  La divina giustizia di qua punge quell’ Attila che fu flagello in terra. Divine justice here torments that Attila, who was a scourge on earth. Inferno, Canto xii, 133-134. The data from all the belligerent countries, collected in this book, go far to prove that, whatever at last you elect to term Shell-shock, you must pause to consider whether your putative case is not actually: A matter of spirochetes? The response of a subnormal soldier? An equivalent of epilepsy? An alcoholic situation? A result of neurones actually hors de combat? A state of bodily weakness (perhaps of faiblesse irritable)? A bit of dementia praecox? One of the ups and downs of the emotional (affective, cyclothymic) psychoses? An odd psychopathic reaction in which the response is abnormal not so much by reason of excessive stimulus as by reason of defective power of response? On a simpler basis, is not our Shell-shocker just a banal example of hysteria, neurasthenia, psychasthenia; and is not this psychoneurotic more peculiar in his capacity to be shocked than are the conditions that purvey the shocks? Put more concretely in the terms of available tests and criteria, open to the psychiatrist, does not every putative Shell-shock soldier deserve at some stage a blood test for syphilis? Should we not be reasonably sure we are not facing a man inadequate to start with, so far as mental tests avail? Should we not verify (even at considerable expense of time and money by so-called “social service” methods) the facts of epilepsy and epileptic taint? Of alcoholism? And so on? There can be no two answers to these questions. Upon the following page is a practical grouping of mental diseases, devised in the first place, not for war psychoses, but for the initial sifting of psychopathic hospital cases. Now A further inspection of this grouping of mental diseases shows not only that it contains many conditions not usually termed “insanity” (such as, e.g., feeblemindedness, epilepsy, alcoholism, sundry somatic diseases, psychoneuroses), but that these conditions are presented for practical purposes in a certain seemingly arbitrary order. Without attempting to justify this selection of scope (not too wide for modern psychiatry, most would readily acknowledge), I shall draw out a little further what I consider to be the virtues of the order selected. In the first place, all will concede, some order of consideration of collected data is a prime necessity to the tyro. Without an order of consideration the diagnostic tyro is but too apt to find in the best textbooks of psychiatry (even more easily the better the textbook) all he needs to prove that the case in hand is—almost anything he selects to make his case conform to! And how much more dangerous this debating-society method of diagnosis (by choice of a side and matching a textbook type) may become in the fluid and elastic conditions of psychopathic hospital practice, can readily be observed by one who contemplates the formes frustes and entity-sketches that the “incipient, acute, and curable” group of cases presents. Chart 1 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| I. | Syphilitic Psychoses | SYPHILOPSYCHOSES |
| II. | Feeblemindedness | HYPOPHRENOSES |
| III. | Epilepsy | EPILEPTOSES |
| IV. | Alcoholic, Drug, and Poison Psychoses | PHARMACOPSYCHOSES |
| V. | Focal Brain Lesion Psychoses | ENCEPHALOPSYCHOSES |
| VI. | Symptomatic (Somatic) Psychoses | SOMATOPSYCHOSES |
| VII. | Presenile-Senile Psychoses | GERIOPSYCHOSES |
| VIII. | Dementia Praecox and Allied Psychoses | SCHIZOPHRENOSES |
| IX. | Manic-Depressive and Allied Psychoses | CYCLOTHYMOSES |
| X. | Psychoneuroses | PSYCHONEUROSES |
| XI. | Other Forms of Psychopathia | PSYCHOPATHOSES |
No conclusions are intended to be drawn in these introductory pages. Such conclusions as are risked are placed in the Epicrisis (see Section E). But so much can be said: If we are ever to surround the problem of Shell-shock (intra bellum or post bellum), we must approach it with no artificial and À priori limitations of its scope. We must not even agree beforehand that Shell-shock is nothing but psychoneurosis: that would be a deductive decision unworthy of modern science. In the collection of these cases, I have tried to place the topic upon the broadest clinical base. Samples of virtually every sort of mental disease and of several sorts of nervous disease have been laid down, some obviously not instances of Shell-shock, some mixed with clinical phenomena of Shell-shock, others hard to tell offhand from Shell-shock—the whole on the basis that we shall earliest learn what Shell-shock, the pathological event, is by studying what it is not. As the sequel may show, we are perhaps not entitled to regard Shell-shock, the pathological event, as always associated with shell-shock, the physical event. We shall, therefore, find in Section A (see tables on pages 6 and 7).
(1) Cases without either physical shell-shock, or pathological Shell-shock—psychoses of various kinds incidental in the war (--+).
(2) Cases with physical shell-shock but without pathological Shell-shock—psychoses of various kinds seemingly liberated by, aggravated by, or accelerated by the physical factor of shell-shock (+-+).
(3) Cases without physical shell-shock but with both symptoms of pathological Shell-shock as well as of other psychosis (-++).
(4) Cases with physical shell-shock, with clinical phenomena of Shell-shock, as well as of other psychosis (+++).
At the end of Section A, accordingly, we shall be left with two more formulae for discussion in Sections B, C, and D, viz:
(5) Cases without physical shell-shock but with symptoms of pathological Shell-shock (-+-).
(6) Cases with physical shell-shock and pathological Shell-shock (++-).
The data of Section A will solidly prove that Shell-shock, however picturesque the term for laymen or in the argot of the clinic, is medically most intriguing. As we cannot get rid of the term (even by suppressing it in parentheses or by condemning it to the limbo of the so-called), we must make the best of it by calling Shell-shock just the ore in the clinical mine. To say the least, the term is harmless: it merely stimulates the lay hearer to questions. These questions he must ask of the expert. 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!
Section A shows how he may—not probably, but possibly—be a victim of say ten other things. But it is not that he has an even chance of being one of these ten other things. As the reader watches the procession of cases in Section A, he will perceive that, amongst the ten major groups there studied, some have far greater diagnostic likelihood than others. Thus, syphilis, epilepsy, and somatic diseases will in the sequel prove more dangerous to our success as diagnosticians than, e. g., feeblemindedness or even perhaps alcoholism. But now let us look at these cases systematically, just as if we dealt with so many cases of Railway-spine or any other “incipient, acute, and curable” cases.
Chart 2
PSYCHOPATHIA MARTIALIS
| ???????????????????????????????????????? | |||
|---|---|---|---|
| ?????????????????????????????? | |||
| SHELL-SHOCK (THE PHYSICAL FACTOR) | SHELL-SHOCK (NEUROTIC SYMPTOMS) | PSYCHOSIS (SYMPTOMS NON-NEUROTIC) | |
| Absent | Absent | INCIDENTAL | |
| Present | Absent | LIBERATED, AGGRAVATED, ACCELERATED PSYCHOSES | |
| Absent | COMBINED NEUROSES AND PSYCHOSES | ||
| Present | COMBINED NEUROSES AND PSYCHOSES (Formula +++) | ||
| Absent | NEUROSES (Quasi Shell-shock) | Absent | |
| Present | NEUROSES (True Shell-shock) | Absent | |
Chart 3
PSYCHOPATHIA MARTIALIS
FORMULAE
| ???????????????????????????????????????? | |||
|---|---|---|---|
| ?????????????????????????????? | |||
| S,N,P | SHELL-SHOCK (THE PHYSICAL | SHELL-SHOCK (NEUROTIC SYMPTOMS) PRESENT | PSYCHOSIS (NON-NEUROTIC SYMPTOMS) PRESENT |
| P = | - | - | + |
| SP = | + | - | + |
| NP = | - | + | + |
| SNP = | + | + | + |
| N = | - | + | - |
| SN = | + | + | - |
An officer of high rank deserts his command in a crisis: alienists’ report.
Case 1. (Briand, February, 1915.)
M. X. was an officer ranking high in the French army, having military duties of a critical nature and of great importance (social reasons forbid Briand’s giving informatory details). Suffice it to say that he was brought before court-martial for abandoning his post at the very moment when his presence was most urgently required. He turned tail, without taking the most elementary military precautions.
M. X. was passed up to alienists. He was not a case of Shell-shock unless of the anticipatory sort. He was somatically run-down and of lowered morale and now 65 years of age. The campaign had been fatiguing.
The alienists decided that the officer had not been responsible for his non-military acts. He had been, they found, in a state of mental confusion at the time of desertion, such that amnesia for his duties and heedlessness of consequences had allowed him to leave the front without looking behind him or securing substitution. This state of mental confusion had been preceded by overwork and several nights of insomnia.
Moreover he was palpably arteriosclerotic. Blood pressure was high. The history was one of slight shocks and a mild hemiplegia. The confusion at the front was only the most recent of a series of transitory attacks of confusion. At the time of examination this high officer was actually in a state of mild dementia.
M. X. was an old colonial man, malarial, and had been a victim of syphilis.
A naval officer sees hundreds of submarines: General paresis.
Case 2. (Carlill, Fildes, and Baker, July, 1917.)
A naval officer, 36, during August, 1916, asserted that he could see hundreds of submarines. At one time he imagined that he was receiving trunk calls in the middle of the ocean. He was admitted to Haslar, and the Wassermann reaction of the serum was found strongly positive. The spinal fluid was not at this time examined. The officer recovered to some extent, was given no special treatment, and was sent on leave.
He came under observation again in October, 1916, having become very strange in his manner, on one occasion passing water into the coal box, and talked about impending electrocution. His ankle-jerks were found sluggish and there was a patch of blunting to pin pricks. The diagnosis of general paresis was made. The spinal fluid was afterward examined and found to be negative to the Wassermann reaction but contained 15 lymphocytes per cubic mm.
Three full doses of Kharsivan freed him from delusions and left him apparently absolutely sane. It was recommended that he should be kept at Haslar to continue treatment. However, he had been certified insane and was therefore sent to Yarmouth, from which he was discharged in February, 1917, having been in good mental health throughout his stay there.
Re syphilis and general paresis of military officers, as in Cases 1 and 2, Russo-Japanese experience was already at hand. Autokratow saw paretic Russian officers sent to the front in early but still obvious phases of disease. These paretics and various arteriosclerotics, Autokratow saw back in Russia in the course of a few months.
Re naval cases, see also Case 5 (Beaton). Beaton thinks that monotonous ship duty, alternating with critical stress of service, bears on morale and liberates mental disorder.
Neurosyphilis may be aggravated or accelerated under war conditions.
Case 3. (Weygandt, May, 1915.)
A German, long alcoholic and thought to be weakminded, volunteered, but shortly had to be released from service. He began to be forgetful and obstinate, cried, and even appeared to be subject to hallucinations. The pupils were unequal and sluggish. The uvula hung to the right. The left knee-jerk was lively, right weak. Fine tremors of hands. Hypalgesia of backs of hands. Stumbling speech. Attention poor.
It appeared that he had been infected with syphilis in 1881 and in 1903 had had an ulcer of the left leg.
The military commission denied that his service had brought about the disease.
Case 4. (Hurst, April, 1917.)
An English colonel thought himself perfectly fit when he went out with the original Expeditionary Force. He had had leg pains, regarded as due to rheumatism or neuritis. He was invalided home after exhaustion on the great retreat. He was now found to be suffering from a severe tabes. He improved greatly under rest and antisyphilitic treatment. He has now returned to duty.
Case 5. (Beaton, May, 1915.)
An apparently healthy man, serving on an English battle-ship, severed a tendon in a finger. The injury was regarded as minor. The tendon was sutured and the wound healed. During the man’s convalescence he was accidentally discovered to have an Argyll-Robertson pupil and some excess reflexes. Neurosyphilis had probably antedated the accident. But from the moment of this trivial injury, the disease advanced rapidly.
Overwork in service; several months exacting work well performed: General paresis.
Case 6. (Boucherot, 1915.)
A lieutenant of Territorials, aged 41 (heredity good, anal fistula at 30, with ulceration of penis of an unknown nature at the same period). In 1907 when off service and married, his wife gave birth to a child; no miscarriages. Had been a good soldier in service before the war. The lieutenant was called to the colors August 2, 1914, and was detached for special duty, for the performance of which he was much praised by the commanding officers. The work, however, was too much for him and on April 1 he had to be evacuated to the hospital with a ticket saying “Nervous depression following overwork in service.” On April 14 he seemed well enough for a convalescent camp, but, apparently through red tape, was sent to a hospital at OrlÉans. On June 23 he had to be evacuated to the Fleury annex. His eyes were dull and features flaccid; his whole manner suggested fatigue. His pupils were myotic, tongue tremulous, speech slow and stumbling. Knee-jerks were exaggerated and gait difficult, the right leg dragging. Headaches. He could not perform the slightest intellectual work and was the victim of retrograde and anterograde amnesia. He was aware of the decline of his mental power and was fain to struggle against it, becoming restless and sad. The gaps in his memory grew deeper, he became more and more impulsive, even violent, and had spells of excitement. Dizziness and palpitation developed. Sometimes there were auditory and visual hallucinations of such intense character that he tried feebly to commit suicide with a penknife. He fell into semicoma, and then had a number of apoplectiform attacks. W. R. +
Apparently the moral and physical situation of the lieutenant was absolutely normal when the campaign began and, as he fulfilled detail duties with absolute correctness for a number of months, Boucherot argues that here is an instance of general paresis declanchÉ by overwork.
Syphilis contracted before enlistment. Neurosyphilis aggravated by service.
Case 7. (Todd, personal communication, 1917.)
A laboring man, 42, who always strenuously denied syphilitic infection, proceeded to France eight months after enlistment. He had not been in France three weeks when he dropped unconscious. He regained consciousness, but remained stupid, dull in expression, and with memory impaired. His speech was also impaired. There was dizziness and a right-sided hemiplegia.
He was confined to bed four months and was then “boarded” for discharge.
Physically, his heart was slightly enlarged both right and left; sounds irregular; extra systoles; aortic systolic murmur transmitted to neck; blood pressure 140:40. Precordial pain, dyspnoea.
Neurologically, there was a partial spastic paralysis of the right thigh which could be abducted, could be flexed to 120°, and showed some power in the quadriceps. There was also a spastic paralysis of the right arm, but the shoulder girdle movements were not impaired. There was a slight weakness on the right side of the face. There was no anesthesia anywhere.
The deep reflexes were increased on the right side, Babinski on right, flexor contractures of right hand, extensor contractures of right leg, abdominal and epigastric reflexes absent, pupils active, tongue protruded in straight line.
Fluid: slight increase in protein. W. R. + + +
The Board of Pension Commissioners ruled that the condition had been aggravated by service (not “on service”).
Re general paresis, Fearnsides suggested at the Section of Neurology in the Royal Society of Medicine early in 1916, that in all cases of suspected Shell-shock the Wassermann reaction of the serum should be determined, and went on to say that cases of so-called Shell-shock with positive W. R. often improve rapidly with antisyphilitic remedies.
Duration of neurosyphilitic process important re compensation.
Case 8. (Farrar, personal communication, 1917.)
A Canadian of 36 enlisted in 1915, served in England, and was returned to Canada in February, 1917, clearly suffering from some form of neurosyphilis (W. R. positive in serum and fluid, globulin, pleocytosis 108).
There is no record of any disability or symptom of nervous or mental disease at enlistment. The first symptoms were noted by the patient in May, 1916, six months or more after enlistment. The case was reviewed at a Canadian Special Hospital, October 11, 1916, by a board which reported:
“The condition could only come from syphilitic infection of three years’ standing” (a decision bearing on compensation); but the general diagnosis remained:
“Cerebrospinal lues, aggravated by service.”
The picture which the medical board regarded as of at least three years’ standing was as follows:
History of incontinence, shooting pains, attacks of syncope, general weakness, facial tremor, exaggerated knee-jerks, pupils react with small excursion. Speech and writing disorder, perception dull, lapses of attention, memory defect, defective insight into nature of disorder, emotional apathy.
1. Was the conclusion “aggravated by service” sound? On humanitarian grounds the victim is naturally conceded the benefit of the doubt. But it is questionable how scientifically sound the conclusion really was.
2. Could the condition come only from syphilitic infection of at least three years’ standing? Hardly any single symptom in this case need be of so long a standing; yet the combination of symptoms seems by very weight of numbers to justify the conclusion of the medical board.
Farrar’s case and thirteen others of “Neurosyphilis and the War” were included in a general work on Neurosyphilis (Case History Series, 1917, Southard and Solomon). For military syphilis in general, see Thibierge’s Syphilis dans l’ArmÉe (also in translation).
General paresis lighted up by the stress of military service without injury or disease?
Case 9. (Marie, Chatelin, Patrikios, January, 1917.)
In apparently good health a French soldier repaired to the colors, in August, 1914, being then 23 years old.
Two years later, August, 1916, symptoms appeared: speech disorder with stammering, change of character (had become easily excitable), stumbling gait. He became more and more preoccupied with his own affairs, grew worse, and was sent to hospital in October, 1916.
He was then foolish and overhappy, especially when interviewed. There was marked rapid tremor of face and tongue. Speech hesitant, monotonous, and stammering to the point of unintelligibility. His memory, at first preserved, became impaired so that half of a test phrase was forgotten. Simple addition was impossible and fantastic sums would be given instead of right answers. Handwriting tremulous, letters often missed, others irregular, unequal, and misshapen.
Excitable from onset, the patient now became at times suddenly violent, striking his wife without provocation. After visit at home, he would forget to return to hospital. Often he would leave hospital without permission (of course the more surprising in a disciplined soldier). No delusions.
Serum and fluid W. R. positive; albumin; lymphocytosis.
Neurological examination: Unequal pupils, slight right-side mydriasis, pupils stiff to light, weakly responsive in accommodation, reflexes lively, fingers tremulous on extension of arms.
The patient had, December 5, 1916, an epileptiform attack with head rotation, limb-contractions and clonic movements. Should this soldier recover for disability obtained in service? Marie was inclined to think military service in part responsible for the development of the paresis. Laignel-Lavastine thought so also, but that the amount assigned should be 5%-10% of the maximum assignable.
SYPHILITIC ROOT-SCIATICA (lumbosacral radiculitis) in a fireworks man with a French artillery regiment.
Case 10. (Long (Dejerine’s clinic), February, 1916.)
No direct relation of this example of root-sciatica to the war is claimed nor was there a question of financial reparation.
There was no prior injury. At the end of March, 1915, the workman was taken with acute pains in lumbar region and thighs, and with urgent but retarded micturition.
Unfit for work, he remained, however, five months with the regiment, and was then retired for two months to a hospital behind the lines. He reached the SalpÊtriÈre October 12, 1915, with “double sciatica, intractable.”
There was no demonstrable paralysis but the legs seemed to have “melted away,” fondu, as the patient said. Pains were spontaneously felt in the lumbar plexus and sciatic nerve regions, not passing, however, beyond the thighs. These pains were more intense with movements of legs; but coughing did not intensify the pains. Neuralgic points could be demonstrated by the finger in lumbar and gluteal regions and above and below the iliac crests (corresponding with rami of first lumbar nerves). The inguinal region was involved and the painful zone reached the sciatic notch and the upper part of the posterior surface of the thigh.
The sensory disorder had another distribution, objectively tested. The sacral and perineal regions were free. Anesthesia of inner surfaces of thighs, hypesthesia of the anterior surfaces of thighs and lower legs. The anesthesia grew more and more marked lower down and was maximal in the feet, which were practically insensible to all tests, including those for bone sensation. There was a longitudinal strip of skin of lower leg which retained sensation.
Position sense of toes, except great toes, was poor. There was a slight ataxia attributable to the sensory disorder—reflexes of upper extremities, abdominal, and cremasteric preserved, knee-jerks, Achilles and plantar reactions absent.
The vesical sphincter shortly regained its function, though its disorder had been an initial symptom. Pupils normal.
The “sciatica” here affects the lumbosacral plexus.
As to the syphilitic nature of this affection, there had been at eighteen (22 years before) a colorless small induration of the penis, lasting about three weeks. There was now evident a small oval pigmented scar. The patient had married at 20 and had had three healthy children.
The lumbar puncture fluid yielded pleocytosis (120 per cmm.). Mercurial treatment was instituted.
The treatment has not reduced the pains. Long thinks it was undertaken too long (six months) after onset. The warning for early diagnosis is manifest. There was somehow a delay under the medical conditions of the army.
Re syphilis in munition-workers Thibierge has much to say of French conditions. Throughout his work on syphilis in the army, he stresses the large number of venereal cases in men mobilized for munition-work. Medical inspections ought, according to Thibierge, imperatively to be made in the munition-works and upon all mobilized workmen, whether French or belonging to the Colonial contingents. These men are under military control in France, but they have more opportunities than the soldiers for contracting and disseminating syphilis. They are, in point of fact, very often infected and in a higher proportion than are the soldiers at the front. The munition-workers should also be obliged to report their infections to the physician, whether or no they are under treatment by military or by private physicians.
Thibierge devotes a chapter to syphilis as a national danger. Not only do available statistics prove that there is more syphilis in the population since the outbreak of war, but the number of married women going to special hospitals for syphilis is abnormally high and entirely out of proportion to the number of married women resorting to these clinics in peace times. A certain number are contaminated by their husbands on leave. Thibierge calls attention to the fact of the extraordinary frequency of syphilis in young men (two or three, sixteen to eighteen years of age, at Saint-Louis Hospital at each consultation).
A disciplinary case: Syphilitic?
Case 11. (Kastan, January, 1916.)
Reports varied about a certain German soldier who came up for discipline. Inferiors thought he was harsh and tricky. A lieutenant declared that the man always wanted to have proper respect paid to him, and that he was unduly excited by trifles. The man had become latterly very nervous on account of battle strain and protracted shelling.
