Elmer Ernest Southard

“ But every time that the expert suavely states that Shell-shock is nothing but psychoneurosis, that expert runs the risk of hurting some patient who may or not have a psychoneurosis but has been called psychoneurotic. All the while, of course, the suave expert is perfectly right—statistically. In fine, the man you have called a victim of Shell-shock is probably a victim of psychoneurosis, but only probably! ”

“ If the tremor of the legs got more energetic, the patient would get up and take a few steps. Any movement, such as laying hold of an object, carrying a spoon or a glass to the mouth, led to an exaggeration of the tremors in such wise that the tremor of multiple sclerosis in its most extreme form was recalled. It was very hard for the man to eat. If the eyes were closed, the tremors grew more marked. The emotion caused by sudden noise or sharp command or memory of his trench life caused motor crises, with coarse, generalized movements, and even loss of balance. ”

“ As to the tremophobia, this patient says “In the tramway or in the subway, I perceive that people are looking at me, and that gives me a terrible feeling. I feel that I am inspiring pity. Some excellent woman offers me her seat. I am deeply touched; but if they look at me and say nothing, what are they thinking of me? This anxiety makes me suffer a good deal. If I am able to speak it is less painful to me, for then it is obvious that, despite my trembling, I am not a coward. What a sad situation this is!”
Meige remarks that therapeutics is not especially successful in these cases of tremor. ”

“ If it is the idea to make me nervous by removing the air from me, by prescribing rest in bed—a punishment only suitable for a boy who cannot keep himself neat—and such chicaneries, these philanthropic attempts are bound to fail on my robust peasant nerves. Of course I know that money considerations make the stay of every paying patient desirable, but I am really too good for that. ”

“ Those who handled best the neuropsychiatric problems of the present war were in large part qualified not merely by a knowledge of psychology and psychiatry, but far more by a thorough training in organic neurology. The problems of psychiatry can be grasped fully only by those who have a fundamental knowledge of the anatomy, physiology, and diseases of the nervous system.
Dr. Southard, preëminently a neuropathologist, is well grounded in organic neurology, and shows at every turn his capabilities for considering the neuroses, psychoses, and insanities from the standpoint of the neurologist. ”

“ However, in the middle of January, 1915, this man began to suffer from headaches and insomnia, with vertigo and buzzing in the head, “as if an airplane inside.” Sometimes arms and legs would stiffen, and the man would tremble, have to lie down, and even lose consciousness for a quarter of an hour, waking up tired, wandering, and with feelings in his head. These crises, at first occurring every week, later grew frequent. Finally there was a very complete attack, in which he fell out of bed, got up, made several turns about the room, and went back to bed ”

“ He got into bed alone.
Next day the patient could walk better and began to talk, but preserved the same absorbed attitude. He told, in monotonous voice, of the shells that his squad had received and of the dead that he saw about him. August 27 he woke up and was unable to tell how he had come to the hospital. He told how the regiment had been bombarded for a time and how a shell burst near him; how he got a splinter in the buttock (of which the contusion was still visible) ; and how he had been thrown down by the windage of the shell. ”

“ Up to the time of his accident, this man, a farmer, had never had any motor trouble, nor was there any nervous disorder in any of his relatives. He had been in several conflicts, August 24-25, September 4-6, in the Argonne and in the Haute Meuse, and he had never found it hard to keep up with his comrades. In fact, once in the Haute Meuse, he took part in an exceedingly difficult and hasty retreat, and only a week before the shell-shock above described he had put in a very long march. Thus a man, perfectly normal before the shock, had fallen into a general state of slight muscular paralysis. ”

“ A good deal remains doubtful: Mendelssohn remarks that the sphincter disturbances ought to be related to disorder of the fourth and fifth sacral segments, and the knee-jerk and Achilles jerk absence with disorder of the lower lumbar, and sacral region; the abdominal reflex disorder with the low thoracic lesion; the distribution of the anesthesia ought to indicate a lesion in the lower part of the spinal cord. Was not the hemorrhage therefore lower down than the spot where the vertebrae were displaced? It is surely of prognostic note that the eschars did not necessarily foretell a fatal outcome ”

