Shell-shock and other neuropsychiatric problems

by Elmer Ernest Southard

A month after the admission of the patient to the nerve hospital of the psychiatric clinic in Jena, there had been no essential change in the immobility and contracture in extension in the left leg. Accordingly, with the permission of the patient, he was placed in deep chloroform narcosis, and the knee-joint was bent at a right angle and fixed in approximately that position with a bandage. This experiment failed because, while the patient was waking out of his narcosis, the leg slipped back into extension, breaking the bandage. Accordingly, deeper narcosis was undertaken, and the leg fixed at a right angle in a plaster cast.

While the patient was coming out of narcosis, it was evident that he had been dreaming of battle scenes. In fact, Binswanger remarks that these dream pictures and the words spoken while going under and coming out of narcosis, are curiously demonstrative of “sympathy with the enemy,” for while waking out of narcosis, he cried: “Dost see, dost see the enemy there? Has he a father and mother? Has he a wife? I’ll not kill him.” At the same time, he cried hard and continually made trigger-movements with his right forefinger.[6] In point of fact, throughout his waking treatment, no one was able to learn what was going on in his mind, his sleep was good and deep, and his emotional state was entirely quiet and patient.

[6] Compare sentiments of a Russian in narcosis ([Case 319], Arinstein.) See also [Case 181] (Steiner).

As the patient was coming out of chloroform and regaining consciousness of his surroundings, he was repeatedly and persistently assured that the bending of his leg was now accomplished and the cramp removed. All that he would now have to do was to get back the strength of his leg.

During the next few days he complained of violent pains in his left knee-joint and in the ankle-joint, but he remained in good spirits and full of confidence. Accordingly, in five days the plaster was removed and the contracture in the knee-joint was found to be completely absent; the knee was easily movable. The ankle-joint was but slightly movable. He could accomplish slight active flexion of the knee-joint while lying in bed, and the toe-joint had already, before the narcosis, been both actively and passively mobile. After a few days, exercises in walking were begun. The patient had a little difficulty with his left knee-joint in walking, walking in fact as if with knock-knee. The foot was not well raised from the ground on account of the persistent stiffness of the ankle-joint. Walking, however, improved daily. He walked for three hours, resting at intervals.

A sensory examination showed that the upper limit of the analgesia had come down five centimeters from its former level, now occupying the left foot and leg up to the junction of the lower with the middle third. There was now a zone of anesthesia interposed between the normal skin of the upper thigh and the anesthetic-and-analgesic skin of the lower thigh and leg. Upon the posterior aspect of the leg, the analgesia and anesthesia had disappeared to a point at about the middle of the upper thigh.

About five weeks after the narcotic experiment, the extended left leg could be actively raised while lying in bed, up to the full extent, with slight tremors. The patient described himself as fatigued by the active movements of this leg. The ankle-joint remained less effective. There was still a trace of resistance to passive movements. Although the passive movements of the toes were normal, active movements of these were weak and hard to execute. There was still a trace of difficulty at the knee in walking and the gait was awkward, trepidant, precipitate. He could get about without a cane, however. If unobserved, his posture was more certain and free. If he exerted himself hard, severe parietal headache on the right side would develop.

It was then proposed to the patient that another narcosis would rid him of the stiffness in his ankle-joint. He feared narcosis and was told that regular and energetic voluntary movements would also rid him of the stiffness. These will exercises consisted in his directing his whole attention to his left ankle-joint until he felt it. Then he was given the command: “Let go the joint”—whereupon he would take his attention away from the ankle-joint at once. In this way, he was told, his will would make the ankle-joint mobile. Meantime he was given twice daily a gram of bromophenacetine for his parietal headache.

The result was a rapid recovery. There were still a few traces of difficulty at date of report. The zone of sensory loss had retreated to the ankle, with a cuff-like zone of hypalgesia above the definite zone of analgesia and anesthesia.

As to the previous nature of this case, although there was neuropathic heredity on the mother’s side, there had been no sign of any individual neuropathic disposition. He had been a volunteer since 1911 in a guard regiment of infantry. His military training had been well borne; in the war he had fought through 20 battles. On November 11, 1914, in a storming attack, he had had his breeches burned from the effects of a shell. He had fallen, unconscious; the unconsciousness lasted about eight hours. He found on awaking that he had had nosebleed. When he wanted to get up, he found that his left leg was completely paralyzed and insensible; in fact, he thought it had been cut away. He crawled for about three meters to a trench in which there were several wounded. In the evening he was taken by automobile to a field hospital, and on the 17th was removed to a reserve hospital at Erfurt. Thence he was transferred to the Jena Hospital, January 25, 1915.