July 28, 1915, the man, who had been drinking with comrades the night before, was excitedly talking to an officer concerning relief of a guard. The soldier stated, “As a sergeant on duty with a service record of 15 years, I think it is my affair.” The lieutenant replied, “So far as I am concerned, the matter is settled.” The sergeant yelled, “As far as I am concerned, it is settled also. By the way, my name is Mr. Vice Sergeant …,” and with that the sergeant wrote down the lieutenant’s words and refused to obey the lieutenant’s order to “Stop writing.” The lieutenant drew his sword and said, “Take your hands down.” The sergeant replied, “Surely I am permitted to write.” Lieutenant: “Subordination; don’t forget yourself, Vice Sergeant.…” The sergeant jeered, “You forgot yourself anyhow;” whereupon the lieutenant: “Well, such a thing never happened to me before.” The sergeant, jeeringly, “Nor to me either. If I were not in undress I should know what to do.” The lieutenant: “Vice Sergeant …, remain here. This matter will be settled at once.” The sergeant: “It is Mr. Vice Sergeant …,” whereupon he gave his notebook to a hornblower and said, “Write.” The lieutenant: “Stay.” The sergeant: “What, stay here. No, I’ll not stay,” and made off. The lieutenant called after him, “Put on your service dress and see the captain.” He made ready but said, “This half-idiot gives an order like that to a sergeant with 15 years’ record.”
The examination showed that the man had a hypalgesia. He complained of violent headaches. He said that he had had syphilis 10 years before; there were no bodily stigmata.
Regulations broken: General paresis.
Case 12. (Kastan, January, 1916.)
A German 1st-lieutenant, on active service before the war, had left the service because there was not enough for him to do in peace times. During his war service, he became drunk and had two soldiers bound to a doorpost, with coats unbuttoned and without their caps—a process quite verboten. While in KÖnigsberg, he reported himself ill, and failed to go to a designated hospital. He was accordingly treated as a deserter. He ran up bills with landlady and servant girls, saying that he was going to receive money from his wife. Under hospital examination, he said he was only a Baden man with a lively temperament. He got angry at the phrase test feeding, refused food, got excited when asked to help in the care of other patients, and wrote a letter saying, “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. [The expenses were being borne by the state.] I have openly stated what is being here done with me is foolery, and I stick to that phrase. The food, already poor enough, is no better, when the meat of a half-rotten cow comes twice to the table.” This patient was, according to Kastan, a victim of general paresis.
Re general paresis and delinquency, Gilles de la Tourette long ago maintained that there was a medicolegal period in paresis. LÉpine in his work on Troubles Mentales de la Guerre speaks of the unexpected frequency of general paresis in the army, and calls attention at the outset to the medicolegal period. The danger of overt delinquency is, in fact, greater under military than under civilian conditions on account of the closer surveillance of the soldier. Desertion and thievery are the main forms.
Unfit for service: General paresis.
Case 13. (Kastan, January, 1916.)
Kastan describes a non-commissioned officer, who came voluntarily into the clinic. It seems that he had absented himself (?) from the army in the suburbs of KÖnigsberg, September 3, 1914. He was arrested October 7th. Once before he had been brought to Kastan’s clinic on the suspicion of general paresis, but had been dismissed as non-paretic. Brought in again in a condition of marked fear, he declared that he had to fall behind his company while he was on the march on account of a feeling of weakness. He had been taken to a hospital and then carried to the suburbs of KÖnigsberg, examined, and found unfit for service.
He had in his 20th year become infected with syphilis, and had recently become forgetful, subject to fears, and easily excitable. He had been very unhappily married with a woman who was hysterical and threatened to shoot and poison him. He lived in a condition of continual quarrels with her. The symptoms that he felt on the march were numbness of the legs and a rush of blood to the head. In the clinic, he was subject to much dreaming and raving about the war. There was excessive perspiration.
1. As to the proper interpretation of this case, details are lacking as to the physical and laboratory side. In fact, it would appear that the suspicion of paresis at his first reception in a clinic was dismissed without resort to laboratory findings.
There are no neurological symptoms in the case clearly suggestive of neurosyphilis, except perhaps the numbness of the legs. The remainder of the picture appears to be entirely psychic. Sensory and intellectual symptoms are missing unless we count the war dreams and mania as intellectual. It appears wiser to count these as emotional in the sense that they were roused by emotion-laden memories. The fear, perspiration, and feelings of head flush are perhaps to be best interpreted as satellites about an emotional nucleus.
Hysterical chorea versus neurosyphilis.
Case 14. (De Massary and Du Sonich, April, 1917.)
There were various complications in the case of a lieutenant (nervous tic in childhood; travel 23 to 30), who was at Antwerp during the period of mobilization. He was taken there by the Germans; was a prisoner in their hands for 55 days; and succeeded under great strain in escaping.
He then entered his regiment, and, passing the examinations, was made an adjutant, and went to the front, March, 1915. He stayed ten months in the Verdun region, under heavy bombardment, and in June was bowled over and buried by a 210. He seemed to be fearless, getting no sensation from shell-bursts except a griping sensation in the bowels.
However, his character had altered in the direction of irritability; and by the end of January, 1916, he had to be evacuated for the first time from the front, for general weakness, with the diagnoses: neurasthenia, neuralgia, dyspeptic troubles, great general fatigue, marked depression. In fact, at Narbonne he was asked no questions for several days on account of his obvious depression. He was given ice-bags for violent headaches, complete rest in bed, cacodylate and sodium nucleinate. In two weeks he was up and about.
At this time appeared choreiform movements, which reached their maximum in two or three days, whereupon he was sent, March 4, 1916, to the neurological centre at Montpellier. Here W. R. positive! Neosalvarsan on the second injection (0.45 and 0.60) yielded a strong reaction, with fever, delirium, vomiting, and then jaundice.
About a month later, he was given twenty more intravenous injections, whereupon the choreic movements now decreased, and July 15 he was given convalescence for three months. October 15 he went back to his dÉpÔt cured; and October 20, on request, went to the front. He was potted and under machine-gun fire at times during the next three months, but the choreic movements did not reappear. January 1 he left the trenches as the division went into billets.
At Royallieu, a lumbar puncture showed a slight lymphocytosis. The headache improved. He was evacuated January 24, 1917, to Val-de-GrÂce, with a diagnosis: Recurrent chorea; first attack followed commotio cerebri, nervous depression, inequality of pupils, various pains, contracted in the army. Another W. R. was positive. Twelve intramuscular injections of oxygen cyanide were given, besides baths. He was then sent to Issy-les-Moulineaux with a diagnosis of tic. He showed choreiform movements affecting the legs alone. When sitting, legs extended and flexed, the knees would abduct, then adduct; the thighs flexed. When standing, flexor movements were produced alternately on the left and the right, the knee being raised high, sometimes striking the patient’s hand. In walking, the thigh and lower leg flexion was always out of proportion to the required step. There was thus a sort of saltatory chorea limited to the legs. The reflexes so far as they could be tested were normal save that the left pupil was fixed to light and accommodation; the right pupil was sluggish to light but accommodated normally. Leucoplakia of the cheeks; nocturnal headaches; and pains resembling lightning pains in arms and legs. Lumbar puncture, March 26, showed blood-stained fluid, and the puncture was followed by headache, vomiting, and slow pulse. The fluid showed a slight lymphocytosis; W. R. negative.
It is clear that a diagnosis limiting itself to the leg trouble would probably content itself with “hysterical chorea.” The lieutenant said that when he saw people “dance” he did have a tendency to imitate them; and when he was cured of that, he did not want to go to Lamalou because he would see the ataxic patients there and might fall back into his “dancing.” However, in view of the pupillary inequality, the lymphocytosis, the leucoplakia, the W. R., and the initial neurasthenia and depression found in the very first hospital in which he was examined, we probably should be entitled to consider that general paresis played a part in the chorea.
Shrapnel fragment driven through skull: General paresis.
Case 15. (Hurst, April, 1917.)
A private, 31, was wounded December 7, 1916, by a shrapnel fragment which entered the skull above the left ear and lodged in the brain, an inch above and 2½ inches below the middle of the right orbital margin. At Netley, December 30, he proved to show a complete internal and external left sided ophthalmoplegia, with the exception of the external rectus. On the right side, there was a complete paralysis of the superior rectus and a partial paralysis of the inferior rectus and levator palpebrae superioris. There was a paresis of the left side of the face. The right plantar reflex was said to have been extensor at the clearing station, but at Netley it and the other reflexes proved to be normal, as were the optic. The patient was stuporous and had incontinence of urine and feces for two days. Shortly after admission, slurring of speech with a long latent period occurred. It was clear that the shrapnel fragment must have passed far above the crus, and it was not plain how isolated lesions of the third and seventh nerve nuclei could have been brought about without injury of the long tracts of the crus.
The Wassermann reaction of the serum was negative, but that of the spinal fluid was positive. Iodide and mercury secured considerable improvement in the mental condition and some diminution in the paralysis. The patient is now extremely pleased with himself and has a speech suggestive of paresis.
Head trauma: Shell-shock effects, over in a few months. Manic-depressive (?) attack more than two years later. X-ray evidence suggesting brain lesion. Serum Wassermann reaction positive.
Case 16. (Babonneix and David, June, 1917.)
A bullet glancing from his gun barrel November 28, 1914, wounded a man in the head, whereupon he lost consciousness and was carried to a hospital and trephined. On coming to, he found that he could not hear and felt pains; but the latter disappeared in a few months. He was given sedentary employment and did his work properly until February, 1917, when he suddenly became sad, wept, slept poorly, stopped eating, had an absent air, and began to complain of his head. He passed whole days without moving, in a sort of stupor, which was then followed by a hypomaniacal agitation in which he walked furiously up and down in the room and threw objects about.
He was found subject to a generalized tremor and he was distinctly weaker on the right side. The tendon reflexes were excessive. The bony sensibility, as well as the pain and temperature sense, and the position and stereognostic senses were completely abolished on the right side. The scar lay on the left side. It was deep and very sensitive to pressure, so that if it was touched ever so slightly the patient began to weep. X-ray indicated loss of substance in the posterior part of the left parietal region. Remains of the projectile were found subcutaneously in the right supraorbital region. The W. R. of the serum was positive. There was no lymphocytosis in the spinal fluid.
Interpretation of this case is manifestly difficult. Four possibilities exist: Syphilis, manic depressive psychosis, traumatic brain disease, and functional shock effects. More than two years had passed between the trauma and the change of character.
Skull trauma in a syphilitic.
Case 17. (Babonneix and David, June, 1917.)
A soldier, 31, sustained fracture of the occiput from shell-burst, and thereafter showed confusion and total loss of memory. Operation November 11 withdrew bony fragments and clots, whereupon the man returned practically to normal. He developed, however, a few seizures, in which he struggled, fell, and lost consciousness, afterward suffering from headache. The tendon reflexes were increased. The occipital cicatrix was a little depressed and slightly painful on pressure.
Lumbar puncture showed a very slight lymphocytosis (5 to 6 cells), practically negative globulin reaction, and a low albumin titer. There were no signs of syphilis in the eyes. The W. R. in the serum was strongly positive. Very possibly the traumatic phenomena in this case can be safely disengaged from the syphilitic phenomena.
Re the mechanism by which trauma evokes or accelerates the course of neurosyphilis, it is probable that most neuropathologists believe that the commotio cerebri causes sundry chemical or physical effects in the nerve tissues such that spirochetes are moved into new and more dangerous places, or such that more appropriate food is supplied to the organisms, which then begin to multiply. Whether the organisms live in a kind of symbiosis in the tissues under ordinary circumstances in the pre-paretic period of the development of neurosyphilis, is unknown. Possibly fat embolism should be added to the list of possible causes of the hastening of the neurosyphilitic process. Fat embolism in the brain has been shown by various authors to be accompanied by minute hemorrhages, in the midst of which by proper stains the fat embolism can be made out.
Shell-wound in battle: General paresis.
Case 18. (Boucherot, 1915.)
A soldier in the Territorial Infantry, 42, a gardener who went to taverns, as he said, “like everybody else,” a widower with two children, a good worker though irascible, had had syphilis as a youth. He was called to the colors at the outbreak of the war and got on well despite tremendous strain. March 9, 1915, he was in a bayonet charge with his regiment and was bowled over by a shell of which a fragment wounded him above the knee and several fragments in the thorax. All these fragments were extracted at a temporary hospital, March 11. The man now became strange, refused to obey orders and did a number of peculiar things so that he was sent to OrlÉans temporary hospital whence he was evacuated to Fleury Asylum, March 19. He refused to give up his things because he was the master. He did not want to go to bed and wanted to keep on walking constantly. He was without sense of shame, satisfied with himself, grandiose as to his millions in bank and the thirty-six decorations he believed had been awarded him. He mistook the identity of the landscape and of the people about him.
Tongue tremulous; pupils unequal; knee-jerks exaggerated; dysarthria; gaps in memory. In May occurred a number of violent reactions.
In June, however, there was a remission; the ideas of grandeur disappeared first, then the tremors and reflex disorder and finally the speech disorder. There was a slight seizure at this point and the man said he had had another such just before he came to the army. July 20 he was invalided out much improved.
In this case of general paresis there is, besides the syphilis, also alcoholism to consider, so that it is not entirely plain that the exertions of campaign liberated the paresis.
Re wounds and paresis, see also Case 5 (Beaton), in which neurosyphilis advanced rapidly from the time of a trivial injury.
Shell-explosion: Syphilitic ocular palsy.
Case 19. (Schuster, November, 1915.)
Schuster notes briefly a curious result of the explosion of a shell, which caused the patient in question to lose consciousness. Shortly after the explosion, the patient came to his senses again, but a surprising paresis of the eye muscles had developed. This paresis looked precisely like a syphilitic paresis clinically.
Examination of the blood serum yielded a strongly positive Wassermann reaction.
According to Schuster, the explosion of the shell had brought about hemorrhage in vessels supplying the region of the eye muscle nerves or nuclei. The reason for the selection of these vessels for rupture due to shell explosion is, according to Schuster, that the vessels were probably already syphilitically diseased.
Re hemorrhages in the neighborhood of the oculomotor nuclei, the phenomena of polioencephalitis may be recalled. In that disease, the predisposition to hemorrhage is presumed to be alcoholic, as the cases of ophthalmoplegia of this group almost always appear in alcoholics. However, the first case of hemorrhagic superior polioencephalitis was a non-alcoholic one of Gayet (1875), in which the symptoms followed three days after a boiler explosion.
A tabetic lieutenant “shell-shocked” into paresis?
Case 20. (Donath, July, 1915.)
An apparently competent German professor in an intermediate school, a lieutenant of infantry reserves, 33 years old, on the 17th August, 1914, was stunned for a while by the shock of a cannon-firing 25 feet away. Urination became difficult. Headaches and limb pains ensued, with paralysis of fingers, gastric troubles, forgetfulness, especially for names, insomnia, and general scattering of mental faculties.
Neurologically, the pupils were irregular, left larger than right; Argyll-Robertson reaction. Right knee-jerk livelier than left. Achilles reactions absent. Slow and dissociated pain reactions in feet, lower thighs and lower quarter of upper thighs, with hypalgesia or analgesia. Station good; gait steady. Mentally depressed, slow of thought. Speech poor and of indistinct construction (mild dementia). Calculation ability poor. No pleasure in work.
Wassermann reaction of serum weakly positive.
It seems that for a year the patient had been subject to spells of anger. He was irritated by his wife who had been nervous since an earthquake.
On the occasion of the earthquake, 1911, the patient himself had had a spell of difficulty with urination. The spell had lasted two or three months. The patient had had a chancre in 1902, “cured” in four or five weeks with xeroform. In 1908, when about to marry, he had had six mercurial inunctions.
Re tabes, LÉpine shows that tabetics are numerous. They are numerous among officers and also in the auxiliary service, in which latter tabetics are maintained on desk duty. Perhaps they had been admitted to such work as unable to march or fight, on the basis of having had so-called
Shell-explosion may precipitate neurosyphilis in the form of tabes dorsalis.
Case 21. (Logre, March, 1917.)
An artilleryman, 38, had a large calibre shell explode very near him and afterward could not hear the whistle of a shell without falling down in a generalized tremor, sweating profusely, urinating involuntarily, in a mental state approaching stupidity. Here was a case that might be regarded as one of morbid cowardice in a psychopath, following violent emotion.
The artilleryman proved to be a victim of tabes and of general paresis. The incontinence of urine under the influence of emotion was nothing but an effect of tabetic sphincter disorder. The crisis of cowardice proved nothing but an initial symptom of general paresis.
Shell-explosion; burial: Tabes dorsalis incipiens.
Case 22. (Duco and Blum, 1917.)
A French soldier was buried by effects of shell explosion September 8, 1914. He sustained no wound or fracture.
Incontinence of urine developed. Anesthesia of penis and scrotum. Reflexes absent; pupils sluggish. Wassermann reactions suspicious.
The diagnosis tabes dorsalis incipiens was made (hematomyelia of conus terminalis eliminated).
The patient was estimated to be “40% incapacitated,” according to the French “Échelle de gravitÉ” of conditions. A full pension would not be justified in the opinion of the French authors.
SHELL-SHOCK PSEUDOTABES (non-syphilitic, serum W. R. positive). Improvement.
Case 23. (Pitres and Marchand, November, 1916.)
Innkeeper B., 36, a shell-shock and burial victim June 20, 1915, was looked on by a number of physicians as a case of genuine tabes.
Even eight months after the episode, he still showed (when observed by Pitres and Marchand, February 3, 1916) absence of knee-jerks and Achilles jerks, a slight swaying in the Romberg position, pupils sluggish to light, incoÖrdination, delayed sensations. There was also a history of pains in the legs, compared by the patient to those of sciatica. These pains came in crises, the longest of which had lasted 30 hours.
It seems that this soldier’s troubles began the day after his shock with a feeling of swollen feet and of cotton wool under them. He stayed on service, however, walking with increasing difficulty.
At the time of his evacuation, July 10, he could walk with great difficulty. “Strips of lead were between his legs.” He could hardly control movements in the dark, or descend stairs. Often his legs would bend under him. Vesical function sluggish.
After a few months the patient could walk better. In February, 1916, he walked thrusting his legs forward trembling, and dragging toes a little. He could not support himself on either leg. Jerkiness and incoÖrdination in extension or flexion of leg on thigh.
The muscular weakness was decidedly against tabes or at all events a pure tabes. The incoÖrdination proved to be due, not to loss of position sense (which was intact) but to unsteady muscular contractions. Deep sensibility was intact.
There were no mental symptoms. There was a slight hesitation in speech and doubling of syllables, but nothing demonstrable with test phrases.
The serum W. R. was positive.
Shell explosion; unconsciousness: Neurosyphilis.
Case 24. (Hurst, April, 1917.)
A private, 31, was in the retreat from Mons, was blown up by a shell and buried in May, 1915, went back to the front after two months leave, was knocked unconscious by a shell December, 1916. He came to himself two days later in the hospital, but remained confused and lethargic. In England, December 21, his legs were still weak and walking was unsteady. The right pupil reacted neither to light nor to accommodation and was irregular, eccentric, and dilated. The left pupil showed the Argyll-Robertson reaction. There was early primary optic atrophy. The right knee-jerk was slightly exaggerated. The vibration sense was reduced over sacrum and malleoli. At this time the man’s mental condition was practically normal.
The Wassermann reaction of the serum and spinal fluid proved positive. Improvement followed rest, iodide, mercury, and seven injections of salvarsan. By the middle of February he was able to walk well. The right pupil regained its power to react to accommodation, but remained inactive to light. Meanwhile, the left pupil had regained a slight power to react to light.
Re treatment of syphilis, both Thibierge and LÉpine give warning of some bad results with arsenobenzol treatment, though Thibierge states that the number of serious accidents and especially of deaths has diminished more and more now that no arsenobenzol (drug No. 914) is given. Encephalitis is the gravest of the untoward results of injection, sometimes appearing in young and vigorous subjects. Hemorrhagic encephalitis appears to occur more frequently after the second injection than after the first, and according to Thibierge may be especially suspected in subjects who after the first injection present much fever, congestion of face, and cutaneous eruptions. Treatment in these cases should be suspended or given in moderate doses.
Shell-explosion: Neurosyphilis. Fit for light duty.
Case 25. (Hurst, April, 1917.)
A corporal, 26, blown up by a shell December 7, 1916, was admitted to the hospital on the 13th, dazed and with symptoms of a left-sided hemiplegia of organic origin. The right pupil was larger than the left. There was a bruise of the scalp in the right parietal region. The man had had syphilis at 16. The Wassermann reaction of the serum was strongly positive. Rest, salvarsan, mercury, and iodides were given, and the general symptoms and hemiplegia gradually disappeared, until on December 12 there was only a moderate weakness of the left side, with knee-jerks in excess, abdominal reflexes absent, and the Babinski reaction.
The Wassermann reaction was still strongly positive. Salvarsan, mercury, and iodide were continued. January 6, 1917, the plantar reflex had become flexor. The abdominal reflex returned. Babinski’s second sign (combined flexion of thigh and pelvis) was now the only evidence of organic disease. Further antisyphilitic treatment removed this sign also. February 28, the man was discharged fit for light duty, with unequal pupils and positive Wassermann reaction, and a complete amnesia for the four weeks following his blowing up in the trenches.