“ One of Meige’s victims of shell-shock tremors was an artist. He stood the hardest sort of trench life for many months without disorder. Under particularly sharp fire, “the machine went off the track,” as the artist said, and he began to tremble. Both arms and head trembled, but especially the head, which was subject to small sidewise oscillations, variable in degree, and almost permanent,—a sort of vibration which the patient could diminish somewhat by stiffening his neck muscles. His manual tremor was not exaggerated by voluntary movements. ”

“ Dumbness is, by far, the commonest disorder of speech, occurring in about ten per cent of shock cases in the first thousand cases of shell-shock seen by Lt. Col. Myers. Stuttering and jerky speech have occurred in about three per cent. Loss of voice is rarer.
As against the view of Babinski, that mutism, being curable by suggestion, must have been produced by suggestion, Lt. Col. Myers argues that the stupor preceding mutism is the antithesis of suggestibility and is, in fact, a condition of extreme autofixity. ”

“ The amnesia may be incomplete, a sort of dysmnesia, or twilight memory, but as a rule, the amnesia is lacunar. The toxic and infectious amnestic confusions have a loss of memory for events following the onset, but these war cases of amnestic confusion have the loss of memory running back far into the patient’s past, slipping from the mind his name, his parentage, age, and vocation. Instead of being like the toxic confusional amnesia, an anterograde amnesia of fixation, the Shell-shock amnesia is apt to be antero-retrograde. ”

“ In short as the first phase of diffuse over-emotionality had been succeeded by a second of obsessions, so the obsessive phase was succeeded by a third phase of mild loss of the feeling of reality. The first phase following the wound was one of disorder of attention, of memory, and in fact of all the mental functions, associated with tremors, tachycardia and dizziness. The second phase seemed, as it were, to crystallize intellectually the anxious apprehensiveness of the first phase. ”

“ A Naval Service man, 20, was thought to have peripheral neuritis. A long history of pain and numbness in arms and legs, a well-marked analgesia and anesthesia over the anterior aspects of forearms and legs, and an anesthetic band across the front of the chest, seemed consistent with the diagnosis. The calf muscles tightly squeezed yielded no pain. Pins could be thrust without pain into the anesthetic areas. When told to say yes when the pin was felt, and no when it was not felt, the man persistently said no when the areas noted above were touched. The deep reflexes were normal. ”

“ According to Myers, the mutism is in nearly every instance closely dependent on some form of stupor, being generally the relic of such stupor after it has passed off. Let the loss of consciousness be a profound stupor due to the lifting or burial of the patient, then from this stage there will be a transition to a state of ordinary stupor in which intelligence is active but the patient is unresponsive to stimuli. The patient is in a condition called by Myers excommunication, in which the inhibitory process may be regarded as protecting the individual against further shock. ”

“ Movements of the left leg were somewhat weak, the left knee-jerk was slightly brisker than the right; ankle clonus could be obtained on the left side and Babinski second sign (paralyzed leg rising higher than the normal leg in combined flexion of thigh and pelvis) . When the man tried to walk, the left leg moved rapidly from side to side round the point of contact of the toes. When the right leg moved forward, the left dragged behind in irregular movement.
Every effort to cure the patient by means of suggestion during hospital care for a month entirely failed. ”

“ According to Babinski’s figure, the organic factor acts as a bait for the hysterical symptoms. According to the Salpêtrière experience, hysteria is incapable of producing a real superficial and deep anesthesia such as is mentioned for this case. For example, no hysterical patient in the Charcot clinic, according to Sicard, could undergo a scalpel operation without some general or local anesthetic. When, therefore, a true deep anesthesia occurs, Sicard’s conception would be that the anesthesia is not a truly hysterical one but belongs to the group of physiopathic phenomena. ”

“ The sphygmometric oscillations of the forearm were twice as small in the paralyzed limb as in the healthy limb, but the systolic blood pressure was normal. There was a mechanical over-excitability of the muscles, and a slight exaggeration of the bone and tendon reflexes. The paralysis was in part of reflex (physiopathic) nature. On account however, of the completeness of the monoplegia, and the fact that the reflex paralyses as a rule affect only the distal portion of the limb, the diagnosis of hysteria had to be made in addition to the diagnosis of reflex disorder. ”

“ A Milanese workman, 28, was exposed to the sun on sentry-go and had an attack of convulsions, on awaking from which he found himself in hospital. He always had attacks in reaction to emotion. One day, in a quarrel provoked by jealousy concerning a prostitute, he apparently lost his mind, whipped out a hunting-knife, and wounded a comrade. Thereafter he lay unconscious until the next day. ”

