Shell-shock and other neuropsychiatric problems

by Elmer Ernest Southard

A farmer, 22, of the foot chasseurs, who had been in various hospitals with a variety of diseases before his injury, was evacuated June 2, 1916, for “contusion of back,” to the temporary hospital at Bussant, from which he was evacuated to Pontarlier for “contusion of back and cerebellar shock” and thence, July 21, to Besançon for “internal contusion and cerebellar shock”; thence to four other hospitals from July 31 to February 17, 1917; finally to the Hospital at Veilpicard with “functional disorders, paraplegia, trepidant astasia-abasia.”

It seems that he had lost consciousness for fifteen days and had thereafter been paraplegic with retention of urine. The abdomen had then increased in size in such wise as to be termed a nervous pregnancy, grossesse nerveuse. The evolution of this pseudotympanites was probably related to the presence of the same so-called “big belly” of a patient who had been in a neighboring bed from May, 1916, onwards. The feet were in equine position with toes flexed, suggestive in all ways of hysterical paraplegia. The abdomen looked like that of a woman six months pregnant and measured 78 centimeters in a plane passing through the anterosuperior iliac spines and the umbilicus. The abdomen was hard, tense, swollen, and on palpation, gave out a low, tympanic note. When the diaphragm was mobilized progressively and slowly, the tympanites could be made to disappear. Slow pressure on the abdomen with flat hands effaced the swelling for the time being; but upon release of the hands the abdomen would swell up again as before. Pressure on the abdomen produced a contracture of the recti. Forced flexion of thighs on pelvis (as suggested by Denéchau and Matrais) also caused the swelling to go down. Faradization of the phrenic nerves in the neck caused respiratory movements with a slight diminution in the volume of the abdomen. There was an obstinate constipation requiring daily lavage. Respiratory movements were short and rapid and of the thoracic type. Abdominal compression caused the respiration to assume almost a normal rhythm. X-ray examination of the abdomen, after 50 grams of bismuth carbonate had been taken in three spaced doses the evening before, showed the intestine to be distended by gas in such wise that the lower border of the liver became clearly visible, as after insufflation of the stomach. The bismuth was found in the large intestine. The splenic angle filled with bismuth was low. On compression the splenic angle was raised with the diaphragm.

The main features of this disease are the large abdomen, simulating what has hitherto been found chiefly in females under the name of nervous pregnancy, but also suggesting a tuberculous peritonitis (one patient was actually evacuated to a hospital for tuberculosis with this disease); gastro-intestinal disorder with aerophagy, aerocoly, and obstinate constipation (one case also showed almost daily vomiting). The genesis of the condition appears to be a contracture of the diaphragm in a low position of forced inspiration. The condition may be termed a diaphragmatic neurosis.

Psychotherapy was applied, the patient was requested to walk, and the movements made in walking required such an intense respiration that the diaphragm was forced to function, whereupon the “big belly” disappeared. The digestive disorders then rapidly disappeared. These authors suggest the name of catiemophrenosis.

War stress; collapse going over the top: Neurasthenia (hereditary taint; alcoholism).

Case 349. (Jolly, January, 1916.)

A German soldier, 35, of a nervous make-up (his mother was nervous, and he had been nervous and tremulous and easily excitable, and alcoholic to the extent of at least 5 glasses of beer every night), was called to the colors in September, 1914. He got through his training well; in May, 1915, was on very strenuous duty in a very exposed position, had frequently to stand up under heavy shelling, had a number of frightful experiences, was surrounded by corpses and mutilated bodies, and frequently took part in storming attacks. His nervousness came to a head with some suddenness; just as he was about to “go over the top,” he had no strength for the effort and collapsed. Thereafter he could no longer stand shelling, could not speak, and was inattentive to surroundings. When he was examined by a physician he fell asleep in his presence, although sleep had latterly been almost impossible on account of the shelling. He was immediately put on the hospital train and taken to the reserve hospital in Nuremberg, where he presented an appearance of extreme exhaustion, wept, seemed much fatigued, and trembled all over whenever he started to do anything. He was very easily excited and especially sensitive to noise. There was a fine tremor of the whole body and especially of the head; the knee-jerks were increased; there was a moderate vasomotor reddening of the skin after stroking; his tongue was heavily coated; but there was no other evidence of internal disorder. His pulse was strong and not rapid.

The patient got well gradually, complained at first of bad dreams, and was given to weeping. The tremors slowly improved. The patient grew better in a hospital at home.

As to the diagnosis of this case, Jolly regards it as one of nervous exhaustion. The remarkable feature is the tardiness with which the symptoms developed under the stress of war. Such a patient would probably never develop a neurasthenia under normal peace conditions. After recovery these patients may be sent back for garrison duty or for other work not directly connected with the firing line. As for the tendency to desire a pension, this wish, according to Jolly, must be strenuously opposed, both in the interest of the state and that of the patient. If there is no will to get well, some of these patients are found vibrating from garrison service to furlough and to hospital.