Re fitness for light duty, see remarks on Case 20 concerning desk duty for certain tabetics.
Re the premature or unexpectedly early appearance of neurosyphilis under war conditions, the early claims of some authors have not been maintained. In the above instance, the infection was at 16 and the shell explosion occurred at 26, namely, at about the right interval for the development of neurosyphilitic signs. Gerver states that military service brings out the lesions of paresis earlier than they would otherwise come. Bonhoeffer has been unable to show that cerebrospinal syphilis is favored in its development by the exhaustion factor.
SHELL-SHOCK PSEUDOPARESIS (non-syphilitic). Recovery.
Case 26. (Pitres and Marchand, November, 1916.)
June 19, 1915, a shell exploded some distance from Lieutenant R. He remembers the gaseous smell, the bursting of several shells nearby and a sensation of being lifted into the air. When he recovered consciousness, he was in hospital at Paris-Plage, covered with bruises and scratches. They told him he had been delirious and had vomited and spat blood.
June 24, his wife came to see him, but this visit he could not remember. Nor could his wife at first recognize him, he was so thin. He roused a few moments and recognized his wife, but relapsed into torpor again. Speech was difficult and ideas confused.
A few days later he was able to rise; but his mental status grew worse, especially as to speech and writing, the latter quite illegible. There was insomnia, or, if he slept, war dreams.
August 7, he began a period of five months’ convalescence passed with his family, depressed, given to spells of weeping, confined to bed or couch, unable to “find words,” conscious of his state and troubled about it, speaking of nothing but the war, and afraid to go out for fear of ambuscade. There was at first a slight lameness of the right leg. Although he could walk, he felt pain in the knee on flexing the right leg on the thigh. He walked holding this leg in extension.
On going back to the colors, he was immediately evacuated to the Centre Neurologique at Bordeaux, January 20, 1916.
Examination found a bored, impatient, irritated man, vexed that a man who was not sick should be sent up “comme fou.”
Omitting negative details, neurological examination showed slight lameness as above, body stiff and movements jerky, difficult, unsteady gait. The lieutenant could stand for some time on either leg. Tongue and face tremulous during speech. Limbs moderately tremulous, especially in the performance of test movements.
Knee-jerks and Achilles jerks absent. Other reflexes, including pupillary, normal. Segmentary hypalgesia of right leg, especially about knee. Tremulous speech and writing. Patient would stop short in speaking for lack of words.
Malnutrition. Appetite good, but a bursting feeling after meals.
Skin dry, scaly on legs, fissured on fingers.
Serum W. R. negative. Fluid not examined.
Mental examination. Conscious and complaining of his troubles, Lieutenant R. claimed persistently that he was not sick. Memory for recent events was in general poor. Errands easily forgotten. Lost in the street. Complaint of corpse odors round him. Everybody is looking at him and making fun of him. He was apt to insult bystanders. He was afraid of German spies. Things in shops angered him as they seemed to him to be of German manufacture.
There were frequent periods of depression, with pallor and no spontaneous speech for some hours to a half-day. Headaches coming on and stopping suddenly.
As to diagnosis, the first impression, say Pitres and Marchand, was that of general paresis. The progress of symptoms after the shock was consistent with this diagnosis. The mental state and the physical findings seemed consistent, although the pupils were normal. His partial insight into his symptoms was not inconsistent with the diagnosis. He had a characteristic self-confidence. There had been four stillbirths (two twins); two children are alive, 11 and 13. Typhoid fever at 30. Syphilis denied. No mental disease in the family.
The patient had never done military duty, having been invalided for “right apex.” But he had volunteered and been accepted in September, 1914.
How was Lieutenant R. cured? Apparently by rest in the Centre Neurologique. Pitres and Marchand do not speak of the subtle relation between mental state and the idea of non-return to military service. This motive might still work even if Lieutenant R. kept protesting sincerely that he wanted to go back into military service.
War strain; shell explosion; unconsciousness. Sensory and motor disorders. Subject an old syphilitic.
Case 27. (Karplus, February, 1915.)
A captain, 34, was under much stress and strain in the field and gave himself over to excesses of alcohol and tobacco. August 25, 1914, at the Krasnik battle he suddenly saw at his right a gleam of fire and was afterward able to remember very distinctly the words of a lieutenant standing near by, “The man is dead.” Three or four hours later he came to himself at a relief post, vomited and bled a good deal from nose and mouth. He heard later that he had been thrown on his back.
Manual tremors and general pains developed in the next few days. Two weeks after the accident a slight nystagmus on looking to the left appeared, but there was otherwise no disorder of head or extremities. He was able to sit up, supported by his arms, and he was able to contract his abdominal muscles normally. As for his legs, active movements were limited and weak. He could not lift his legs. The paralysis was more marked distally. He could walk with the support of two persons, but was unable to lift his feet from the ground. The right upper abdominal reflex was elicited, and both patellar reflexes were tolerably active. Cremasteric and plantar reflexes were absent. Neither of the Achilles jerks could be produced. There was hypesthesia and hypalgesia of the lower extremities, and of the back up to a horizontal line corresponding with the ninth dorsal segment; thermo-hyperesthesia and disorder of vibration sense in the lower legs. Both the motor and the sensory disorders were more marked on the right than the left. Insomnia and battle dreams.
The gait disorder and paresis gradually improved. There was no alimentary glycosuria and adrenalin produced no mydriasis. In the course of several weeks the patient gained seven kilograms, began to sleep well and showed gradual
This man had had syphilis at twenty-two, had gone through an inunction cure, and repeated W. R.’s came through negative. He had suffered from vomiting spells and anxiety feelings for a number of years which had been diagnosed by physicians as cardiac neurosis. Yet for a year before going into the war he had felt absolutely well.
Shell-explosion: Amnesia; syphilitic hemiplegia. Recovery except for amnesia as to brief period and loss of occupational skill.
Case 28. (Mairet and PiÉron, July, 1915.)
A man of 40 underwent shell shock June 15, 1915, and had no remembrance of what happened up to July, 1915, when in hospital at Tunis he felt “born again.”
Examined in January, 1916, it was found that he had a left hemiplegia (in fact, he had a syphilitic hemiplegia on that side, several years before, which had disappeared under antisyphilitic treatment). This hemiplegia passed, but he then had crises of depression due to his despair at not being able to know who he was and what he was doing. He could speak French and Spanish, and knew from the hospital ticket that he was born in Spain; but he had no idea what had happened to his relatives or what he was doing in France. He had, however, a very correct idea of what happened during six months after July, 1915.
One morning in April, 1916, his old memories came back all of a sudden on waking. The gap was filled up to the moment of the shock. There was no gap left except for a period of about 25 days following the shock. He now found that he knew a little English but that he had lost his stenography as well as his professional skill at typewriting.
Re French statistics for the occurrence of general paresis, Lautier found 27 cases in 426. Early in the war, Boucherot at Fleury received four cases of paresis among 107 cases; the majority of these, however, had not left the interior. Consiglio in Italy received two cases out of 270.
Re hemiplegia in this case, it may be inquired whether the hemiplegia which developed after the shell explosion on the same side of the body on which the patient had a true syphilitic hemiplegia, was really syphilitic or not. Was it not, perhaps, in some sense psychogenic? A similar question may be raised concerning cases in which the locus minoris resistentiae becomes the site of symptoms. See Cases 409-414.
Shell-shock: Hysterical blindness. Signs of cerebrospinal syphilis: Nevertheless, amaurosis functional.
Case 29. (Laignel-Lavastine and Courbon, March, 1916.)
A soldier of the class of 1906 underwent shell-shock August 13, 1914, regaining consciousness 20 days later, but blind. The light of the shellburst, he said, was the last thing he had seen.
For sixteen months, he was transferred from hospital to hospital, looked on sometimes as blinded; sometimes as feigning. Finally, on the isolation service of Maison-Blanche, December 15, 1915, he received an ophthalmologist’s diagnosis namely, hysterical amaurosis. At this time there were found: stereotyped winking, with slight lachrymation, a slight left external strabismus, limitation in movement of all the extrinsic muscles of both eyes, especially to the right and in convergence and elevation; pupils slightly smaller than normal—and the general impression of a genuinely blinded or amblyopic subject. He seemed to be able to distinguish faint whitish spots, without contour or color, in objects brought to a distance of at least 40 cm.
He also complained of bad feelings inside his head on the left side, and he proved to have a left-sided hemianesthesia of hysterical nature. There were no other sensory disorders and no reflex disorders.
The nasolabial fold on the left side was flattened out, and there was also on the same side a slight diminution in the lower abdominal skin reflexes, and no response to plantar stimulation. Examination of the mouth showed leucoplakia, and the history showed that the man’s fifth child was born before term and died at two months. Lumbar puncture yielded lymphocytosis (55 cells) and an excess of albumin. The fundus examination showed a slight papillary disorder, suggesting a retrobulbar affection of the optic nerves.
However, the preservation of the pupil reflexes seemed to indicate that nine-tenths, at least, of the amaurosis was
Laignel-Lavastine and Courbon suggest that there was a dynamic disorder in this case, bearing the same relation to vision as mental confusion bears to the process of ideation. Analogous phenomena have been found in the sense of hearing, in such wise that the victims can, as it were, passively hear but do not listen.
Re functional eye cases, see below, especially Cases 432-437.
Shell shock (functional) phenomena in a syphilitic.
Case 30. (Babonneix and David, June, 1917.)
A marine, 26, on land service March, 1916, was buried by the explosion of a large calibre shell which killed most of his comrades. He remained for a time in a sort of lethargy. Coming to, he found himself victim of a right hemiplegia and deafmutism, which phenomena vanished under electricity.
In July, however, he had to be sent to a hospital on account of his sufferings, which received the diagnoses commotio cerebri, disorder of consciousness, disorientation, delirium, amnesia, over-emotionality. He was sent back to the front in December, 1916, but promptly reported sick, with headaches and insomnia.
Examination showed nonorganic nervous disorders, consisting in a variable and patchy anesthesia of the legs, anesthesia of the conjunctiva and pharynx, and over-reaction, with sighing, during the course of the examination. The organic signs were: exaggeration of tendon reflexes, equilibration disorder, and incapacity to stand on one foot or execute a half turn or to stand still with eyes closed, and disorder of position sense. The lumbar puncture showed no cells, a slight globulin reaction, and an albumin titer within the normal. There was a leucoplakia and a positive W. R. The man was emaciated, febrile, and showed signs, with the X-ray, of bronchial lymph node disease. According to Babonneix and David, the normality of the fluid indicates that the phenomena here were Shell-shock phenomena, despite the indisputable syphilis of the blood serum.
Re occurrence of functional phenomena in syphilitics, Freud’s remark may be recalled to the effect that a large proportion of his hysterics and other psychoneurotics are the offspring of syphilitics.
Consider in this connection also Case 28: an old syphilitic hemiplegia was followed by a probably psychogenic or hysterical hemiplegia on the same side.
Vestibular symptoms in a neurosyphilitic.
Case 31. (Guillain and BarrÉ, April, 1916.)
A soldier, Colonial, 29, was twice in the 6th Army neurological centre. The first time, February, 1916, he was under observation for astasia-abasia, having been invalided twice for this disease,—once in 1915. This man had had syphilis at 21, and was then taken care of at Saint-Louis Hospital and at Cochin. A volunteer for the duration of war, September, 1914, he had intermittent disorders of station and walking, which caused his invaliding January, 1915. As the trouble stopped, he asked to go back to the front in September, but the same difficulty reappeared with fatigue, and he was sent to the army neurological centre. When standing, there was a ceaseless trembling of the whole body but especially of the legs, with tendency to propulsion. In walking also, there was a trepidant abasia, sometimes dizziness, and even a sudden fall. Standing on one foot he trembled and fell.
Examined on his back, muscular strength was found intact in all limbs, and there was no trembling or incoÖrdination or intention tremor in the performance of any movements, though there was a slight trembling of the raised fingers and hand. Reflexes were normal. The right pupil was dilated; the left pupil reacted sluggishly. There were lateral nystagmiform movements to the left. Caloric nystagmus appeared from the right ear in 15 seconds, from the left in 30. Rotatory nystagmus appeared in 35 seconds on both sides. Lumbar puncture yielded a fluid with a slight lymphocytosis; albumin, .3 grams; chloride, 7.30; sugar normal.
Rest in bed improved the astasia-abasia, and the man was sent back to his corps, February 20, 1916. He came back March 16, having had a dizzy spell, with suffocation feeling and a fall, whereupon the trepidant astasia-abasia had reappeared. There were none of the so-called defensive reflexes. The neuromuscular excitability of gastrocnemii was less on the right than on the left. A von Graefe sign was sometimes found; no diplopia save on looking far to right.
Lay reflections on syphilis: Suicidal attempts.
Case 32. (Colin and Lautier, July, 1917.)
A man was called to the auxiliaries at the outbreak of the war, and served as stretcher-bearer at the Marne. He then became an attendant at the Grand-Palais. Acquiring gonorrhoea, he was cared for but he grew depressed. The blood was examined and the W. R. found positive. The physician immediately made known the result without circumlocution, and knowing vaguely that the W. R. meant syphilis, the patient felt an irresistible impulse to suicide, and cut his throat. It seems that he had often before said that if he got syphilis he would kill himself. Recovering from his wound, he was invalided to Villejuif, Sept. 19, 1916, breathing through a cannula and responding to questions in writing. He had always been a nervous and emotional man, a farmer in Auvergne; he was married and the father of several children.
Examination showed that the recurrent nerves had been cut and that the man must needs always breathe through the cannula. In point of fact, the W. R., only partially positive at the outset, did not indicate syphilis, and the gonorrhoea was now cured. But though the patient knew these facts, his hypochondria persisted, basing itself upon the suicidal wound. He said that his larynx had been stolen and he wondered why. He said that he had violent crises of suffocation, though there was, as a matter of fact, no difficulty with his breathing. Verdigris, he said, was forming on his cannula. Self-accusations about the suicide developed. On being transferred to his department asylum, he made a suicidal attempt on the trip.
Of course the gonorrhoea may have served as a partial factor in the genesis of the case, and his own mental attitude toward the contraction of syphilis may have been another factor.
The imitation of chancre.
Case 33. (Pick, July, 1916.)
A married German farmer, 32, was in Prague hospital in 1908 during his period of military service and was then treated by inunction for a local chancre. He was given mercurial injections a year later for rash.
In 1912, he had signs of syphilis in the mouth.
He was sent home from service in 1913, with ulcers of hand.
At the beginning of the war he was found to have ulcers on the knee, legs, and mouth, and was sent home for six months.
Again called up in 1915, the ulcers were still in evidence; he got inunctions in a military hospital four months.
He was sent to his corps in July and had no relapse until July, 1916, when he was detailed for active service. Thereupon, ulcers began on the left hand and right leg. He reported sick, but was sent nevertheless to the front. In hospital he was found to have several scars about one inch across on each leg, on the dorsum of the left hand, at the right of the left index finger, and elsewhere. These scars were deeply pigmented. One of them was square! There were other recent ulcers that closely resembled tertiary ulcers. The most recent of these ulcers was angular, intensely red, and showed remains of a collapsed vesicle. There was a deep dark scab on the mucous membrane of the left cheek.
There is no doubt that these ulcers were produced by some caustic, the nature of which remains unknown. The patient had, however, been able to evade military obligation during peace time and for two years during war time.
Re simulation, according to Pick, some 5 to 7 per cent venereal diseases in the German army have been simulations. Gonorrhoea is simulated by soap, balanitis by cantharides, soft chancre by soap and mercuric or mercurous chloride mixed, hard chancre by a fluid or powder containing NaOH, Na2CO, and NaCl. Secondary syphilitic signs are imitated by cantharides or garlic, producing scrotal dermatitis. Tertiaries are imitated with caustics.
RamÓn to Rosina: a soldier’s letter to his fiancÉe.
Case 34. (Buscaino and Coppola, January, 1916.)
“I am here to stay a month. Believe me, it is better here than in the army. There is a rule that we may eat as much as we can and everything is of the very best. The servants treat us like brothers. Do not think it is a nuisance to be inside four walls with a wee bit of a garden. No, indeed! But I have got to act the fool and from the very first day I began to play and act crazy with a kitten, so that if you had seen me you would say: “RamÓn is really crazy.” Rosina, dear, to avoid paying taxes you have got to be a smuggler. And now that I am at the ball I have got to dance. I want to see if after all the suffering I cannot get something better. I am better off here than at the regiment. I sleep in a fine warm bed, and they have only cold straw; I have good food and drink and plenty of milk, and they have poor food and drink and so little.
“I expect to go home in about three weeks. I would have been there before if some fool of a spy at our place had held his tongue and minded his own business. At the same time, Rosina, dear, remember what I told you at Leghorn: that they had some officers sent there to get information and instead of going home they asked somebody else and were told that I had never been sick and had never had neurasthenia. When this information was got from the officers I was called to the office and they read to me that all that I had said and done was not true. I kept on acting the fool, and as they were still doubtful they sent me here, where there is a professor who passes me every morning in the garden and says: “How are you?” I always say: “I am the same,” acting like a crazy man. Let me tell you, Rosina dear, not to say anything contrary to this in your letters because they open and read everything in order to find out everything that happens and everything that is said. Now what you must do is to ask me how I am feeling, and whether my headaches are gone, and whether I have them all the time as formerly, and any other trifle that will help me.”
Rosina’s fiancÉ had a strongly positive W. R. in the serum. It was negative in the fluid. He was returned to the front.
(THE FEEBLE-MINDED GROUP)
Moron of use at front (alienist’s report).
Case 35. (Pruvost, 1915.)
Vigouroux reports concerning a tanner of 19 who could not read, write or calculate (3 plus 8 equals 14) and had been of the 1916 class in an infantry regiment at Brest, on the occasion of his asking to be sent to the front more speedily:
Mental weakness, with insufficient school and theoretical knowledge but with the ability to assimilate practical ideas, though not knowing how to read, write or calculate; seems to have earned his living in several lines.
An imbecile, superbrave.
Case 36. (Pruvost, 1915.)
A loquacious, active fellow, 22, with very slight school knowledge and no idea of military ranks (treated his superiors like his comrades), was often punished in the barracks. He did not get on well with his instructors. His activities were never interrupted by any obstacles or by derision. He kept singing and talking enthusiastically during the mobilization. He was the butt of his section.
At Dinant he did very well; though his section was losing a good many men he remained calm. He was careless of danger and remained at his post firing ceaselessly at the enemy and giving a magnificent example to the few comrades who remained with him. In fact, he remained so long in his shelter that he was surrounded and taken prisoner. He escaped, swam the Meuse and got back to his regiment.
An imbecile of service in barracks work.
Case 37. (Pruvost, 1915.)
A farmer, 36 (father alcoholic, mother always sick, two brothers at the front; patient had typhoid at an unknown age; had gone to school at 13 but “learned nothing”; worked in fields with his brother who gave him some pennies on Sunday), was put into the auxiliary service by the Council at 20. Patient said he was not strong enough for this service. In 1914 the Council reconsidered the case and put him into a regiment of infantry. He could not be given military instruction or execute the most simple drilling manual. He said that 4 plus 2 equalled 7; 4 plus 3 equalled 5. He was of an excellent character, very docile and easily directed. He did all his comrades’ barracks work and was very proud because, as he said, “I do everything they tell me to do.” He was happy in working, everybody was good to him, but he had no comrades. He had no general knowledge and knew nothing about the war but that they were fighting the Boche.
Re imbeciles, Colin, Lautier and Magnac found amongst 1000 soldiers entering Villejuif, 53 imbeciles. Twenty-four of them had been either exempt or retired at the outset of the war, when military surgeons had reviewed them and considered them fit for service. Several of the 29 others also had shown previous evidence of imbecility.
Of course, French military surgeons may have felt that a number of these men would be of just such service in barracks and otherwise as Case 37 (Pruvost). But for one or two cases like Cases 37 and 41 of Pruvost, there are great numbers of other imbeciles who prove quite useless in the army. Two of the Villejuif cases had been volunteers: one volunteer declared that, if he had been intelligent, he never would have enlisted! Ten cases proved unable to use a gun; one turned his gun upon his mates. One regularly forgot the password. One (see Case 42 of Lautier) thought the war too long and tried to take command of the company in order to finish the war one way or the other. Three of the imbeciles had to be evacuated for desertion (unmotivated fugues); two of them cursed their officers. Some of the imbeciles had an emotional diarrhoea throughout their service.
Colin suggests that line officers and military surgeons ought to agree that these men are not fit for service, and that the civil authorities of the home towns should advise the review boards about known imbeciles and criminals. In point of fact, previous knowledge of imbecility could have been obtained quite readily in 27 of the 53 cases observed by Colin.
A feeble-minded inventor.
Case 38. (Laignel-Lavastine and Ballet, 1917.)
A jockey of NÎmes, 31, entered the service May 15, 1917. He retired before the war. He was in the auxiliaries at the moment of mobilization. Nothing is known as to any pathological episodes in his past. He said he had been a poor scholar, had left the primary school at eleven hardly knowing how to write or spell, but he had a lively imagination and was a happy-go-lucky youth, playing many tricks on the trades people. He tried a variety of ideas in the industrial or commercial world with very varying success. He had a mechanical taste. The Colonial Exposition at Marseilles caused him to float a variety of projects, from that of having the visitors photographed on a camel to the sale of lemonade. He said he had been a jockey and then a trainer and had finally become a valet de jockey at Maisons Laffitte. He was a gambler and invented a “system.” He made various inventions in relation to horses. At the end of 1914 he had plans for a bomb thrower and placed his discovery at the service of the War Minister. He was not discouraged by the lack of success of the bomb thrower. He now made an aerial torpedo carrier. He had the idea of the tanks. However, he found the secret of his torpedo carrier printed in a magazine. There was a slight difference between the German apparatus and his own.
