympanum. There was at this time a trismus. The jaws were opened with the dilator and the man had a syncope during this operation. The question of surgical intervention for a cerebral lesion was raised, but he was first sent to the neurologists at Bordeaux. There, December 31, he was found with a facies of anguish, unstable gait, inclination to the left in walking; no Rombergism; occasional dizzy spells. In walking, the right foot was pointed outward and on request to direct it forward he complained of pain in the loins, reaching as far as the scapula. Walking with eyes closed, he leaned to the left and lost balance. With eyes open, no disorder of balance. With eyes closed, the body leaned backward. If requested to go back, he failed to flex his legs to keep balance. If he was asked to put a foot upon the chair in front of him, he immediately fell backwards. He could not support his body on the right leg more than a few moments. He had difficulty in raising both legs from the bed at one time and he could lift the right leg not so high as the left. Movements of the legs were performed hesitatingly and slowly and with greater difficulty with eyes closed.

He could not thread a needle and could hardly dress himself. Eyes closed, he could with difficulty perform the finger to nose test; eyes open, with much less difficulty. Adiadochokinesis; muscular strength less in right than left; plantar reflexes absent; knee-jerks lively; hemianalgesia, right side. Loss of deep and bony sensibility on right side and diminution of testicular sensibility. Retraction of visual field, right; diminution of smell and loss of hearing, right; position sense absent on this side; stereognostic sense preserved. Mentally, memory was poor; he was unable to read or do mental work. He slept little and had bad battle dreams. He was very impressionable and emotional and constantly complained of occipital pain. He had lost 8 kilos weight.