Shell-shock and other neuropsychiatric problems

by Elmer Ernest Southard

The chances are, if we should collect all our civilian cases of Railway Spine and of industrial accident with traumatic neuroses, we should be able to prove this same strange relation between slight wound in a particular part of the body and the local determination of hysterical symptoms to that region. Of course, the determination follows no known laws of nerve distribution to skin or muscles, and the effect is apparently a psychopathic or, at all events, a dynamic process without clear relations to the accepted landmarks.

I do not mean to suggest, that aside from the hurry of war, the differential diagnoses here are more difficult than those in civilian practice; but the difficulties are at least as great as those that have faced the civilian practitioner. What needs emphasis is that just because we have concluded that the statistical majority of the cases of so-called Shell-shock belongs in the division of the neuroses, we should not feel too cock-sure that a given case of alleged Shell-shock appearing in the war zone or behind it is necessarily a case of neurosis.

After the early “period of election” for psychotherapy in the war zone has passed, there can be no excuse except general war conditions for not according to every case of alleged Shell-shock a complete neuropsychiatric examination, having due regard to the ideas of Babinski concerning medical suggestion of new increments and appendices to the original hysteria, developed in battle or shortly thereafter.

We have, however, been able to find in the literature good instances of puzzling diagnosis in which such conditions are in evidence as acute meningitis of various forms, hydrophobia, tetanus, and the like.

Especially in the diagnosis against Shell-shock hysterias we may need to think of the abnormal forms of tetanus, to which an entire book in the Collection Horizon has been devoted. The differential diagnostic tables here draw up distinctions between local tetanus, involving, let us say, the contracture of one arm, as against a hysterical monoplegia.

79. The focal brain group of psychoses here termed encephalopsychoses, is illustrated by a comparatively short series of cases, 16 in number ([Cases 103-117]). Many more cases of this group are presented in [Section B, On the Nature and Causes of Shell-shock]. The motive here is to show sundry effects of focal brain lesions produced in the war and not related with shell-shock. [Case 103] was the curious case (see above) of aphasia with hemiplegia—not upon the right side, but upon the left side. There had been a wound in the left parietal region, and the aphasia was presumably consequent upon a direct affection of the left hemisphere. On the other hand, the left-sided hemiplegia may probably be regarded as due to lesions on the right side of the brain produced by contrecoup. The case not only has surgical implications and suggestions of importance, but also it throws some light on the possibilities in concussion of minor degree. As the cases in [Section B (On the Nature and Causes of Shell-shock)] show, shell-shock, the physical factor, is apt to produce anesthesia and paralysis or contracture on the side exposed to the shell-shock. The means by which these symptoms ipsilateral with the shock are produced is commonly thought to be the “hysterical mechanism,” whatever that may be. Lhermitte, however, suggests that in some cases such phenomena might be due to an actual brain jarring with contrecoup effects. However, it must be granted that [Case 103] did not come to autopsy.

80. [Case 104] might perhaps better be considered in the section on alcoholism, since a gun-shot wound of the head may be regarded as having produced intolerance of alcohol in the classical manner, similar to that described in [Case 97], wherein, however, the trauma was ante-bellum. Peculiar crises associated with cortical blindness, vertigo, and hallucinations, characterized a case of brain trauma by bullet ([Case 105]). [Case 106] is that of a Tunisian, who before the war had had a number of theopathic traits with mystical hallucinations, but after a gun-shot wound of the occiput developed lilliputian hallucinations and micromegalopsia.

81. [Cases 107-112] are cases of infection or probable infection. Cases [107] and [108] are instances of meningococcus meningitis, the second of which appears to have followed shell-shock (?). [Case 107] led to psychosis with dementia. [Case 109] developed a meningitic syndrome, which followed shell explosion a metre away, the syndrome lasting 14 months. The spinal puncture fluid was several times found to contain blood. There was apparently no infection of the fluid as in [Case 112]. Possibly [Case 109] should be set down as an unusual example of shell-shock psychosis, chiefly dependent upon meningeal hemorrhage.

82. A syphilitic ([Case 110]) in which appropriate tests were made and found positive, showed at autopsy a yellowish abscess or area of softening in the right hemisphere. The curious point about this case was that the only neurological phenomenon in the case was the absence of knee-jerks in the early part of the day; later in the day, they would appear once more. Possibly [Case 111], a case of somewhat doubtful nature but presumably of organic hemiplegia, ought to be aligned more with the group of cases illustrating the nature and causes of Shell-shock. The case was not one with the physical factor shell-shock, since the phenomena began ten days after a serene convalescence following an operation for chronic appendicitis. Perhaps the case was one of organic lesion grafted upon a neurosis.