From this time he began to be mistrustful, and now he jealously avoided entering into any details about his inventions and he did not let his officers see his plans. The Commandant offered to give a place in the safe to his documents, but he could not embrace the offer. He now invented a counter-torpedo machine. He went on leave to Paris, asked an audience of the Minister of Marine, who put him in relation to the Committee on Inventions, who put him off, desiring that he should forward all his plans. He emerged from one of his interviews so excited that there was a scandal on the public street and the police commissary evacuated him to Val-de-GrÂce, but the patient says he does not remember
According to Laignel-Lavastine, we deal with a feeble-minded person who has for many years had a dÉlire raisonnant of the inventing group.
Re feeblemindedness in the British Army, Shuttleworth found 70 who had joined from special schools for the feeble-minded in London, and 100 from Birmingham in the year 1915. The institutional “children” were in general good at drilling and obeying. One of them, given to lying and stealing, got into constant trouble in Flanders.
Sir George Savage stated that he had sometimes run the risk of allowing enlistment of men who had shown earlier in life a weakness for lying and pilfering, and remarked that such men might make good soldiers. A case like the above (38) would run counter to this view. On this matter, see below Case 183 (Henderson), one of pathological lying.
An imbecile who walked lame.
Case 39. (Pruvost, 1915.)
A soldier, 20, eight days after being called to the colors, complained of pain in the knee and hip. He was observed for 18 days in hospital and then sent back to his company; but he continued to complain of the pains, and the regimental surgeon sent him to a neurological center where the joints were found to be normal and where no sensory, motor or reflex disorders were in evidence. The man continued to walk lame and insisted he could not get about without a cane. He also complained of his mouth and his belly and, though he was very ruddy, said he was Á bout de forces.
It was a question of simulation. The man, however, was a feebleminded person who could not read, write or calculate. He was invalided as such.
Enlistment to improve character.
Case 40. (Briand, February, 1915.)
A village boy had passed for simple ever since typhoid fever at 8. He had learned to read and write, but had always been impulsive and subject to fugues, running to see his grandmother, or off as a truant. It was decided that he, at 19, should enlist to improve his character. But one fine day, even before the war, he deserted. He said, in explanation, that he had lost his way, and he was being examined mentally when mobilization began.
He looked ape-like, with spread ears; had a low forehead, a head flattened behind, an asymmetrical face, prognathous jaws, an arched palate, and defective teeth. He talked freely of homosexual relations, and said he wandered off because it occurred to him to do so. He was determined to be unfit for service.
An imbecile who may be sent to the front.
Case 41. (Pruvost, 1915.)
A Parisian sandwichman, 25, of unknown parentage and a state ward, placed out with a farmer at 12, escaping with a friend to Bordeaux at 14, thence leading a wild, improvident life at Lyons, Marseilles and Paris, sleeping in fields and hedges, earning 22 sous a day but in no case mixing with the police, was examined for physical inefficiency at 20 years. He wanted to enlist but was refused. He insisted and was very proud of the fact that he got in as the Major said to them, “Let him go in.” He could hardly read, write or calculate but was by reason of his adventurous life full of practical resources. He was irascible and frequently crimed, whereupon he would cry under the Captain’s window, “Robber band, idiots, I shall write to the Minister.” He was passionately fond of military life, though he had but the vaguest notions about the commands, the names of generals and the like. He wanted to drill. His comrades played practical jokes upon him asking him to look for a trajectory, for the squad’s umbrella and the key to the drill ground. They also told him he had been proposed to be corporal, whereupon he was greatly overjoyed and immediately sewed stripes on his sleeve and began to give commands. He said if they put him among the auxiliaries he would throw the adjutant in the water. He sang and swung his gun with joy when he went to the front. He thought there were stripes hanging to the barbed wire and wanted to pick as many as possible. Such a man may be safely sent to the front although he will bear watching. At the date of report this man had been at the front two months doing very well.
Re the comparative success of the Germans in the matter of excluding imbeciles, Meyer found that 8 per cent of the mental cases in the army were cases of mental defect.
Imbecile with sudden initiative.
Case 42. (Lautier, 1915.)
A soldier, 41, a farmer, from the Department of the Marne, married, childless, was called to the colors August 31, 1914. He was on guard duty until May, 1915, watched prisoners until October and was finally sent to the front, February, 1916, where he fell sick.
“He was tired in his head.” “His commanding officer made him drill without rhyme or reason; he would have been able himself to have commanded with greater intelligence.” He once attempted to put himself at the head of the company to lead them against the Boche; this idea arrived to him all of a sudden in a phase of perfect confidence and sang froid. He thought his comrades would follow him and that the officers would do likewise. He hoped thus to be able to end the war one way or the other. He was getting tired of the war and regretted his family life and kept saying that this was no existence for family men. “We ought to attack or ask for peace.” No one followed him and his comrades said he was un peu fou but he did not share this opinion.
In point of fact he hardly knew how to read or write and at home lived with his relatives, submitting himself entirely to their guidance. He was much afraid of being punished and often feared that he had done badly as he had trop de conscience. He was non-alcoholic and without hereditary or acquired neuropathic taint. He had no pronounced stigmata of degeneration. He was rather reticent about certain mystical ideas of a political tinge. At Villejuif, whither he was brought February 17, 1916, he received a diagnosis of imbecility.
Emotional fugue in a subnormal subject.
Case 43. (Briand, February, 1915.)
A soldier in the Territorial Army, 40, appeared before the examining board in a depressed, dejected-looking state, speaking slowly but collectedly and lucidly. Mobilized the second day, this man was much afraid that he could not get through the marches, and asked for a special examination to determine whether his feet did not make him unsuitable for fatigue. Two physicians thought he was unsuitable for marching, and another thought he put it on. A trial march was not executed well. He was kept in barracks but jumped the wall, put on civilian clothes, and made off for Paris. But a relative, warned by his wife, finally got him to go to the authorities. He was told that he ought to return in the afternoon, when suddenly he was arrested.
It seems that the man relied on the opinion of the two physicians and discounted that of the third. He thought himself the victim of an injustice, and not knowing how to get on, it occurred to him that he would abandon the regiment and get out of the difficulty. It was without resistance, however, that he gave himself up as a prisoner. This fugue was neither unconscious nor amnestic, nor was it due to an irresistible impulse; nor can we say that it was due to a genuine intellectual disorder. It was an emotional fugue, and partly due to the man’s long-standing depression. It seems that he had inherited this character from his father. He was below normal intelligence, had a very poor education, lost his wife, and grew more and more sombre. He married again, but this time a neuropath. He began to be preoccupied with his health and he had even some ideas of suicide. At the time of his leaving the regiment, he had passed through a phase of depression of about 6 months’ duration, and at this time had a number of hypochondriacal ideas with poor appetite and loss of weight.
Diagnostic dispute between regimental surgeon and alienist.
Case 44. (Kastan, January, 1916.)
Julius Q. was sent on guard April 14, 1915, with orders to remain there. While on guard he made a noise and made a movement as if to take a knife from his pocket. Ordered to empty his pockets, he attacked the other guards. The witnesses said that he was drunk.
Upon examination, it appeared that he had recognized and called by name those present in the guardhouse, despite his supposed intoxication. There were red spots on the skin and a certain amount of analgesia. His powers of computation and reasoning were poor. He was unable to explain the meaning of a picture shown him. He maintained that he had an indomitable desire for drink. A diagnostic draught of alcohol yielded no reaction. Upon dismissal, he got drunk at once again, and had again to be imprisoned in a state of excitement. What the outcome in this case was is not stated by Kastan.
The previous history seems important. Julius Q. had been a state ward. He had escaped several times from the institution but had always to be brought back again because he could not be trained at home. He had once attacked a supervisor in the state institution with a knife. It seems that he had at this time been drunk, having been brought back drunk to the institution.
Two years before the war he had been taken to the Breslau Hospital for the Insane on account of fits of insanity. In 1913 he had been a patient in Wuhlgarten on similar grounds. The diagnosis there had been epileptoid degeneration, psychopathic constitution, imbecility, or epilepsy(?). He had been convicted of crimes a number of times and put to labor. He had been given to cruelty in childhood.
Despite this, he was declared perfectly healthy in mind and body by the regimental surgeon.
In 1914, Q. fell suddenly ill in prison (he was presumably in prison for a military offence), and smeared the cell with feces, saying that he was able to do that as he could pay for anything. He stared at the floor and failed to answer questions. He remarked, however, that he had frequently been convicted for breach of the peace and assault and battery, and he said his father had been a drunkard, and he acknowledged hallucinations to the extent of saying that he heard his name called when he was alone.
The story of this case warrants our inquiring why such a patient was kept in the army. He was kept there clearly on account of the report of the regimental surgeon, who could not have taken seriously the previous history of the case, or else thought the patient perfectly good cannon fodder.
The hypothesis of syphilis apparently need not be entertained. That of feeblemindedness is possibly the fundamental diagnosis, yet epilepsy was considered by the German diagnosticians, doubtless on account of the sudden violent attacks and breaches of peace on the part of the patient. There is clearly something behind mere alcoholism in the entire story of this state ward. On the whole, the periodicity of the attacks is equally consistent with the picture presented by numerous feeble-minded persons, and the institutions that had to deal with Q. regarded him rather as epileptoid. There seems to be evidence of actual intellectual defect. Accordingly it seems wiser to consider the case of Julius Q. one of feeblemindedness, possibly of the moron group. We should then consider the epileptoid features as part and parcel of the feeblemindedness. We should consider the intellectual defect a part of the process; and the uncontrollable impulse to drink, the sudden violent attacks, and the cruelty in childhood would then be regarded as merely symptomatic of the feeblemindedness. It seems clear that either mental tests by the regimental surgeon or an examination of the patient’s previous history would tend to exclude such a patient from the army.
How can a rifleman be an imbecile?
Case 45. (Kastan, January, 1916.)
Anton K. was down in the list as “missing.” He was found at home. He said his feet had become sore from the marching. He had lain down and become unconscious. Coming to his senses, he was possessed only of trousers and a shirt but he got a civilian suit in a village. He had gone home part way by train, part way on foot. It seems that he did not tell his father any details about his coming back although he expressly denied deserting.
It seems no mental weakness had been noticed in the army. It had been observed, however, that after seeing the first corpses he was deeply impressed and did not want to see any more. On examination in the hospital he gave the impression of indifference and low spirits. He had to be urged to eat and work. No great amount of intelligence defect could be determined, though his knowledge and capacity were below the average. The physician examining him thought his depression was either caused by or increased by his imprisonment; but this examiner thought that the protection of Section 51 did not extend to the patient at the time of his desertion. The examiner thought that an examination by a psychiatrist was not necessary, though both judge and prosecutor urged it.
When examined in the clinic, he seemed to be disoriented for time. He claimed to have been able to stand the shooting and the sight of the corpses. After becoming unconscious, he had wakened and eaten cucumbers and carrots in the fields, wandering on for a period of three or four weeks, until he came to a place where he had formerly worked. The reason he had thrown away his uniform was because Russians had been about. He had not known that it was his duty to report to the army again.
It was found that the patient’s father was poorly developed as to mind, that his brother was subject to periodic mental disturbance so that he had to be watched. It was found also that K. himself had had a similar mental disturbance,
He himself said that his people were of sound mind; that during school days he had felt bad in his head, once running into the woods after being told something. He was able to give the names of his former superiors. His calculations were only partly correct. He was poor at reasoning and at simple distinctions; for example, asked the difference between a bird and a butterfly, he replied that a butterfly was a bird too. He did not know the difference between a river and a lake. He thought Russia, England, and Austria were the enemies of Germany.
He sat about or lay on the floor, motionless and indifferent, with a newspaper stuffed into his trousers, unoccupied although saying that he wanted to work, and even allowing his fingers to be burned by cigarettes he was smoking.
He was tried once more and the first medical expert still adhered to his former opinion, pointing out that K. was a rifleman and that only an intelligent man could be a rifleman. The court, however, accepted Kastan’s opinion and granted K. the protection of Section 51.
In comment upon this case, it seems clear that ever so slight a knowledge of K’s home town reputation would have naturally excluded him from the army. However, what is to be said “when doctors disagree,” as noted by Kastan in this very case? It seems impossible, also, that his comrades should not have noticed something odd about him (over and above the deep impression on seeing the first dead) which might have given occasion to the regimental surgeon for a special mental examination. However, to the military mind, mayhap the man seemed to be sufficiently “effective.”
Re imbecility in a rifleman, the compiler has studied somewhat elaborately the brain of a feeble-minded murderer with some North American Indian blood in him. This man was a crack shot despite his subnormality. It would seem that the German regimental surgeons castigated by Kastan as above were very properly so castigated.
Hypomania in an imbecile.
Case 46. (Haury, August, 1915.)
A brusque little man, of a somewhat bold and talkative disposition, though giving a good first impression, was evidently a bit feebleminded, though (as Haury says) of the active group. He had a sister like himself, whose children were taken care of by the State, and at home he had had a number of fugues, about which details were lacking. It was soon evident what sort of soldier he would make, and he was put in one of the Territorial regiments, but it was not noted that he had a genuine mental disorder, as he was thought to be just a peculiar person.
His new relations caused him to do a number of eccentric things. He shortly proved to be in a sort of rudimentary maniacal state; talkative, restless, scheming rather feebly to go back to his village. He said that he couldn’t walk on account of corns, and that these corns required a certain drug, which he wanted to get from home. He said that he had been struck by lightning twice; that he had fires in his body, etc. He wanted only to be retired on a pension of one or two hundred francs so he could take care of his farm, his hay and his fields. There was no need of trying to get land by means of bullets, he said, since he had enough.
The mental disorder of this man was much deeper than appeared, and in fact, he did a number of dangerous things compromising the security of the entire regiment.
Re the dangerous tendencies of Case 46, see the remarks above drawn from Colin, under Case 37.
Insubordinate desire to remain at the front.
Case 47. (Kastan, January, 1916.)
Friedrich L., on March 4, 1915, was ordered to go back to the baggage-train. He did not obey. He said to the non-commissioned officer who then came to him, “I am not going; you have nothing to say anyhow, you ox-tender!” He stood with his hands in his pockets, and, when the officer seized him angrily by the collar, L. struck the officer’s face.
He stated at his hearing that no one had the right to send him back. At that time even he conveyed the impression of being not quite normal and was let off with his arrest only. Later he refused again to go on guard duty, saying, “You have nothing to say at all. Perhaps you will find out that we shall meet each other again in hell tomorrow morning.” He was taken before the physician, who considered him mentally inferior and not entirely appreciative of the nature of his acts. He was told that the death penalty would meet such behavior, whereupon he remarked, “I am not afraid of the death penalty,” staring excitedly at the officer and trembling throughout his body. It seems that he had already made an impression of mental inferiority in the troop, and had once before said to an officer who wanted to send him to the front, that he would not go; this had been regarded as almost a breach of discipline. He had been in the habit of not reacting to the calls of his superiors, and had smiled at their reproaches. He seemed to hold the opinion that not even a company commander had power to order him to go back. Examined in the clinic he held to the same opinion, that there was no need of his going back; that they took volunteers; and that he wanted to remain at the front. On the day of the deed, he had drunk a rye whiskey. He had shaken off the non-commissioned officer because the leader had seized him by the throat. In the clinic he often smiled and wrinkled his forehead. He gave evasive and inadequate answers. Asked about oaths and perjury, he remarked,
He said that one of his sisters was a little stupid. Study of his previous history indicates that Friedrich L. had formerly been a quiet and steady man, although he often had attacks of rage, breaking out upon sudden excitements. As to his capacity in school, nothing could be learned, since the Russians had taken the school registers away.
The analysis of this case seems to reduce to the question of feeblemindedness and schizophrenia, unless some form of inborn qualitative inferiority of mind be preferred as the diagnosis. On the whole, possibly, the diagnosis of feeblemindedness seems preferable. The entire symptom picture seems to relate to the patient’s one mental attitude about sticking at the front, ruat coelum.
A French soldier who admired Germans.
Case 48. (Lautier, 1915.)
A man with the extraordinary first name of Agapithe (Laurent insists on the frequency of strange first names in degenerate families) came from Val-de-GrÂce to Villejuif June 5, 1916, with the diagnosis of mental weakness, interpretative ideas of persecution, mental excitement, recrimination, logorrhoea, and a tendency to revengeful reactions.
On arrival the patient said he must be in an insane asylum because he heard spiritiques talking together. He, however, was “not insane” and began expounding his plans for revenge with the words “Kill,” “Cut-throat.”
This man had been placed in the auxiliary service by the Council, called to the colors December 13, 1914, and finally sent to the front in May, 1915. In July he was made prisoner in a brush. He said, “I cried out, ‘Comrades, what difference does it make to me whether I am German or French? My officers are imbeciles that drink the blood of us unlucky ones!’” He was interned in some camp whose name he could not exactly give and reported that the Germans were very gentle with him, that his real enemies were the French, for the French were against him night and day. “As a matter of fact, among Germans the French are nothing but cochons malades. The Germans are fine types.”
He was repatriated in May, 1916. He kept making verbose and neologistic eulogia of the Germans. He had been a farm boy in Brittany, where he had had headaches. He had been at Quimper Asylum in 1910. In fact, he said his parents had tried to poison him and to have him assassinated; they had charged him with setting fire to their house. His mother was an imbecile, he said, who believed she was the Queen of France. His recriminations did not stop short of himself. He had been accused of kissing a girl and stealing apples; as a matter of fact he knew what to do with girls.
He had a coarse face and a number of stigmata besides his name Agapithe. He was kept at Villejuif as an imbecile.
Unfit for service: Question of feeblemindedness.
Case 49. (Kastan, January, 1916.)
Walter N. was declared unfit for military service in 1912, on the ground of mental incapacity. He had shown this clearly during his period of training. He committed a number of slight offences secretly, but not so secretly but that they were immediately discovered and punishment meted out therefor. He could do nothing without aid. It appears that his mental weakness had not been noticed in school, but that his employers had thought him both feebleminded and irresponsible. Nevertheless he always executed orders properly. While in hospital in 1912, he had occupied himself very little, sitting indifferently, quiet and dreaming. At that time, he had shown poor calculating ability and decreased power of perception. It also appears that he did not grasp the nature of simple orders, the requisite associations being disturbed.
Despite this history, on September 11, 1914, he found himself being transported. He claimed to be very tired. Upon reaching the city, he picked up a large stone and raised his arm as if to strike the transport leader. While N. was being bound by the transport leader in consequence, he kicked at his leader’s shins.
In the clinic he resisted examination, moving his legs without speaking, staring at the floor, moaning frequently, sitting motionless with head hanging, answering monotonously repeated questions, but turning his head at a loud noise. He felt ill. It appeared that he was oriented and that his knowledge was well preserved although his calculation ability was poor.
It would seem that psychiatric examination, possibly with the aid of psychological work, would have excluded Walter N. from the army.
Oniric delirium (RÉgis) in a somewhat feebleminded Esthonian.
Case 50. (Soukhanoff, November, 1915.)
An Esthonian, 21, a soldier in a reserve regiment, came to a psychiatric section towards the close of 1914. He was negativistic, mumbling, restless, fugacious; later more tranquil. One day he entered the physician’s office, walking up and down, mute, looking at articles and attempting to take them away.
February 21, 1915, he was evacuated to the Notre Dame Hospital for the insane at Petrograd,—a tall, healthy, agitated-looking youth with a rapid pulse. He explained in poor Russian how he was now among Germans and feared that they were going to hurt him. At first in the hospital he was seclusive and morose. March 9 he became excited, and tried to break through the door. He was placed in the bath, agitated and yelling. An Esthonian interpreter did not quiet him. The Germans were going to make a martyr of him. After an hour of this he grew quieter, and next day complained only of head weakness and malaise, was in good humour, smiling, and reading an Esthonian paper, and well behaved in church, though tired and pale.
He now got better, began to work and wrote letters. It seemed as if he had waked up from a painful dream. He explained how he thought he had been in captivity; that he was going to be hanged. He had thought that the Germans could talk Russian. He had had hard work in his regiment, as he did not understand Russian and had never before left his little village in Livonia. His mental disorder had started in the autumn, but all that was now like a dream. He said that he had had a mental disorder of short duration following some bodily disease, at the age of thirteen. According to Soukhanoff, this is a case of Meynert’s amentia, in a somewhat feebleminded person. The twilight state might well receive (according to Soukhanoff) the term “oniric delirium” invented by RÉgis.
Shell-shock; burial: Incapacity to rationalize the situation.
Case 51. (Duprat, October, 1917.)
A soldier, 39, a herdsman, was shell-shocked at Hill 304 May 23, 1916, buried twice, slightly wounded in right eye, and carried unconscious to Bar-le-Duc. He was then forty days in a semi-confusional state with headaches and dreams of the Boches wanting to behead him. Some of these dreams came in the waking state, in which state he could recognize them as imaginary. In April, 1917, he said he had always been afraid, even in daytime, that he would be hurt and had been especially troubled by the fear of shells. He was also bothered by nocturnal enuresis which might become an incurable disease and bring impairment of memory and attention. Although not feebleminded the man was of but moderate intelligence, and his emotions, according to Duprat, were such as to defeat any complete resolution of his plight by the intellect.