“ A true neurasthenic, however, ought not to be a confused person. He is a man with a rather unusual clarity of view as to his situation; and his trouble appears to him to be somatic rather than as of the nature of a depression. He feels that, if he could only rest, he could be cured. Neurasthenia, according to Lépine’s war experience, is practically always the disease of a highly cultivated nervous system, and appears in men who have undertaken responsibilities. ”

“ A third fugue, a few weeks later, sent him back to court-martial, and thence to be examined by alienists. He was perfectly conscious at the time of the fugues and understood his duties and possible punishments. All he would say was, “It is stronger than I am.” Fear outweighed every consideration after the episode of the shell burials.
The man may be regarded as a hypobulic, somewhat feebleminded person, able to get on in civil life but thrown out of gear by war. Of course, the concept of fear as a disease can easily be overdone ”

“ An Italian soldier of the Class of 1895, a peasant (family healthy; non-alcoholic; good scholar) was, July 19, 1915, helping drag a heavy cannon up hill. The big gun slid, hit several men, and grazed the patient, making a slight abrasion on his leg. He immediately lost consciousness, and arrived at the camp hospital in a stupor, which lasted so long that catheterization was necessary.
A week later he was observed in hospital, immobile and non-reactive, with a swollen abdomen and fecal impaction. The pupils were widely dilated and reacted poorly to light. ”

“ The patient can walk perfectly, though sometimes there is a pseudocoxalgia and lameness. Attempts to straighten the body lead to visible forcible contractions of various muscles, but the kyphosis remains persistent. There is a sense of active resistance on the part of the patient, which can be demonstrated by palpation. If an active attempt at straightening is made, lumbar or sacral pain develops, followed by a very lively and emotional state of anxiety on the part of the patient, with interrupted and accelerated breathing, an expression of terror in the face, and a rapid pulse. ”

“ An example of such an incompatibility might be that of a patient who should, three months after a sudden hemiplegia, show complete or almost complete flaccid paralysis and but slight exaggeration of tendon reflexes—yet the Babinski reflex. Of course, the Babinski reflex would permit a diagnosis of pyramidal tract disease. Yet a sudden intense hemiplegia lasting three months, if it were merely a matter of pyramidal tract disorder, ought to show hyperreflexia of a pronounced degree as well as contracture. ”

“ A man, injured by shell fragments in the head and sustaining fracture of both arms and a thigh, got well of his wounds, but fell into a nervous state with headache and dizziness. He was given prolonged observation psychiatrically and then sent back to the front as fit for service, but was shortly returned to hospital and sent to Cologne under the suspicion of simulation.
The picture was of unilateral increase of tendon reflexes, accelerated pulse, disorder in the intake of ideas, difficulty in finding words and delayed associations. His gait suggested a psychogenic disorder. ”

“ A man (also injured in 1906 by the fall of a heavy weight on his back) went to France in 1914 as a soldier, and eight months later was hurled into a shell hole so that his back struck the edge. He was rendered unconscious. Upon recovery of consciousness, the right leg was found to be swollen, and there were severe pains in the legs and back.
Upon return home the patient went from one hospital to another, for the most part unable to walk, suffering from agonizing pain in head and eyes. Insomnia and waking dreams. ”

“ Marriage states that the psychical deafness due to shell-shock is usually bilateral and absolute. It is accompanied also, as a rule, by other nervous signs and symptoms, such as aphonia, tubular vision, paralyses, and anesthesias. Milligan and Westmacott state that the deafness is due to a functional suspension of neuronic impulses. They regard the brain as in a state of physical fatigue, and the mind as in a state of strain. There is no organic lesion. The neuronic impulses which are temporarily suspended are those which run from the higher cortical cells to the periphery. ”

“ Roussy and Lhermitte say that emotion and concussion are the causal factors; but in a case like 341 we have persistent war dreams of the same general nature. Such a case as Mott’s would not be regarded as one of oniric delirium, for the patient is not living throughout the day in a dream, but merely has certain set dreams. The true oniric delirium cases may lead to fugues of medicolegal importance. Mott’s conception is that the terrifying experiences that come to light in the dreams are repressed by the conscious activity of the mind in the waking state. ”