Shell-shock and other neuropsychiatric problems

by Elmer Ernest Southard

Meige has studied shell-shock tremors, especially those occurring without external wound.

A corporal was with his squad on the Nouvron Plateau, January 13, 1915, when he was thrown against the wall by a bursting shell, which killed or wounded several comrades but did not wound the corporal. Whether he lost consciousness is unknown, but he lay on the ground for some time, until he could be moved through a communication trench. After the explosion he began to tremble, and was still trembling on his trip back. Constantly trembling, he lived on at the front for a fortnight, but without eating; and, although he had been a good rifleman, he had lost all his former skill with a gun.

There was a delay of a month before evacuation, but the trembling did not cease, and he was passed through various units, to the neurological center at Villers-Cotterets, where he remained for two months,—April 13 to June 15, 1915,—with a diagnosis of hysterical chorea. He was examined by Guillain, who found, besides the generalized tremors, lively knee-jerks and Achilles jerks, an excessive emotionality, particularly marked when the guns were going or bombs bursting. Lumbar puncture yielded a perfectly normal fluid.

June 19 the corporal went to the Salpêtrière under P. Marie. July 14 he was evacuated to the civil hospital of Arcueil, where he remained till September 24, when he was sent home to convalesce, from October 26 to December 15.

He returned to the Salpêtrière December 15, 1915. Throughout these various movements from hospital to hospital, his status was unchanged. At the time of report about a year after shell-shock, he was still constantly and uniformly trembling. All four limbs were affected, perhaps the right arm and the left leg more markedly. There was no tremor during sleep, but there was a tremor when the patient lay awake in dorsal decubitus just as when he was sitting or standing. The tremor was worse in the evening than in the morning, and the patient could get to sleep only very late. There was slight tremor of the head; the eyelids and the tongue showed a few tremors, which were not synchronous with those of the limbs. Nystagmus was absent. To diminish the effect of the trembling, the patient held his forearms flexed and kept his elbows close to his body. If the trembling of the legs got intense, the patient would rise and walk a few steps. Any movement, such as carrying a spoon or a glass to the mouth, led to an exaggeration of the tremors; and there was at this time a suggestion of the intention tremor of multiple sclerosis. The tremor was increased when the eyes were closed. Any sudden noise or sharp command, or recalling to mind of trench service, would bring about extraordinary motor crises, in which there was an intense and generalized tremor, so the patient would lose his balance. Any attempt at eliciting reflexes would produce generalized violent tremor. Sensations were normal; tendency to hyperidrosis; pulse in repose, 60, rising to 120 if one struck the table sharply.

Meige remarks that a number of examples of tremors suggestive of Parkinson’s disease were observed in the War of 1870. Might the explosion have caused properly situated lesions in the encephalon of such a nature as to produce a Parkinsonian tremor? The tremors were stationary, and if due to some lesion, the lesion remains now exactly what it was at the beginning. There was no digital tremor such as is characteristic of Parkinson’s disease. Moreover, the intention tremor of such a patient, rather than Parkinson’s disease, suggests multiple sclerosis, of which latter disease, however, there is no other sign. Nor does there seem any evidence that these tremors were of cerebellar, paretic, goitrous, or of any definite toxic origin. On the whole, Meige regards it as a neuropathic manifestation resembling what is found in traumatic neurosis. He believes that there is not sufficient evidence that it is the consequence of any structural change in the nervous system.

Meige remarks that the analysis of any case of tremor must take the mental state into account. This patient, perfectly conscious of his tremors and their critical exacerbations, was much chagrined thereby. He suffered mentally from his impotence, especially when bystanders would intentionally bring about his paroxysms. He looked like one shuddering from fear, and it is actually probable that he was afraid of his own tremors and shuddering. He was, besides subject to tremor, also a victim of tremophobia,—a kind of phobia described some years since by Meige, somewhat resembling ereutophobia, or fear of blushing, described by Pitres and Régis.

Four hours in a freezing bog: Hysterical glossolabial hemispasm twelve hours after rescue. No sensory disorder of face or tongue; sensory disorder of arm, but no motor disorder.