An affective complex, passing from the surprise of the shell-shock over to a fright based on clear though wrong ideas of what might happen to him, had left him without sufficient power of autocritique.
Weakling, twice buried by shell explosions in one day: Change of character; fear; three fugues (“It is stronger than I am”).
Case 52. (Pactet and Bonhomme, July, 1917.)
An infantryman, Class of 1913, at the front from September, 1914, had a somewhat infantile build physically but was intellectually of average powers, having been a type-setter (three years in a job). However, the confined life had borne hard upon him and his father put him on a farm. He passed through his military service successfully, though he was given two weeks in the guardhouse for overstaying Easter leave. He was suggestible enough at this time to think that he would not be punished very severely, since there were other men whose leaves did not expire at the same time as his own.
He was buried twice in the same morning, March, 1915, at Bois Le PrÊtre, spent four or five days in hospital, and went back to his battalion. But now there was a change in his character. Formerly indifferent to danger, he was now apprehensive every time he went to the line and felt an almost irresistible impulse to make for the rear. He was condemned to five years in prison, June, 1915, but was finally sent back to the front.
However, in July he left his company a second time as it was going into the trenches, and this time the captain simply asked him to do better. 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; however, here was a case in which three desertions occurred; the third after severe punishment. In the differential diagnosis, epilepsy, alcoholism, impulsive poriomania, must be considered, as well as feeblemindedness.
(THE EPILEPTIC GROUP)
Diagnosis “epilepsy” revised to neurosyphilis.
Case 53. (Hewat, March, 1917.)
A Scotch soldier, in the Royal Navy, 43, was admitted to the Royal Victoria Hospital at Netley, as major epilepsy. He had been 12 years a stoker, and 16 years before admission had suffered from syphilis, a chancre locally treated with black wash, without secondary rash.
After leaving the Navy, he had worked in a fire-brigade and as dock laborer. He had been very alcoholic when funds permitted, although never “primed.” His first convulsive seizures came at 40, while working at the docks, following a night on which he had drunk a bottle of whiskey. He thought he had been about half an hour in the fit.
He joined the A. S. C., January, 1915; served in France; later at Salonica. He had eight convulsive seizures, some in France, and others at Salonica, always after much rum.
The man was tall, powerfully built, without visceral disease, speech defect, or other symptoms except that both pupils showed the typical Argyll-Robertson phenomenon. The deep reflexes of arms and lower legs were increased. The superficial reflexes were diminished, and the Wassermann reaction strongly positive. A seizure was observed by Hewat and the diagnosis of major epilepsy was revised. The diagnosis of cerebrospinal syphilis, non-paretic, was preferred to that of paresis on account of the absence of all the ordinary symptoms of paresis and of tremor. It might be asked whether these fits were chiefly alcoholic in origin. However, the patient had two or three fits while in hospital during a period of eight teetotal weeks. Hewat remarks that the case suggests that the serum of any patient developing epileptiform seizures for the first time say between 35 and 50 years of age, should be given the Wassermann test.
Syphilis may bring out epilepsy in a subject having taint.
Case 54. (Bonhoeffer, July, 1915.)
A man of 35 in the Landwehr acquired syphilis some time in the summer of 1914. He was a good soldier, passed through several clashes, and was promoted to Unteroffizier.
To understand what followed it must be stated that he had been a bed-wetter to 11, had been practically a teetotaler (Bonhoeffer’s point is perhaps that otherwise epilepsy might have developed sooner?), and, when he did drink, vomited almost at once, and had amnesia for the period of drunkenness. His father drank. His sister had fits as a child.
February, 1915, the Unteroffizier lost appetite, got headaches, and went to hospital for a time. Upon getting better, he was sent on service to Berlin. In a Berlin hotel he had his first convulsions and unconsciousness, biting his tongue. He was confused for several days, and, when he had become clear, had a pronounced retrograde amnesia together with a tendency to fabricate a filling of events for the lost period.
This retrograde amnesia is uncommon in epilepsy and suggests organic disease. No sign of such was found, or signs of the epileptic make-up. The serum W. R. was negative. On the whole, Bonhoeffer regards the epilepsy as “reactive” to the syphilis, as a syphilogenic epilepsy.
Alcoholism caused amnesia in this man in the same way as the syphilitic epilepsy now did.
Re epilepsy and syphilis, Bonhoeffer states that he has repeatedly seen syphilis giving no other symptoms than epilepsy develop in the campaign. At the same time, Bonhoeffer does not find that the incubation period in paresis can be shortened by war factors; at all events, by the exhaustion factor in war (see Case 25). It might be questioned whether the above case (54) was not psychogenic; that is, whether the syphilis did not act in combination with being sent to Berlin on service as a psychic factor. However, this epilepsy on the whole seemed not psychogenic.
Syphilis in a psychopathic subject. Convulsions 5 days after Dixmude.
Case 55. (Bonhoeffer, July, 1915.)
A soldier in the reserves, 23, was, subsequently to his being brought to hospital, described by his wife as a rather over-sensitive fellow, who could hardly look at blood and was meticulous about the household. He had always been subject to headaches, especially after hard work. However, he had passed through his military training well in 1910, not even having been bestraft.
He began service in October and fought at Dixmude on the 19th. On the 24th in the trench and while being carried back, he had several spells of pallor, falling stiff, and then having convulsions. Brought finally to the CharitÉ in Berlin, he had more spells of sudden pallor, collapse with brief convulsions, tossings in bed, as well as absences, post-convulsive headaches, and mild bad humor.
There were numerous attacks several days apart in the first seven weeks. The patient was not of an “epileptic” disposition, though readily dissatisfied and headachey.
The serum W. R. was positive. Treatment by mercurial inunctions. No further convulsions. Prognosis doubtful.
Re epilepsy and the war, during the first six months Bonhoeffer observed 33 cases in the CharitÉ Clinic in Berlin. Twenty of these 33 cases, unlike Case 55, had attacks before the war, although ten of these had become epileptic rather late, namely, after the period of active military service, at ages from 22 to 27. The development of epilepsy like Case 55’s is not without frequent precedent.
Bonhoeffer states that aside from epilepsy directly due to brain injury by shells, there has been no certain case in which we have the right to regard the war itself as the total cause of the epilepsy. Some, like Case 55, are of syphilitic origin. No subject with a severe long-standing epilepsy has been able to get into the field, according to Bonhoeffer; when they do, they prove constitutional subjects.
An epileptic imbecile, court-martialed.
Case 56. (Lautier, 1916.)
A Belgian soldier was condemned by court-martial February 27, 1915, to five years imprisonment for leaving his post in the presence of the enemy. It seems that he was mounting guard with two of his comrades and all three left to eat as no food had been brought to them.
A physician examined the Belgian soldier and declared him responsible, although a little sick. All three were condemned to imprisonment. The Belgian attracted attention in prison through crises of anxiety and agitation; he had terrible nightmares, seeing Germans in his cell and hearing gunshots. He was accordingly sent to a special infirmary of the dÉpÔt, whence July 24 to Sainte-Anne, July 26 to Villejuif. He talked Flemish, hardly understanding French, and spoke slowly and with difficulty. He hardly knew how to read or write. He had been a truckman.
At 18, this soldier, according to his own account, began to have nervous crises in which he fell, lost consciousness, bit his tongue, foamed at the mouth and urinated involuntarily. The attacks were somewhat rare. His father sent him in 1910 to Gheel where he stayed two years. Returning home he helped his father in the trucking work.
When the Germans came the family fled to France and, about the end of 1914, he was put into the military service and sent to the front after a very short period of instruction.
The man had followed the example of his two comrades without taking the slightest thought. He did not understand the gravity of his act. He was not remorseful, regretful or angry against his judges. He was well oriented but quite indifferent. He was a tall, intelligent looking man with adherent lobules, slight facial asymmetry and evidence of tongue biting. He wrote like a child and read slowly, spelling out the complicated words. He was employed at various manual tasks during his sojourn at the asylum and had no epileptic attack. He was given over to the Belgian military authorities October 5, 1915.
Seizures in a feebleminded subject—psychogenic components.
Case 57. (Bonhoeffer, July, 1915.)
A 21-year old tailor, unused to marching, went into the field in August. A month later, after a period of long standing, he was nauseated and fell in a faint. Upon waking, his fingers were stiff and he had pains in his legs. He got better in the reserve hospital and was sent back to the line. On the way he had a similar seizure, with nausea and fainting. On the way back to Berlin, he had a seizure in the railway station, and was carried to the CharitÉ Clinic. At the clinic he stated that he could feel an attack come on; that he first had Angst all over his body, and that it was hot inside of his head. Latterly he had been able to stop an attack by clenching his teeth, after which the attack would not proceed except that all became black before his eyes.
He was observed for four weeks but no seizure appeared. He was somatically negative; his Wassermann reaction was negative. There was nothing hysterical about his make-up; he was somewhat surly and of low mental grade. He was unwilling to walk alone for fear of attacks.
As to the heredity of this soldier nothing is known. He had been an illegitimate child; he was a sleep-walker in childhood; he had sometimes spoken out loudly in sleep as a boy. At school he had been somewhat backward, fought readily with his mates, and often complained of dizziness and headaches. He could not stand smoking or drinking well, getting drunk upon two glasses of beer. He had not held positions well. He became a pionier in 1914, working chiefly as a tailor.
Early in his time as a soldier he had obtained an ulcer of the glans, which had been excised and burned. There had been no secondary symptoms.
According to Bonhoeffer, this is an example of a not infrequent condition. Although the attack itself and the habitus of the patient did not look hysterical, the manner in
Re reactive epilepsies, Bonhoeffer considers that there is a group of reactive epilepsies in which the war process plays an important part. The prognosis of these cases ought to be relatively favorable. In point of fact, Case 57, although a feebleminded subject, seems to have had a relatively favorable prognosis: at all events, no new seizures appeared under prolonged medical observation. These reactive seizures may occur in cases with a labile vasomotor system. They are, according to Bonhoeffer, aligned rather more with hysteria than with genuine epilepsy. Genuine epilepsy has not been developed in the war cases observed by Bonhoeffer except where an endogenous factor was clearly in evidence; or else where there was the requisite antebellum soil for the development of an epilepsy. In short, genuine epilepsies developing in the war are all, according to Bonhoeffer, predispositional. The antebellum soil was clearly in evidence in Case 57. Even before the war, according to Bonhoeffer, many German soldiers during the period of military service gave evidence of their epileptic soil by sundry suspicious phenomena. Among these were fainting spells during hard drilling and other exercises, spells of enuresis, abnormally deep sleep, and even phenomena of somnambulism. One of the Bonhoeffer epileptics had been released during his reservist practice as unfit for military service, and had only been put into the line at his own urgent request at the outbreak of the war. Three volunteers concealed their epileptic history. One man, who had had merely petit mal attacks before the war, regarded them as of little consequence, entered the service, and developed epilepsy.
Responsibility of a drunken epileptic.
Case 58. (Juquelier, March, 1917.)
The question of responsibility arose in the case of a soldier who left his camp the morning of October 23, 1916, and went to a neighboring place, where he drank, with four others, two quarts of wine. At about three o’clock in the afternoon, his captain met him on the street, lost, and looking drunk. He told him that he would send him to the trenches in the evening. The man lay down and went to sleep. At about six o’clock, it was found that he could not put on his equipment alone, and in fact threatened the other men with his bayonet, and then went to sleep. He woke up and explained that he had had one of his nervous crises. He remembered the matter of the bayonet but had forgotten everything else about the struggle.
This soldier was 29 years old, the son of an alcoholic, and the ninth child of a mother who died shortly after her tenth pregnancy. He had had measles and bronchitis as a child, and in childhood had had bad dreams; at the age of ten he had swooning spells. He became a quarryman and a habitual drinker, subject to dyspepsia, nightmares, and nocturnal cramps. There had never been any crises, however, up to wartime.
January, 1916, when a shell burst near him, the first sharply-defined epileptoid crisis came, and was followed by a number of others, either on leave or on service, March 8, June 2, and July 13. These attacks showed a sudden fall without warning, loss of consciousness, convulsions, tongue biting, incontinence of urine, a period of more or less coÖrdinate agitation at the time consciousness was reappearing, sometimes a fugue, and often amnesia for the whole. He had a scar on the left border of the tongue.
Should this epilepsy be regarded as entailing irresponsibility? He left camp before the crisis, accordingly in a period when he was in full possession of consciousness and will, and he had gotten into an irregular situation by drunkenness
Re epilepsy in the army, LÉpine notes the serious theoretical and practical problems to which it gives rise. In the first place, epilepsy occurs in the army more frequently than in the same number of men in civilian life. Consequently, the diagnosis as to the really epileptic nature of the attacks observed is not too easy. Again, the situation affords much opportunity for simulation (see, for example, the case of sham fits (Case 78, Hurst), and the case of epileptoid attacks controllable by the will (Case 79 of Russell)). Wounds may produce it, and even wounds which do not affect the brain; besides which, a variety of war conditions, short of trauma, may produce it. When the ordinary impulsiveness of the epileptic turns into automatism and to epileptic equivalents (États seconds), much of medicolegal interest may happen. Case 58 was just short of a murderer. Cases of actual murder in epileptic equivalents have been known under military conditions. Fugues with amnesia for the phenomena (which look to the military man like intentional desertions) form another group of epileptic events; but aside from the manias and the fugues, there are still more dubious epileptoid phenomena of a delusional and confusional nature, such that the proof of epilepsy comes only afterward, when frank convulsions supervene. Re fugues and desertion (the most frequent of military delinquencies according to RÉgis), we may think of the fugue reaction, according to LÉpine, as a natural reaction on the part of both the true delinquent and the mentally sick subject. The loss of liberty, alcohol, fatigue, minor phenomena of commotio cerebri, may lead to states of mental depression that favor the fugue. It is an
According to LÉpine, there are fewer guilty fugitives than there are innocent ones, or at least partially innocent ones. In the decision, one takes account of the duration, the course, and the peculiarities in the termination of the suspicious flight. According to the military code, there are cases like Case 58 in which the fugue itself was carried out in an unconscious state, and yet in which the martial responsibility of the man was absolute. Drunkenness is no excuse for the fugue, even if the latter is automatically carried out. Of course, the paretic is not responsible for his fugue any more than the organic dement, the delirious uremic, or the chronic alcoholic, who is already severely demented. For a case of this sort, see Case 1 (Briand).
In the differential diagnosis, we must also consider that fugues may be carried out in confused states as well as at times in various paranoid states, and even in melancholia.
A disciplinary case: Epilepsy.
Case 59. (Pellacani, March, 1917.)
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. The court-martial decided that he was not fully responsible.
Eventually, he was sent from the front for having insulted and struck a superior officer. The report read also that he was a prey to delirium and had frothed at the mouth. In the interior he had convulsive attacks, with falling and loss of consciousness. He told of arguing with a sergeant about a bicycle, of seeing darkness before his eyes like a veil, and of subsequent amnesia. In hospital he had intense headaches at times, with spells of sullenness, hostility, and complaints concerning nurses and attendants and other patients. At other times, he was quiet and comfortable. One day he went into an excitement and wept, asking to be sent back to the army, striking the table with his fist and head. He then screamed, flew into a passion, and fell to the ground in semi-stupor, shaking his body and trying to kick and knock away those who intervened. He was placed in bed but remained agitated and unconscious, with anesthesia and frothing at the mouth. The abdominal and cremaster reflexes were absent in this attack, and the pupils were rigid and myotic. The pulse was rapid and the blood pressure high. Afterwards he was sleepy, stupid and weary, and showed fine rapid tremors of hands, tongue, and eyelids. The abdominal reflexes now returned in excess, and a marked dermatographia developed.
Upon investigation, it was found that the patient’s father was also an epileptic and was alcoholic; that one paternal uncle had died in an asylum; another of apoplexy; that two
Re violence and epilepsy, LÉpine remarks that a pure epilepsy unclouded by alcoholism may occasionally give rise to acts of extreme violence, but these pure epileptic violences are infinitely rarer than the alcoholic ones. The Milanese was in point of fact alcoholic, and in his ancestry were a number of alcoholics as well as epileptics. According to LÉpine, when subjects are “out for blood,” they are almost always either, like this Milanese, hereditary alcoholics, or else strongly predisposed subjects, or even the offspring of the insane.
A disciplinary case: Epileptic attacks with amnesia.
Case 60. (Pellacani, March, 1917.)
A Veronese, 23, quarrelled with his comrades, and one day wounded one. Another time, when reproved by a superior, he struck him with a shoe; and at still another time, hurled himself upon his superior officer and bore him to the ground. Yet he seemed to have a perfect amnesia for all these violent acts. At other times, he had convulsive attacks with a mental state which seemed to combine anger and depression, after which he would fall to the ground, lose consciousness, go into clonic spasms, spit bloody saliva, and cause wounds and abrasions upon his body. Once, after such an attack, he passed into a brief excited spell. Finally he was so insubordinate and violent to superior officers, that he was brought under hospital observation, having been excited and confused for a day.
Next day he was lucid, oriented, and tranquil; entirely amnestic for what happened the day before, though his acts were sufficiently unusual. He had threatened his superior officer and been reproved and sent to prison to think it over. In prison he had suddenly thrown himself against another innocent person and clutched him tightly about the neck. He threw another violently to the ground and then ran to help the previous victim! Bound fast, he had succeeded in freeing himself and thrown himself furiously against the prison door, whereupon he had fallen to the ground in an epileptic fit. He had tachycardia (120) and a generalized hypalgesia. The vasomotor reactions were excessive.
Upon investigation it proved that his mother had been subnormal and that the patient had been constitutionally excitable and unstable, given to attacks of anger and impulsiveness from youth up. In fact, he had been in prison several times for violence. He described himself in his restless spells as feeling a trembling all over his body as if his blood were boiling in his heart and his head, whereupon he would lose knowledge of what he was doing. He had been a
Case 60 is clearly in the same group as Case 59. The Veronese falls into the same frame with the Milanese except that he appears not to have been alcoholic. The insubordinations of the Veronese were apparently carried out in a state of unconsciousness. The majority of insubordinates appear not to be epileptics. Some authors have called attention to pathological politeness as an occasional symptom in epilepsy. Perhaps the majority of insubordinate cases are feebleminded or schizophrenic.
Desertion in epileptic fugue.
Case 61. (Verger, February, 1916.)
A blacksmith from the Rochefort Arsenal, 27 (nothing known as to grandparents; father, now in the fifties, for 30 years in an asylum with frequent attacks of furor; mother, 45, well and apparently well-balanced; brother with the colors, wounded and decorated with the military medal; a cousin-german, who has had a typical epilepsy—in the patient himself enuresis up to 13 or 14, later, less frequently; apparently no tongue-biting; no information as to infectious diseases; graduate from primary school, apprenticed to a blacksmith; an unskilful worker; never able to rise to the level of a frappeur), in 1909 had passed the board of review and been put in the sixth division of the line. Antebellum there was a history that one night at supper, he had slipped away from quarters and gone 30 kilometres, home. His astonished mother sent him back to the military post by railway.
Upon the night of May 26-27, 1915, this soldier found himself in the position of a sentry, opposite the enemy. He told his comrade that he had to go away for a time, leaned his gun against a tree, disappeared, and did not return. It was then one o’clock in the morning. At six o’clock, he was found two kilometres away from the lines, in a village. He was in front of a barn where his company had been quartered before taking possession of the advanced posts.
He was brought up before the military authorities; but upon stating that in civil life he had wandered off several times without knowing where he was going, he was submitted to neurological examination. There was available a letter from his family physician relative to his antebellum military service. It appeared that he had committed a number of breaches of discipline, and that he was regarded by the physicians as a dÉsÉquilibrÉ. He had lived with his mother a very quiet and good life; there was no history of sexual irregularity, and no history of illness except a slight catarrhal jaundice. He had frequently suffered from headaches; there
During the mobilizing and first months of the war, both in quarters and at the front, however, his conduct had been that of a good soldier. Suddenly, about March or April, 1915, the nocturnal enuresis began to be frequent again, occurring twice or three times a week; but the patient hid this misfortune as far as possible from his comrades. The captain thought he looked tired and depressed sometimes. Upon the days following the nights with enuresis, there was intense headache and marked moral and physical depression. There was no proof of nocturnal convulsions, and it is very problematical whether there was tongue-biting.
Another odd feature was that the patient, who had been sober in civil life, had become intoxicated several times after going into the army. Physically, he was of low stature, but otherwise well built. Neurologically, he was entirely negative. There was no sign of venereal disease. There were a few stigmata of degeneration; for instance, there was very little hair upon the face, the ears were unequal in size, and the teeth were somewhat anomalously set. Mentally, he was below par; for instance, he could not add mentally two numbers of two digits.
As to his desertion, the patient says he does not know what he did; that he learned of his act only from his comrades in the morning; that he remembered having left his duty pour aller satisfaire un besoin.
A specialist in escapes (epileptic fugues).
Case 62. (Logre, March, 1917.)
An epileptic fugue with recidivism is described by Logre. He described himself as a specialist in escapes. As a schoolboy, he had practised escapes and run away without purpose, and without remembering fully what he had done. His father would bring him back to school. At first they had punished him and then would pardon him. These escapades in his work as a shoemaker caused him to lose various places, but he had been kept by one employer for a long time nevertheless. From 11 years on, this patient had never ceased living either in foreign parts or in prison.
The fugues on military service began to multiply. The military chiefs did not abide the escapades like the schoolmaster or the employer. Every punishment he received had to do with some fugue. Three times he gave himself up to the military authorities. Three times after a few more days’ service or a week in prison, he left the barracks or escaped. There had never been any appeal throughout this history to an alienist. On the declaration of war, he had returned to Belgium and was put into the army; whereupon in January, he carried out a fugue of a few hours which was rewarded with eight days in prison. There was a five-days fugue in July, whereupon he was taken before the council.
Upon investigation, these fugues seemed to have the classical features of epileptic fugues. They were sudden, unconscious, blindly automatic, almost completely forgotten afterwards and of a stereotyped and recidivistic nature. Most of the fugues had been preceded by a slight excess in drinking. An investigation was made to see if there were any convulsive antecedents; none were found. This mental epilepsy, then, it was thought, must be an isolated symptom, free from every motor symptom. But his mother and one of his brothers had also shown a number of attacks of some sort of epilepsy. In all three cases there was impulsivity, unconsciousness, absurdity, recidivism, and refractoriness to
Re such specialists in escapes as Case 62, LÉpine speaks of a type of military delinquent which he calls Ceux qui sautent le mur. Some of the fugue subjects, as well as other types of imbalance can apparently be held by no possible kind or degree of discipline. They jump any guardhouse or any other form of imprisonment through what amounts to a wild instinct for liberty. In some cases, this instinct appears in a relatively pure form; that is, without any combined tendency to dipsomania and without any sexual factor. Some of them are, in fact, very good soldiers, especially in shock troops. They, in fact, belong to what one might call the good element among delinquents. In the French Army some of them have been old legionaries and have even been, as in Case 62, previously condemned for desertion. They form a curious minority among the wall jumpers. Wall-jumping makes, so to say, the entire pathological phenomenon, and the recidivism is a part of the disease.
A disciplinary case: Epilepsy and other factors.
Case 63. (Consiglio, 1917.)
An Italian private in the artillery (father dead of general paresis) had been a victim of infantile convulsions and of convulsions with loss of consciousness up to 18 (convulsions with shouts and violence in the streets of Rome; had to be put in a straight-jacket at the municipal hospital).
He developed more convulsions during antisyphilitic treatment in the military hospital. He was a very poor soldier, of the rough and violent sort, and after eight months of service had to be assigned to a special disciplinary company, with which he remained for fifteen months. Here also he was punished frequently, and was given a period of four months’ imprisonment for refusal to obey the officers. Then for a period of several years he had no convulsions whatever.
During the war he was given to alcoholism, and one day in June, 1916, he struck an officer and ran away to arm himself. He was at this time observed by psychiatrists and declared sane. He was regarded as an emotional and alcoholic epileptic but not as neurotic or psychopathic. He was again placed in a special disciplinary corps.
Re the convulsions which this Italian developed during antisyphilitic treatment, it would be interesting to know whether intravenous injections were used. In case they were used, one might compare the case of this Italian with Bonhoeffer’s volunteer who developed epileptic convulsions after antityphoid inoculation.
Re the insubordination and violence of this Italian, compare remarks of LÉpine noted under Cases 59 and 60. Re the “other factors,” compare remarks of Bonhoeffer noted under Case 57.
An epileptic goes through Mons and two years fighting without symptoms. Then strange conduct with amnesia.
Case 64. (Hurst, March, 1917.)
A private, 26, epileptic from 11 to 18 (mother also epileptic) entered the army at 20, attempted to commit suicide in 1912 (amnestic for this attempt), and went to France with the expeditionary force in August, 1914. The retreat from Mons and further fighting caused no recurrence of the symptoms. September, 1916, he was in fact put in charge of eight men doing guard duty. At this time he was able to get to bed only every other night. The charge of the telephone worried him, as he had never before been made to assume responsibility. After two months of this, he was found one night arresting civilians without cause and driving them before him with fixed bayonet. He was let off court-martial on the medical evidence, and at hospital remained confused and suspicious. November 16, he was seen by a medical officer in a typical attack of petit mal. Of all this, on reaching England December 19, he had no recollection, and was keen to return to duty.
Re the remarkable delay in the return of epilepsy to this soldier of Mons, Bonhoeffer remarks that one of the epileptics observed by him at the CharitÉ Clinic had passed through nine battles, and another through 18 battles before the first attack of epilepsy. Bonhoeffer regarded the strenuous marching as a liberating factor of epilepsy in five cases, actual fighting in seven cases, shell explosions in two cases, and bullet wounds in three.
Re the apparently psychogenic factor in Hurst’s case (epilepsy coming on after assumption of too great responsibilities), compare remarks of Bonhoeffer under Case 57 concerning psychogenic factors. Sir George Savage has called attention to a form of functional epilepsy following shock or injury, in which recovery occurs after removal from the strain, but in which there is a relapse if the men go back to duty.
Therapeutic (antityphoid inoculation) epilepsy.
Case 65. (Bonhoeffer, July, 1915.)
A volunteer without psychopathic signs except a slight stuttering, and without psychopathic history of any sort, went into service at 17. After he had been a short time in the field, a shell fragment injured him in the upper part of the thigh. He lay up in hospital four weeks. He then spent four weeks in the reserve.
He was then given antityphoid inoculation, and a half hour afterward had epileptic convulsions. These appeared four times more during the next fortnight, as a rule followed by a delirious excitement. No fever was reported. After the fourth attack, he was transferred to the CharitÉ Clinic.
At the clinic there were no attacks, and there was nothing epileptic to discern in the make-up of the patient. His nervous system was normal to examination. There was, however, one fact in the family history of note, namely, that an older brother of the patient, 20 years of age, suffered from convulsions.
What is the relation of the antityphoid inoculation to the epilepsy? According to Bonhoeffer, we must not forget the family history even if we regard the inoculation as the liberating factor. Curiously enough, the shell injury did not itself serve apparently to bring out the epilepsy. Bonhoeffer has seen three other instances of epileptic attacks or epileptoid phenomena following antityphoid inoculation. However, in the hundreds of thousands of inoculations, it is not to be wondered at perhaps that there should be a number of instances of epileptic attacks. One was a man with severe epileptic taint; in the others, there was a question of pathological intoxication.
Re antityphoid inoculations, a French observer—Paris—remarks that these inoculations may occasionally start up the symptoms of general paresis. Compare in this connection also Case 63, in which a syphilitic developed convulsions during antisyphilitic treatment. The psychogenic factor of intravenous injection itself, with its possible effect
Shell-shock; (apparently slight) scalp wound: Jacksonian seizures. Operation, decompressing the edematous upper Rolandic region. Recovery.
Case 66. (Leriche, September, 1915.)
A Moroccan of the Seventh Tirailleurs was thrown to the ground by the explosion very near him of a large calibre shell, lost consciousness, and woke up with a slight contusion of the right side of the head. The date of this injury is unknown. He was evacuated to the interior, but stopped May 25, 1915, at the evacuation hospital because his pulse in the train stood at 51. An hour later in the hospital he had a Jacksonian epileptic attack, followed by a left-sided flaccid, brachial monoplegia, and after a quarter of an hour a second crisis, and then a third,—a sort of epileptic status occupying an hour. The attack seemed to start in the left hand. After the crisis, hand and arm became flaccid and inert.
Lumbar puncture in the crisis gave fluid under small tension in a few absolutely limpid drops. The wound was a superficial skin wound as big as a 25-centime piece, near the middle line, roughly corresponding with the upper Rolandic region. It was hardly a wound—a mild abrasion not passing the epidermis; periosteum and bone intact.
The patient was trephined and a thin layer of clot was found over the dura mater. The clot was removed and a crucial incision was made into the dura mater. The brain seemed a little edematous, hemorrhagic and bruised. It soon began to beat and was tamponed.
May 26, complete brachial monoplegia without seizure.
May 27, seizure at 2 in the afternoon, starting in left arm.
The wound was going well and from this time forward no more seizures. May 28, a cast was made for the hand.
June 4, lumbar puncture yielded a clear liquid under the pressure of 58. That evening an hour after the puncture, the brachial monoplegia disappeared. The arm was still a little weak June 5. June 8 the man was evacuated to the auxiliary hospital at Laversine. June 18, complete recovery.
Fall and blow to head: Hysterical convulsions. Cure by studied neglect.
Case 67. (Clarke, July, 1916.)
Clarke had seen in the war but one case of hysterical convulsions, though this particular patient had severe hystero-epileptic fits occurring in series. The man had never suffered from epilepsy and was 20 years of age. He received a slight wound and fell back into the trench a distance of six feet, striking but not contusing the back of his head.
On admission to the hospital he was found drowsy and dull. Fits occurred a week later, following one another at brief intervals in series that lasted one or two hours. The arms would be raised and extended in clonic spasm; the patient would resist violently if held, and then turn to his right side with rigid extension of legs and back in opisthotonos. The eyeballs underwent irregular movements, and there was a well marked hippus. Though the tongue was protruded in these attacks, it was never bitten. It was doubtful whether there was a complete loss of consciousness. Between attacks, the patient was morose and sullen, and showed a varying incoÖrdination of the movements of the left leg, which was anesthetic to the knee. There was also a glove anesthesia of the right forearm and hand. Fields of vision were contracted.
The fits recurred with intervals of a day or two, for a fortnight. The patient was then strictly isolated in a small room with an observation window. His bed was made up on the floor. He then had very slight attacks, as a rule when the nurse came into the ward; no notice was taken of these attacks and in a fortnight they ceased. The paresis of the leg and the anesthesia also cleared up without treatment. He remained in the general ward three weeks longer, at first dull and listless, but later cheerful and active. Clarke suggests that this patient was below normal intelligence.
Shell injury with unconsciousness; delayed attacks of epilepsy: superposed hysterical hemihypesthesia. Previous history consistent with the hypothesis that a genuine epilepsy had been developed.
Case 68. (Bonhoeffer, July, 1915.)
An excellent soldier, of good build, 29 years, a member of the Landwehr, passed unscathed through eleven battles in the 1914 campaign, but finally succumbed to fragments of shell which struck his chest and the lower part of his thigh. He fell down, nauseated, and lost consciousness. He is said to have struck about him with his arm and to have voided urine. There was a second attack three weeks later, in which he fell upon his face.
In the CharitÉ Clinic he had three attacks, two of them nocturnal, one in the daytime, followed by a long period of somnolence. He once cried out suddenly in the night as if warding off an attack. He complained of headaches, and was often irritated and out of humor. Somatically, there was a hemihypesthesia on the side of the injury.
The history indicates that this patient up to his sixteenth year had been a victim of occasional enuresis, often cried out in his sleep or even rose from bed. Occasionally he suffered from such violent sudden headaches that he would have to sit down. He was easily irritated, and had once been arrested for assault. As a soldier, however, he had never been guilty of any breach of discipline. Mild headaches would follow drinking. These phenomena in the history pointed in the direction of epilepsy. According to Bonhoeffer, we cannot entirely exclude contusion of the brain from the shell injury. However, there were no cerebral symptoms, and the interval before the occurrence of the attacks rather indicates that we are dealing with a genuine epilepsy. As for the hemihypesthesia, this is a hysterical “superposition,” which does not interfere, according to Bonhoeffer, with the genuineness of the epilepsy.
Shell-wound; musculocutaneous neuritis: Brown-SÉquard’s epilepsy.
Case 69. (Mairet and PiÉron, January, 1916.)
An infantryman, 30, a gardener, was wounded in the right forearm by a shell fragment, which fractured the ulna, September 7, 1914, at Revercourt. Despite much fragmentation of the bone and suppuration, the wound healed with two cicatrices, where the fragments had gone in and had come out. The scarring process was over in December.
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; and in the morning, was dull and disoriented. Accordingly, he was sent to the central military neuropsychiatric service of the general hospital at Montpellier, November 10.
Besides the two extensive cicatrices, there were motor disorders. Pronation and supination were almost impossible, as well as extension of the hand and fingers and abduction of the thumb. There was a radial paralysis without R. D. Electrical excitability of the extensors was diminished on the right. The hand was weak. The right thumb was atrophic. There was a hypertrichosis as well as redness, heat and perspiration of the right hand. There was a hypesthesia for all forms of stimulation in the hand, especially in the radial region; less in the ulnar region. This hypesthesia rose along the posterior surface of the forearm and covered all the territory of the ulnar nerve; but there was a corresponding hyperesthesia in the musculocutaneous distribution, as well as in the internal cutaneous distribution. Above the
The convulsions appeared two or three times a day, the pain would get worse along the arm, rise to the head, following the hyperesthetic zone, then invade the interior of the head, whereupon objects would appear to turn and the ears would buzz. The right leg, and especially the right arm, would begin to tremble. The man would have to support himself to avoid falling. He saw shadows moving, colored trees, occasionally persons. When the vertigo got stronger, he lost consciousness. The extremities of the right side stiffened and carried on jerky movements. These sometimes extended to the left side. The seizure lasted from five to fifteen minutes, and sometimes occurred in the middle of the night. Fatigue followed but headache disappeared after an attack.
The diagnosis of Brown-SÉquard’s epilepsy was made. If the musculocutaneous trunk was compressed, a crisis was produced with pain radiating to the head, obscuration of vision, numbness in the arm, and tremors. Electrical treatment was resorted to for analgesic effect. There was a certain improvement during May, so that the diurnal dizziness disappeared. May 19 he had a period of 24 hours without any vertigo. In June no further improvement occurred.
An operation was performed June 23, 1915. The two cicatrices were excised, and some fragments of cloth were removed. Three Jacksonian crises followed the operation, and there was another seizure next day. Frequent headaches followed without crises. More seizures appeared in
The occipital pain had now become less; the musculocutaneous nerve was not so large. Only a few headaches followed during the months of October, November, and December. After November 3 the baths were stopped and the arm was kept wrapped in a warm compress. There was still a certain hyperesthesia, the knee-jerks had become less exaggerated. Massage and mechanotherapeutic exercises were begun. There were no more attacks after September 27.
Re Brown-SÉquard’s epilepsy, LÉpine remarks that besides the case of Mairet and PiÉron, Hurst and Souques have published cases. LÉpine himself has observed two cases: one followed a nerve wound in the foot; another, a penetrating wound of the chest. As a rule, such Brown-SÉquard epilepsies appear a number of months after trauma; as a result of irritation in the scar. LÉpine’s subjects were taken for simulators because they had not received any cranial wound. The prognosis should be guarded, though the outcome in Case 69 appears to have been favorable.
Epileptic episode at 24 years following bullet-wound of hand, in a soldier who had had convulsions in childhood (sister epileptic). Reactive epilepsy? Epilepsia tarda?
Case 70. (Bonhoeffer, July, 1915.)
A man in the reserve, 24, bore the stresses of the war very well in the campaign in East Prussia until he was shot in the hand at Deutsch-Eylau. He had always been well aside from rheumatism, and was discharged with a good record from his military service.
Sent to the reserve hospital for his hand injury, he had, two or three times in the night, convulsions with loss of consciousness and dilated pupils; after which there was a thirty-six hour period of depression with refusal of food. Thereafter this soldier had amnesia for both the seizures and the subsequent depression. He was observed six weeks longer in the CharitÉ Clinic but had no more attacks, and indeed nothing more of note either mentally or somatically.
The history showed that there had been convulsions in the third and fourth years of the patient’s life. There had been, however, nothing epileptoid in the later childhood or developmental years of the patient. However, a sister of the patient had suffered since childhood from convulsions. It remains a question whether this episode is to be regarded as reactive epilepsy—reactive, namely, to experiences in the war—or whether we are dealing with a true epilepsia tarda.
Re this episode following bullet wound, the compiler has placed it after Mairet and PiÉron’s case of Brown-SÉquard epilepsy, but apparently Bonhoeffer regards his case as probably a reactive one. Unlike the case of Mairet and PiÉron, Bonhoeffer’s case had an epileptic soil (convulsions in childhood and epileptic sister). Re the so-called reactive epilepsies, see remarks by Bonhoeffer under Case 57.
Epilepsia tarda in a lance-corporal without hereditary taint or previous history save dizzy spells and excitability.
Case 71. (Bonhoeffer, July, 1915.)
A reserve lance-corporal, 24 years—a soldier from 1911 to 1913 without disciplinary record, and in his second year becoming lance-corporal—was in the campaigns in Belgium, East Prussia, and Poland, making long marches and going through several battles. In the middle of October, 1914, he fell from a horse and suffered a contusion of the thorax, after which blood appeared in the sputum. In November he was brought to the reserve hospital in Berlin, and there had convulsive seizures. Before transfer to the CharitÉ Clinic, a seizure occurred, and he was brought into the clinic in a characteristic dazed state. Thereafter he was clear but often out of humor and irritated. Three weeks later came a brief attack, probably epileptic in nature, with restless half-delirious sleep following.
There was nothing in childhood or in the family history to indicate epilepsy. However, the patient himself stated that from 1913 onward, after his period of military service, he had from time to time felt attacks of dizziness after exertion, and that he had become more easily excitable than before.
The attacks in the lance-corporal are probably not to be attributed to the thoracic contusion, according to Bonhoeffer, because of the long period that elapsed after the thoracic injury, and their development nocturnally without special occasion. According to Bonhoeffer, we are probably here dealing with a late epilepsy.
Re late epilepsy, see also under Case 57. Bonhoeffer makes a considerable point of the lateness in attacks of epilepsy in some of the military cases, pointing out their beginning at the ages of 22 to 27 in the period of peace practice undergone by soldiers. The theory is that cases of severe and long-standing epilepsy are known to the authorities, so that
Re thoracic contusion, compare remarks of LÉpine under Case 69, on Brown-SÉquard epilepsy following thoracic wound.
Convulsions by autosuggestion.
Case 72. (Hurst, November, 1916.)
A private, 27, is described as a typical martial misfit—in private life a music hall falsetto singer, and afterward a valet. He joined the army in 1915 and proceeded to France, and worked in a canteen. A week later, men broke in and threw a mallet at him, whereupon he immediately had a fit, and was dazed, dumb, and unable to walk for two days. Thereafter occasional further fits occurred, with nervousness and insomnia. He was sent home in September, 1916. Discharged to duty, he again in December returned to France, had six fits in the first week—three in hospital, two on the boat, and between two and four for four days after admission. The diagnosis of genuine epilepsy was made in France by a medical officer who had seen one of the convulsions. However, he had never passed urine or bitten his tongue, had no family history, and had never had fits before going to France.
He was hypnotized and given the suggestion that he would have a fit. In the convulsion which followed the plantar reflexes remained flexor, but otherwise the convulsion was quite like the genuine epilepsy. He was told that he would not have any more convulsions, nor did he have any more except on Feb. 16, 1917, when some talk was made to him about returning to duty. Bromides used in France did not help the epilepsy at all. This patient developed a gait and speech defect copied from two patients in the wards. These symptoms, due to autosuggestion, disappeared on persuasion.
Re autosuggestion, Bernheim has returned to the fray (1917) in a book on automatism and suggestion, dealing only in small part with war problems. The most general formula for suggestion appears to be that it is an idea accepted. A suggestion offered but not accepted is in effect not a suggestion at all. Any accepted idea, says Bernheim, is from the psychological point of view as well as from the medical point of view, a suggestion. A suggestion may be direct or indirect, reasonable or unreasonable, brought about by
(a) mere verbal assertion,
(b) hypnotic state,
(c) persuasive explanation, rational or emotional,
(d) emotion (that is, emotion not the effect of any form of suggestion offered by the physician, but emotion brought about by some event affecting the sentiments of the subject).
Epilepsy of emotional origin.
Case 73. (Westphal and HÜbner, April, 1915.)
A lieutenant without neuropathic tendencies (except that his mother was in a hospital for the insane) was under shell fire for some time. Finally, a shell burst near him, whereupon headaches and transient spells of confusion followed. Shortly upon the news of the death of his Major, he had a spell of violent excitement and confusion, dancing about on the ground and breaking things up. He passed into a stuporous condition with a suggestion of catatonia. There were a few isolated delusions to the effect that he was poisoned. After sleeping a long time, he suddenly cleared up. There was an extensive amnesia covering a period of weeks. He had forgotten the Major’s death and everything thereafter. He complained of headache, difficulty of thinking, and forgetfulness. An agoraphobia developed, as well as great sensitivity to sounds, and a feeling as if the bed and surrounding barracks were moving. There were a few illusions of a visual nature. He had complete insight into his condition. Conduct was normal. There was general hyperesthesia and ageusia.
According to Westphal, this case of deep disorder of consciousness of some duration in a healthy person is probably one of a dazed state following the so-called “affect epilepsy.”
Is Case 73 Shell-shock? Note that, in Case 73, the shell explosion at first occasioned mere headaches and confusional spells. The true occasion of the convulsions appears to have been the news of the death of a superior officer. It is, of course, possible that the transient spells of confusion were actually epileptic equivalents. LÉpine remarks that Pierret and others, observing such spells of confusion often accompanied by agitation, have inquired whether manic depressive psychosis is not a kind of epilepsy. This question remains unresolved. These phenomena of epilepsia larvata (see also Case 81 of Juquelier and Quellien) are to be sharply distinguished from attacks of confusion occurring in pronounced epileptics. These latter attacks often follow a crisis and suggest exhaustion; sometimes they last several days.
Fatigue; fear; hysterical convulsions. Visual aura (approaching fire wheel) built up after the third crisis (scotoma after look at sun).
Case 74. (Laignel-Lavastine and Fay, July, 1917.)
A sapper, 23, with his company under heavy bombardment, October, 1916, was overcome by weariness and fear (he had always been of a timorous disposition). The order for the rear came, but the convoy was hardly en route when the sapper felt a griping in the pit of the stomach and the blood going to his head; whereupon he lost consciousness and went into convulsions.
This incident seems to have made a powerful impression upon the sapper. A fortnight later, while working in the trenches, he had more epigastric sensations with vague discomfort. He thought about the earlier crisis and about his wounded comrades, and again fell down and had more convulsions lasting a quarter of an hour. The tongue may have been slightly bitten in this seizure. In the genesis of this second seizure we may consider that the feeling of discomfort and the epigastric sensations served to recall the first seizure, so that the second one may be regarded as due to autosuggestion—that is, as hysterical.
A little later, on a hot day in the trench, while working, the sapper turned to a comrade and saw a great black spot on his face. He turned toward another and saw another great black spot on this face also. He was frightened, felt strange sensations, fell, and had a third convulsive crisis. The black spots that he saw were due to a scotoma, the result of a transient glance at the sun.
After this scotomatous episode, his crises always had a visual aura. He would feel rather uncomfortable, leave the supper table, feel a gastric sensation, warmth in the face, and oppression. He would go out in the cold for the air, look about for something, appear frightened, fix his gaze upon a certain point, and cease to reply to questions. His head would jerk back suddenly, and he would utter strangled cries
War strain; anxiety; confusion; fugue. Demotion and detail to the interior.
Case 75. (Barat, November, 1914.)
A lieutenant, 25, an officer in a regiment on active duty near the front, was called before a special board charged with desertion in the face of the enemy. He had been assigned to a certain position but not only had not complied with the order, but had wandered off to the British sector and been arrested there as a spy.
The prisoner was well developed, without stigmata; heredity, negative. His career in the army had been courageous and he had been advanced several ranks and was about to be given a medal for bravery. He said that he had been under a severe strain for several days.
One evening he had been given the order to attack. The artillery opened fire. He found that the Germans had erected barbed wire defences. The loss of men was terrific. His order was to shoot all who held back. A poor territorial crouched down and would not go forward—supplicating the prisoner not to shoot him. The prisoner spared him.
The next night the order to attack the German trenches was again given. This time he was overcome with anxiety and discouragement. The last he remembers was the order to attack. Next day he felt sick and his mind was foggy. He remembered leaving his regiment and wandering round for several days until he fell into the hands of the British and was arrested. Then he understood what he had done.
The prisoner asked to be allowed to return to the front. The testimony of one of the lieutenant’s men verified his statements. On the day before he left the front he had been anxious, had cried often, and would speak to no one. On the day he left the trenches without permission, he was nervous and disoriented.
There was no doubt that simulation could be ruled out; the differential diagnosis lay between a “confused state of emotional origin” and an
For epilepsy there was a history of attacks with falling to the ground and loss of consciousness, without involuntary micturition or biting of tongue, during the time when he was a sergeant. Moreover, irritability and unwarranted suspiciousness had been present at these periods. However, there were no other epileptic symptoms; these two attacks were isolated and of quite long duration, leaving no headache or malaise after them. Also there was no basis for the diagnosis “epileptic dazed state,” since there was no abrupt commencement; the loss of consciousness was never complete (the subject was able to converse with persons while the attacks were on); and some remembrance was present of incidents during the attacks.
For Barat, the important points are that the attacks were preceded by long periods of anxiety and the disturbances resulted more from moral than physiological causes.
The importance of the psychological factors lead the author and his colleagues to the diagnosis “Mental confusion of emotional origin.”
The board decided to return him to the interior and give him a barracks position at the reduced rank of drill sergeant.
A solitary epileptic episode in an artillery officer (slight concussion of the brain two years before) following extraordinary campaign stress (38 artillery battles in two months).
Case 76. (Bonhoeffer, July, 1915.)
A first lieutenant of artillery, 35, was able to count 38 artillery clashes in which he had taken part in two months of very strenuous, almost daily fighting. Then appeared headaches, anxiety, dizzy feelings, insomnia. Finally one day suddenly, after eating, the lieutenant sustained a loss of consciousness with convulsions, which sent him to his home reserve hospital. The officer had felt nothing before his convulsions came on. The medical report, however, yields no doubt of the epileptic character of the attack.
When he was examined, there was a slight psychopathic depression with a feeling of insufficiency, anxiety, insomnia, restless dreams, over-sensitiveness, and a pessimistic outlook on the future. There were no epileptic traits whatever. There was nothing alcoholic, luetic, or arteriosclerotic about the officer. There was nothing in the childhood or youth of the patient, though there had been a fall two years before, with phenomena of concussion without sequelae. In fact, this fall with concussion had led to no medical examination.
As to the relation of the concussion two years before to the epileptic attack, Bonhoeffer is inclined to interpret the case as one of genuine “reactive” epilepsy on the basis of continuous overstrenuous work for a period of weeks. He regards the previous concussion as soil for this epilepsy.
Re amount of stress occasionally required to bring out epilepsy, compare Hurst’s Cases 64 and 80. It may be recalled that Bonhoeffer is decidedly of the belief that exhaustion has not brought about any actual psychoses, calling attention to the remarkable absence of psychoses among the Serbians after their exhausting campaigns. A general review of war experience indicates, according to Bonhoeffer, the marked power of resistance of the healthy brain.
Nocturnal narcoleptic seizures accompanied by spells of somnolence in the day, both to be regarded as due to the “brain fag” of trench life.
Case 77. (Friedmann, July, 1915.)
A tradesman, 23, had been in the German infantry since the beginning of the war. Never sick, he had been, in a general way, nervous; and a brother had had, at the age of 30 years, some sort of severe brain disease, in which he became blind, dying a year later.
The man was for a long time in the trenches and proved himself a courageous and stalwart soldier. He went to hospital after a slight bullet wound of the leg, with a benign paralysis of the peroneus.
In the hospital he began to show a somewhat pronounced emotional depression, with a nervous tachycardia.
Friedmann reports the case on account of certain peculiar seizures which, upon the man’s own story, had begun five weeks before, in the field, although he had told no one about them. He had never felt anything like them before. At first, they came three to five times almost every night. He would suddenly wake and find himself unable to move, to speak, or even to think. These seizures, however, were not accompanied by any feeling of anxiety or any respiratory distress. Consciousness remained clear, and after 10 or 15 seconds, he could begin to think normally again. It was clearly a question of psychopathic absences of a mild narcoleptic type, occurring, however, only at night.
Daytimes, also, throughout the whole period in which the nocturnal absences occurred, there were seizures of another description. During the many hours in which he had to sit in the trench, about twice a day for half an hour long, he would plunge suddenly into a sort of irresistible lethargy. Without any external occasion whatever, there would be a feeling of great fatigue. In the spell he could not move or think, would lean his head upon his hand. He was unable to overcome the feeling of weariness and became convinced
The patient was physically healthy and stalwart, mentally not excitable, and tolerably tranquil in the midst of shell fire. He would never have been reported sick had it not been for his wound. Aside from the tachycardia, of which he himself complained little, nothing wrong was found in the hospital. There was, to be sure, a feeling of discomfort without any hysterical tinge, and sleep was restless. Aside from the peroneus palsy, the injury made a good recovery. The nocturnal attacks persisted; bromides and even luminal failed of effect. There was, however, no longer any somnolence by day. In fact, for the five weeks of observation, there was no change in his condition.
Friedmann states that mild emotional alterations are not infrequent in the trenches with minds disposed thereto, although emotional shock, especially in shell fire, is the most frequent cause. However, these particular seizures are quite unusual. The stresses of field service lead to a sometimes complete paralysis of mental power, interfering transiently with service. There is no evidence of sudden circulatory disturbances such as would bring about dizziness, pallor, nausea, or fainting spells. According to Friedmann, the regulative brain functions, especially those that maintain consciousness, become weak on account of a condition which he terms GehirnmÜdigkeit, or, as we should say in English, brain fag. The situation forbids due completion of sleep. Thus, the explanation of the daytime attacks follows rather obvious lines of brain fag. The accidental awakening it is, which at night produces the absences; the wakenings are due to the general restlessness of the patient. The general weakening of cerebral function produces the disorder at the moment of wakening, since the regulative factors of consciousness are already out of order. The condition in the absence rather closely resembles the state of consciousness just before going to sleep, and also perhaps the state of consciousness during the process of awakening. It is as if the process of waking were somehow delayed a few moments. Friedmann
Sham fits.
Case 78. (Hurst, March, 1917.)
An unwilling conscript developed numerous fits on board ship coming from Jersey, three days after enlisting. Fifty more developed during two days in hospital. He was sent to Netley.
On the hypothesis of hysteria or malingering, he was hypnotized. A fit was suggested to him, but did not come off. The Sister was informed in the patient’s hearing that the man was clearly shamming, as in all genuine cases a fit would occur after this treatment. A fit with marked opisthotonos immediately occurred. This fit immediately stopped when he was ordered to stop it and to wake up.
The man after waking promised to have no more fits.
Epileptoid attacks, controllable by will.
Case 79. (Russel, August, 1917.)
A man was received in No. 3, General Hospital: Diagnosis, epilepsy. He was shortly sent to the convalescent camp and then returned, having had two attacks. Russel watched for another attack, felt it was not genuine and “put the situation up to” the soldier whose story was as follows: He had been at the front without leave for twelve months since the German retreat. Leave was due him. A sister’s letter said his brother was severely wounded and his mother was praying for his return. When he thought these things over an attack came. He could, however, control the attacks. Russel told him, if he would play the game, he would be sent to the base with a recommendation for leave. In ten days the man was remarkably changed and had no further attacks.
Hereditary epileptic taint brought out by two years service with eventual shell-shock and burial thrice in one day.
Case 80. (Hurst, March, 1917.)
A private, 24, in the army from 16, never epileptic (sisters epileptic), was wounded four times in the war from September, 1914. Shell fire did not worry the man, but he gradually became depressed after his father and five brothers had died in active service. He was blown up and buried three times in one day in July, 1916. He was unconscious for two hours after the second blowing up, but carried on for two hours more until blown up for the third time.
After this, he became nervous and shaky, and began to sleep badly, and a month later had a typical attack of major epilepsy. Fits occurred with increasing frequency. As many as 19 occurred in a single day. Rest and bromides caused the fits to cease, and there had been none for six weeks at the time of his discharge.
Re the extraordinary delay in the bringing out of this epileptic’s taint, refer back to Case 76 of Bonhoeffer, with its discussion, and to another case of Hurst (64).
Re Shell-shock and its relations to epilepsy, see below, discussion under Cases 82-84 of Ballard, who has erected a theory of Shell-shock as in some sense epileptic.
Shell-shock: Epilepsia larvata.
Case 81. (Juquelier and Quellien, May, 1917.)
A soldier, 29 (father alcoholic, died in hospital for the insane), a decorative painter without plumbic history, non-alcoholic, non-syphilitic, was wounded once, September, 1914, but returned to the front in 1915.
May, 1915, a shell burst near him. He lost consciousness, regained it a few days later at Brest, and was so far recovered that he could go on leave in seven days. While on leave, he had short attacks of delirium, followed by a total amnesia; there was, however, no crisis, fall, or convulsion. After the first attack, he had for 24 hours malaise and headache, but got well and went back to his dÉpÔt. Shortly afterward more attacks of this sort recurred, and he went to hospital and thence to the neurological centre at Tours. Whence, August 9, 1915, he got a two-months’ leave for “mental disorder post-confusional, second État, probably hysterical (commotio cerebri), and organic hemiparesis.”
November, 1915, after returning to the dÉpÔt, there were more spells and he went again to hospital. Invalided December, 1915, he passed a year at home, but the spells continued. Although the epileptic nature of these attacks was maintained by Francais at Évreux, he was placed in the auxiliaries, December, 1916, but had to go to hospital almost at once, and, February 28, 1917, entered the neurological centre of the 9th Region for the second time. Here, when called to be examined two days after admission, he was observed in an attack. He suddenly rose from the bench, made a few steps, seemed to be listening and anxious, as if he ought to be on guard. He looked up, seemed to be looking for something whose noise was approaching, lowered his head, made a slight jerking movement, and said, “Poum!” as if to express the noise of an explosion. He took a few more steps, the same movements were repeated, and the same “Poum!” was uttered. This lasted for about a quarter of an hour, during which the patient was unaware of his surroundings. He could be guided all about the hall without
These spells varied in number but occurred once a week. The patient was able to tell of certain attacks that had occurred while he was out of doors at home.
Now and then, there was another theme in the hallucinatory delirium, namely, a pencil drawing of a woman’s picture, of no great artistic worth but carefully done, at which the patient was much astonished on awaking.
It seems as if auto- and hetero-suggestion can be eliminated from the genesis of these attacks. Neither hysterical nor epileptic crises have preceded or ever alternated with these seizures. Nevertheless, on the organic side, the patient had a general increase of tendon reflexes on the left side, most marked in the knee-jerk, and fell to the left in voltaic vertigo. There was a left hemiparesis, apparently of organic origin, which had been determined as far back as July, 1915.
There was no true dementia. Past memories were but slowly recalled, and inattention interfered with the fixation of recent memory. He complained of troubles in his sleep and dreamed of war experiences somewhat analogous to those in his attack of amnestic delirium. After the seizure, there was a marked hebetude and mental inactivity, torpor, and a severe headache. The case was presented to a special commission as one of epilepsia larvata in a person hereditarily predisposed who had never before presented epileptic signs, suffering from a disease characterized by frequent short attacks of hallucinatory and delirious automatism, following shell explosion which had at the same time produced a slight left-sided hemiparesis and mental inhibition.
To illustrate an epileptic theory of Shell-shock; three cases:
1. Fugue; minor symptoms: later, epilepsy.
2. Epileptic confusion eight months after explosion.
3. Mine explosion: stammering replaced by mutism; mutism replaced by epilepsy.
Case 82. (Ballard, 1917.)
Atmospheric concussion from shell explosion, October, 1915, was followed by unconsciousness in a soldier described by Ballard.
Blindness for a month followed recovery of consciousness. “Neurasthenia” (anxiety neurosis) after return of sight. Apparently nearly complete recovery after latent period of a few weeks. Return of blindness in one eye in December. Five days automatic wandering (the man was found in a west country town five days after leaving home to rejoin his dÉpÔt and seen by a medical officer who reported that he was dazed and amnestic for that period); admission to second Eastern General Hospital, December 15.
On admission he proved to be suffering from minor hysterical symptoms such as an inability to open his eyes and to see clearly when the lids were raised. The symptoms rapidly cleared up under suggestive conversation and did not return except for amnesia and slight emotional depression. He remained well until December 25. On that day he began for the first time to have definite epileptic fits and nocturnal epileptic delirium. In January he was discharged as an epileptic. There was no epileptic temperament or feeblemindedness. Finally, there had never been any personal or family neuropathic or psychopathic history.
Case 83. (Ballard, 1917.)
A soldier was blown up, April, 1915, and had a spell of unconsciousness. Later, pains in the head, slight amnesia and a condition of asthenia developed.
He was eventually admitted to the second Eastern General Hospital at Brighton, January, 1916. At the time of admission he was semiconscious, stuporous, confused, disoriented, anxious in a dull sort of way, talking about his expectation of “a sailor with a card.” Speech was intelligible, though fragmentary and infrequent. The man obeyed commands but gave no replies to questions. The mental processes were slow and impaired.
According to Ballard, we have here a case of epileptic confusion, eight months after the initial concussion. This particular attack ceased three days later, leaving amnesia for the attack and a certain amount of mental retardation. The man was not epileptic in temperament and his personal and family history proved negative.
Case 84. (Ballard, 1917.)
A soldier was buried in a mine explosion, October, 1915, and for several days thereafter was unconscious or semi-conscious. He emerged deaf and subject to stammering and a condition termed “neurasthenic.” The stammering was soon replaced by mutism, which lasted several weeks. The mutism was then supplanted by epileptic fits.
He was observed by Ballard in a dreamlike, disoriented and inaccessible state, in which he was anesthetic to pin pricks, lay awestruck, dumbly following with his finger hallucinatory airplanes. Flexibilitas cerea was also shown at this time.
Next day he emerged from the dreamlike state with mental processes somewhat slowed, disorientation for time, amnesia for the attack, memory disturbance and a return of the stammer. On the next day following, all these symptoms had disappeared except amnesia for the attack. Another spell of epileptic fits occurred later. It seems that the man had had a convulsion thirteen years before and occasional convulsions since. In fact, he, seven years before, had had what was called “a stroke” and residuals of a slight hemiplegia were still present. (There is no statement in the case report relative to syphilis.)
Emotion; shell fire: Epileptic equivalents.
Case 85. (Mott, January, 1916.)
A man, 19, suffered from shock due to emotional stress and shell fire. He had terrifying dreams. After a short time, he developed paroxysmal attacks of maniacal excitement. Just before the first attack he had been helping in the kitchen, lay down on his bed, went to sleep, woke, startled, flushed, and sweating, and made for the door as if terrified. He remained in this state as if suffering from hallucinations of sight and hearing, and without ability to recognize his wife, the doctors, or the Sisters. When two strangers in uniform came in to observe him, the adjutant became violent, as if the uniforms had started terror anew. The attacks lasted from a few hours to a few days, coming on suddenly, without apparent cause. One day he tried to get over the wall of the playground. He came back and buried his head in his hands. Major Mott spoke to him, whereupon he got up, looking terrified, made for the door, and four orderlies were required for his restraint. At Napsbury Hospital, to which he was sent, he made a complete recovery.
Mott suggests that we are dealing with a psychic equivalent of epilepsy.
Re epileptic equivalents, compare notes from LÉpine under 58 and 59.
(THE ALCOHOL, DRUG, AND POISON GROUP)
Pathological intoxication.
Case 86. (Boucherot, 1915-6.)
A Territorial infantryman, aged 37, was in the habit of drinking a good deal without getting drunk, and at the front drank a good deal of bad brandy. He had just taken a considerable quantity when his regiment got the order to charge. The charge was hardly over when the man became greatly excited and hallucinated. He thought he was surrounded by Germans and tried to transfix his comrades with the bayonet. Howling and struggling he was carried to the rear.
He was soon brought to the asylum at Fleury after howling all night and seeing the Boches and animals fighting among themselves. His hands and tongue were tremulous and there were cramps in the calves of his legs. On the 6th he expressed astonishment to find himself in hospital and was found to have but slight memory of what had happened. He remembered, however, that he had tried to kill his comrades. With the deprivation of alcohol he became rapidly normal and was sent back to the dÉpÔt in a few days.
Re alcoholism under army conditions, LÉpine remarks that alcohol has played in this war a rÔle analogous to that of malaria in the epidemiology of some countries. Many of the victims are, to start with, unbalanced subjects and dÉtraquÉs who are hereditary alcoholics. Alcoholism, according to LÉpine, dominates the pathology of the interior and has a marked bearing upon conditions at the front. In fact, alcoholism would have been disastrous in France had not measures been taken against it; measures still insufficient (1917). More than one-third of 6000 cases studied by LÉpine during three years have shown alcohol as a sole or, at all events, principal cause of the difficulty. It would be within
Chart 4
PHASES OF WAR PSYCHIATRY IN FRANCE
| I. | Antebellum phase of Psychiatric Neglect: Groundless fear that recruiting would be disorganized by psychiatric sifting processes. |
| II. | Phase of Alcoholism of Mobilization: Hospitals unprepared. |
| III. | Phase of the Marne: Alcoholism restrained by law; psychoses few; psychiatrists optimistic. |
| IV. | Phase of Trench Warfare: Overemotionality; and of High Explosives (January, 1915); now psychiatric services were systematically established along evacuation lines. |
| V. | Phase of Systematic War Psychiatry: Filterwise system of management (a) near trenches, (b) in main body of army, (c) on evacuation lines, (d) special hospitals. |
Chiefly from data of Chavigny, 1915.
Pathological intoxication: criminal prosecution stopped.
Case 87. (Loewy, 1915.)
An orderly, in private life a teacher, one day about noon-time, when going on duty, called the commanding officer to account because he (the orderly) had had to wait. He said he had been ordered to come at two o’clock and it was already long thereafter! He was severely reprimanded but addressed a number of the officers present with questions having no relation to military service. In fact, he seemed to have forgotten entirely that he was on military service.
This was the more remarkable as the teacher-orderly had many times distinguished himself upon dangerous patrol expeditions and in critical situations, winning the confidence of his superiors and the likelihood of promotion to corporal. He had been a discreet, earnest, and clever soldier.
Loewy observed him during this affair and noticed that he did not by language or movement suggest intoxication or hilarity but merely a certain excitement. He was entirely oriented for time, place and person, and his outward behavior was correct enough except for his military rank.
Sent to his quarters near by, he gave the impression to his immediate superior officer of deep drunkenness. He murmured something and soon fell into a deep sleep. After waking, he had an almost complete amnesia, knowing only that something disagreeable had transpired. He remembered that he had been offered several little glasses of cognac brandy by a comrade, and that he had drained them off quickly before going on duty. He said that he had never drunk cognac before, and in fact had drunk nothing for a long time.
The diagnosis of pathological intoxication was made, and the soldier was thereby cleared of his dangerous situation; a criminal prosecution was not instituted. He thereafter behaved with entire sobriety and modesty, and he achieved his corporalcy and later became file leader.
Desertion in alcoholism may deserve the term “pathological.” Case of fugue.
Case 88. (Logre, July, 1916.)
A “deserter” said: “I went because I drank a glass. I just went, comme Ça, without any motive.” He was somewhat feebleminded and, in explaining the impulsivity of his act, he added: “I went like a broken-down beast. I walked straight ahead, without knowing where I was going and if I had been going to be killed, it would have been all the same to me.” He could not that afternoon remember very well; but next morning, after having slept, he regained full consciousness. He said that he then found himself in a field near a cemetery. He had carried his gun and equipment with him, but had lost them somewhere, and from a military point of view, his desertion was complicated by loss of effects. On coming to, he said to himself, “Where am I? How foolish after fifteen months in the line! Probably I have deserted again.” In fact, he had a month before left his post under exactly the same conditions in the midst of a period of alcoholic excitement.
This alcoholic fugue is typical: drunkenness, impulsive and subconscious ambulatory automatism, with partial amnesia, disorientation, with mislaying of objects, followed by sleep and immediate return to normality.
Re fugue, see discussion under Cases 58 and 59. The French military code cannot excuse victims of fugue even though executed in a quite unconscious state, if the fugue is due to alcohol. There was a certain procursive suggestion in the fugue of Case 88, who went “like a broken-down beast,” straight ahead, without knowing where he was going.
Alcoholism: Amnesia experimentally reproduced.
Case 89. (Kastan, January, 1916.)
February 15, 1915, a German soldier drank beer in the canteen and at roll-call appeared tipsy. He then went to bed, but rose an hour later to go to town. A quarter of an hour later, he went to a clerk’s house and asked for paper, on the ground that the next day he was going to march to Warsaw. The clerk gave him no paper, which he then tried to get by force. A policeman arrested him and he said, “You just wait, lame dog!” Upon examination he denied that he had ever been guilty of any crime but had been in institutions on account of delirium. In point of fact, this man had grown up in very bad surroundings, amongst quarrels and disputes of his parents, who kept a disorderly house. At 19 he had been convicted of incest. He finally admitted having been convicted for rape. It was found that he had once run out into the front trenches; had been removed by an advance guard to a stable, and then wondered why he was not in school. He described a number of attacks of delirium although he had not drunk more than moderately.
He was given an experimental dose of 50 c.c. of alcohol, and in ten minutes became excited, tried to get out of bed, attacked other patients without reason, and was able to speak neither spontaneously nor in response to questions. In a period of two hours he became clear and asked what the trouble was. He knew only that he had taken alcohol.
Re the experimental excitement produced in Kastan’s case by the exhibition of alcohol, it is of note that BÉrard has been much impressed by the agitation that surgical cases of alcoholism undergo when anesthetized. It may be that the anesthetics act similarly to the experimental alcoholism of Kastan’s case. According to BÉrard, these phenomena of the anesthetized wounded (who are men recently evacuated from the front and other hospital cases) are of larval alcoholism brought out by the anesthesia. BÉrard wonders whether rum issues at the front are at all responsible therefor.
Desertion, drunk. Contributory factors.
Case 90. (Kastan, January, 1916.)
Gottlieb S. left the barracks, January 25, 1915, met friends and drank with them, remaining all night in the railway restaurant and waiting room. He was promptly arrested.
According to the patient, he had always drunk a good deal and had once fallen from his horse in the campaign, and become unconscious. After this fall, he said he had been able to stand less alcohol than before.
There is doubt as to the syphilis of Gottlieb. He said he had been infected once, but his further statement that he had six relapses is, of course, questionable. As to the hypothesis of feeblemindedness, it appears that in childhood he had learned badly and had been a stammerer. He had been a herdsman, and after that a laborer. He finally became a travelling man for a specialty photographer.
He had previously been convicted of an embezzlement, brawling, and breach of the peace.
As to his military crime, he said he had been celebrating the emperor’s birthday the last three days, being urged on by acquaintances and drinking whiskey. He was, in fact, on a spree and did not eat properly. He had met a student in the railway station and had forgotten all about his military service. He remembered having spoken with the waiter, remembered telling the student that he was going to commit suicide, and the student had drunk seltzer with him. January 29, he for some reason drank no more, and then it occurred to him that he ought to go back to duty. He remembered that he was easily led astray. He had once thought of becoming a tanner but had been dissuaded from the trade because of its bad smell.
The analysis of this case must consider, first, syphilis. Supposing, however, that this hypothesis is not substantiated by laboratory findings, the hypothesis of feeblemindedness might well be raised. It seems possible, if not probable, that this patient was in the subnormal group, lying between normality and feeble-mindedness
Re German and French war alcoholism, Soukhanoff remarks that the conditions in these countries were in strong contrast to those in Russia. In Russia there was a great decrease in the number of cases of acute alcoholic psychosis; particularly at the time of mobilization, there were few cases of alcoholic psychosis. He says that during the Russo-Japanese war, alcoholic psychoses constituted a third of all the mental cases observed. This figure corresponds with that quoted above from LÉpine (see under Case 86). Soukhanoff, writing in 1915, had not observed personally a single case of alcoholic psychosis. Incidentally, the number of cases of psychosis in the Russian army had remained in general small.
Desertion by mild alcoholic dement.
Case 91. (Kastan, January, 1916.)
Emil S. made a number of statements when he came for examination. He had once had a treatment by injections. Both his mother and his grandmother had been insane. He said that his brother was an officer in the navy, but this statement was found to be false.
According to his story, he had lost touch with his troop at the end of September, 1914, and had lived in several lodgings in T—— up to October 19, when he was arrested. He said that he did not know that a man who had lost touch with his troop had to report.
A week after his arrest, S. entered a shop and asked for coffee, saying that he had a furlough of 24 hours and wanted cake for his comrades. He said he was the owner of an estate and would send a roebuck for the cakes. The shop-man gave him cakes to the value of one mark. Bystanders said that he had been lodging in T—— for about two weeks. It seems that he had told his landlady that a city official had quartered him upon her and that he was on furlough. He went away in the morning and came back in the evening. He had written to a bank of which he had once been a representative, asking for money. One night he had lodged with another landlady, being given a meal, and he had there stated that he was in the City of T—— on duty and that his horse was in the barracks. He offered a thousand marks for his board and lodging.
At another lodging he had given himself out as a courier. In fact, the letter to the above-mentioned bank had been signed “Otto S., Land-owner, at present, courier.”
“If I do not revoke this in person or by writing on January 1, 1915, I beg you to pay to Mr. and Mrs. M. of T——, one thousand marks and deduct it from my balance.
“This is to be considered as my last will. As witness: present: Joseph B.”
The letter was addressed “To the direction of Commercial-Counsellor P——.” There was no stamp on the letter.
A second letter reads:
“Honored Sir, Commercial Counsellor:
I beg you to send by return mail to the address given below 1000 marks, and deduct this amount from my account. I have been in Russia. Well, things are moving now. Thank God, we have reached the point we have. Write me please more in detail about my property and estate and give me your very valuable advice.
With best regards to your esteemed wife, I remain
Sincerely and respectfully yours,
Otto S., at present courier, otherwise, land-owner.”
As for this Commercial-Counsellor P., P.’s son stated that his father had been dead for three years and a half.
S. gave himself out in T—— as a land-owner, falsifying his name, asking for beer to the amount of a mark a day, borrowing from his landlady ten marks, paying nothing, but remaining on friendly terms with the landlady and her women lodgers, making a contract with a superintendent ostensibly for his estate, and borrowing money from him.
Observed in the clinic, he said he was a bank representative and had been very nervous since being divorced in 1911. The divorce was due to his wife’s adultery. Sometimes he would not know really what he was doing, once even tried to shoot himself, and again once threw a burning lamp into his wife’s face without knowing it.
He had gone to the City of T—— without furlough in October because others used to, too. Only five days later had he noticed that his troop was no longer there; and upon inquiring about the troop he could find nothing as to its whereabouts.
He had been a heavy drinker and was always somewhat intoxicated, which, according to the patient, made him forget everything. He had drunk 20 glasses of beer and liquor daily. He wrote to P. because he knew his father.
As for the frauds, he said he knew nothing about them. He did not know even the baker from whom he had gotten the cakes. In fact, he had been drunk the whole day long.
He said that he had learned badly in school and had not passed any examinations. In active service he had already been convicted of drunkenness once. Referring to his treatment by injections, he said he would rather be dead. He had only sought diversion in looking over estates. Both his ability to reckon and his memory had suffered greatly. He and another patient eloped from the clinic one day but were captured a few hours later.
Remarks: Details are lacking as to the physical and laboratory side of this case. On the whole, there appeared to be no convincing features of paresis or cerebrospinal syphilis. The phenomena are very possibly in part alcoholic. There appeared to be no sensory disorders, and in particular no hallucinations. The intellectual disorder is chiefly amnestic. There is little or no evidence of emotional abnormality. The curious conduct seems hardly to indicate a primary disorder of will. The main feature psychologically appears to be amnesia coupled with an inability to reckon. To be sure, the letters are written externally in sufficiently good form; the amnesia does not appear to extend to details. It is a question of whether the disorientation which one suspects is not merely amnestic. On the whole, however, it would appear that there must have been at various times disorder of consciousness, as indeed is indicated by the patient’s own account of his ignorance of the cake-roebuck episode.
Dismissing the hypothesis of a syphilitic dementia, we might cling to that of alcoholic dementia more or less punctuated by acute alcoholism. Yet it is also possible that the patient was actually somewhat feeble-minded; this would be consistent with his own statement. The question might arise whether this soldier could have been excluded by careful psychiatric examination before entering service. It would seem that a knowledge of the insanity of the mother and grandmother, and an inspection of school records, if available,—to say nothing of the episodes which may or may not have been accurately related, between himself and his afterwards divorced wife—would have sufficed to throw doubt upon the military effectiveness of this man. We know also that he had already been convicted of drunkenness on military service before the episodes mentioned.
Desertion by alcoholic. Contributory factors.
Case 92. (Kastan, January, 1916.)
Carl B. was a soldier about whom the captain thought that his intellectual power had been weakened by drink. An inquiry after arrest showed that he had been odd also at home. He had once been sued for perjury, but the suit had been stopped for lack of evidence. He had been several times convicted of drunkenness. It appears that on March 30, 1915, after mounting guard, he said nothing and went home, remaining at home until the next day and then returned to the guardhouse in the street-car. He declared, this time, that the non-commissioned officer had given him permission to leave, although this statement was not correct.
Again, on April 6, B. was about to leave the quarters, but the surgeon, finding him drunk, kept him back. He did not go home that night, and the next day when he was wanted at the hearing, he could be found only in the afternoon. He replied confusedly and somewhat irrelevantly to the questions asked. On arrival at the clinic he was in tears and much depressed. Given 50 grams of alcohol, he became somewhat livelier. Upon examination, his perceptions were found diminished; he felt, he stated, a cracking and crackling in his neck. In his cell he had felt as if sparrows were roosting in his face; he had heard voices and seen pictures, and had not known what he was doing. He asserted his innocence, blaming his imprisonment for all his troubles. He had been in the habit of drinking three liqueurs and two glasses of beer a day. He had been drawing a pension since a fall from a scaffold.
A sister had suffered from continual headaches. The patient himself had three sickly children and ten of his children were dead; there were also two premature births.
The analysis of this case would clearly show the benefit of considering, first, the hypothesis of syphilis. Not only is the history of his children suggestive, but the impairment of mind noted by the captain as due to alcohol may very possibly be syphilitic in origin.
A disciplinary case: Alcoholism.
Case 93. (Kastan, January, 1916.)
A German soldier, brought up for examination for disobedience and insubordination with intoxication, was found already to have been convicted 33 times of a variety of crimes. Once he had drunk a bottle of shoemaker’s polish, evidently with suicidal intent.
In the canteen he had assaulted superior officers and tried to strike a sergeant. He said he had been attacked by the sergeant and pushed into a cell, whereupon he had lost his mind.
He came from a family of drunkards, and had been himself very alcoholic formerly. On the day in question, however, he had drunk very little. According to his account, he had fits of this sort if any one injured him. He was amnestic and had forgotten his previous convictions. Anything he might have done, he said, had happened a long time ago, in his youth. For example, concerning a theft, he said that it was merely that he had fallen into some Christmas trees and stuck fast there, and no one wanted to be paid. Tremors of hands, feet, head. Analgesia of thorax.
Re alcoholism and disciplinary cases, we find alcoholism bulking large in LÉpine’s account of military delinquency. Fugue subjects are not infrequently alcoholic. Minor disobedience is also often alcoholic. Acts of violence are characteristically alcoholic, or executed by subjects with hereditary alcoholic taint. (Such acts were in France especially common before the anti-absinthe law in 1915.) Alcoholic episodes and impulses often culminate in arson. No doubt, espionage employs alcoholism for a portion of its technique, though delusional mystics and subnormal hypersuggestibles are more often the purveyors of information to the enemy. The theft list, also, shows its share of alcoholics. Alcoholics are less common amongst those who, contrary to rules, assume shoulder-straps or other decorations. Here the sub-normals and victims of imbalance, as well as the drug cases, are more likely to figure if the matter is psychiatric at all.
Remarks upon an atrocity.
Case 94. (Kastan, January, 1916.)
April 15, 1915, a German soldier went with three comrades to a farm, to select a sheep for slaughter; they were obliged to go to three farms. The man carried a revolver and cartridges in his pocket. He threatened the farmer that he met with this revolver, and desired to rape the farmer’s daughter. He was very drunk, and said to the non-commissioned officer who was called in at the time, “You have served only a year longer than I have.” He staggered, struck violently with his hand at the sergeant, and gave insolent replies.
He had already choked the peasant’s daughter, scratched her face, and bitten her fingers, hand and arm. She could not run away as she was lame. The soldier held the revolver to her face and shot it off several times, offered sex assault, scratched her feet with his spurs, and tried to twist her neck. The non-commissioned officer threatened to shoot him, and he then became still. He said to the first-lieutenant before whom he was taken, that he would do anything but allow himself to be beaten, and at this moment moved his arms about in the air, and bloody foam came from his mouth. The first-lieutenant previously had always thought him to be normal except for a strange flicker and unrest of the eyes. There was a history that he had already once attacked a servant girl. The man had amnesia for the affair, only remembering how the non-commissioned officer had come on a white horse. He remembered nothing about the peasant and the girl. He said that he had been given to earache on the right side in winter. There was a history of his having fallen from a tree in childhood, becoming unconscious. He had been a sufficiently good scholar up to the second class in school. He had been an excellent soldier.
Alcoholism: Atrocity.
Case 95. (Kastan, January, 1916.)
September 15, 1914, a German soldier was missed. He had said that he wanted to get to the enemy quickly, and that he was going to march alone against the Russians. A shot was fired that night by this soldier, on the ground that he had been insulted by a civilian, although no civilian was present.
September 21, a farmer in a wagon reached a farm, where he found the soldier aiming at a woman. He fired, wounded the woman severely, and jumped on the farmer’s wagon and rode off with him. It seems that the soldier had come to the farm at noontime and accused the woman of treachery, ordering her to come with her husband to a certain farmhouse, where she should be placed against the wall and be shot. The soldier had shot her and wounded her husband also. According to the woman, the idea was to take revenge because she had denounced certain persons as spies.
He was arrested during the night, and told how he had left his troop because he could not get at the enemy. He had been informed that there were spies who ought to be shot; there had been talk in a certain inn about it. He did not know he had wounded the husband, and he only wanted to give that dangerous woman a piece of his mind.
After wounding the woman, he had given himself no further thought about her, but had gone to partake of the holy sacrament at the pastor’s. He then had drunk another glass of beer and gone to bed. He was, in fact, still drunk at the time of arrest. He had not been aware that he would be punished for the crime of going alone against the Russians.
Some days later, he wrote that he did not intend to kill the woman, that he had been drunk at the time and was always a bad man when drunk; that he had other times when he absented himself from home for days when drunk. He had had, he said, a number of attacks of delirium, in which he had seen animals. At one time, he had fallen on his head. On the day in question, he had drunk 1½ litres of liquor. He was remorseful for his deed.
A disciplinary case: Alcoholism; amnesia.
Case 96. (Kastan, January, 1916.)
A German soldier, New Year’s Eve, 1915, got away from his company, drank whiskey, and came back drunk. He bothered his comrades so that the non-commissioned officer had to call for help; whereupon the soldier said, “A man who comes on late and hasn’t been in much, hasn’t much to say. If it is a non-commissioned officer, I shall hit him in the snout.” The officer kept talking to him kindly but he cried “Halt’s Maul, you crooked …!” He staggered up to the lieutenant without saluting, but at a slight push fell prone into the straw.
It transpired that the man had not been intoxicated enough to lose all control of himself. He did not remember anything about what he had done; he had drunk a half-bottle of rum during the evening. There was a demonstrable lack of memory. He did not know the German provinces, and thought that Bismarck had once been war minister. There was a tremor, hypalgesia of the left leg and analgesia of the left arm and left shoulder.
It was found that he came from a strongly tainted family, with two insane sisters and three insane cousins. He had been a good soldier during his service, but had accused his father of alcoholism baselessly. He had always been difficult to manage when drunk and had been convicted nine times: five for dangerous assault and battery. He drank up to 1? litres of whiskey a day if he got time, and also took ether. For some ten years he had been amnestic for what he did while drunk; nor, according to his wife, had he been able recently to stand so much alcohol. He said that he had had a fall from a wagon in 1911 or ’12, after which he had been unconscious.
Antebellum, run over by an automobile; intolerance of alcohol; episodes of amnesia after moderate alcohol.
Case 97. (Kastan, January, 1916.)
A German soldier was advanced in rank February 26, 1915, and in honor thereof drank six or seven glasses of beer. On his way home, he met a captain and failed to salute him. When called to account, he said he could not see, and made remarks about regrettable behavior. He refused to go along with the officer. Afterwards he remembered that he had been stopped by an officer but had forgotten subsequent happenings.
March 24, he was riding in an electric car with a lieutenant. He said to the lieutenant who had unbuckled his sabre, “It is a piece of insolence and improper to unbuckle the sabre.” He repeated the phrase on questioning. He was then asked to give his name, and replied, “I know my name but what is your name, Mr. Lieutenant?” He looked drunk at the time but afterwards remembered nothing.
Physically he was tremulous and showed blepharospasm. His face grew red on bending over.
This man had been run over by an automobile in 1910, after which he had become excitable, slow-thinking and forgetful. The spinous processes were painful on pressure, as was also the hip joint. The history showed that he had been convicted six times of various crimes, such as disturbing the peace, embezzlement, and the like. Since this accident he had not been able to work effectively. He had gone into the army in a spirit of enthusiasm.
Adventure with a stranger in Paris.
Case 98. (Briand and Haury, 1916.)
A soldier had seven days’ leave in Paris, beginning December 27, 1915, and the first day drank a good deal of wine with another man on leave. They met, in some place that the patient had forgotten, a well-dressed man whom they did not know, and all three fell to drinking. The stranger told them he knew a trick to prolong the leave to 3 or 4 weeks. “All I have got to do is to prick you, and it will cost only 100 sous.” The operation was done at the cafÉ after payment in advance. The operation was a puncture with a needle between the middle and ring fingers of the left hand. Next day there was a phlegmon of the dorsal surface of the hand, and he was put into hospital saying that he had gotten a barbed wire prick in the trenches. The surgeon who opened the phlegmon was surprised at its gummy appearance, gangrenous odor, and greenish tint. In point of fact, petrol had been injected.
Morphinism: Tetanus.
Case 99. (Briand, 1914.)
Mdm. L. was a morphinist. After the outbreak of the war, she went to a general hospital to recover from morphinism, but was too excited to be kept there. Accordingly, she had to be sent to Sainte-Anne, but upon arrival she developed distinct signs of tetanus.
It seems that Mdm. L. was the widow of a Colonial who had given her the first injections ten years before, for dysentery. She tried several times to stop. Daily dose 1.5 grams.
She was in a cachectic state, and according to her mother, took no care of her syringe, trailing it about everywhere. Her thighs, arms, and anterior aspect of the body were covered with scars. There were small phlegmons in places. Did she inoculate herself with bacillus tetani from an infected needle? In any case, she died of tetanus.
Medicolegal question concerning a morphinist.
Case 100. (Briand, 1914.)
A man worked in Paris on the ’Change, where there are a number of syringe victims. He had been brought up in Paris but was not a Frenchman. Enthused by his friends and the prey of deep emotion, he enlisted. He was of an introspective nature and himself wondered whether the morphine did not have something to do with his enlisting. He said, “I had been unnerved for a number of days by reading the papers, and after a number of heavy injections, I went to a recruiting station and signed on.” In his regiment, he continued the injections, but shortly found that he would be unable to replenish his diminishing stock of drug. He explained his unhappy fate to the corps physician, and was sent to Val-de-GrÂce. He asked to be retired, alleging that he was under the influence of a poison when he went to the recruiting office and had therefore committed an illegal act.
Social effects of the war on two drug addicts.
Cases 101 and 102. (Briand, 1914.)
Fernand and Emilienne were two recidivists in morphinism. Although neither was over 22 years of age, both had been several times convicted of shop-lifting. They stole only if they had no money for morphine. Prostitution served to care for Emilienne, while Fernand was at times a cocaine seller, and at times made money in devious ways at Montmartre. Emilienne’s patronage scattered with the war, and it was the same with Fernand’s. Accordingly, there was no money for either morphine or cocaine. Moreover, the shops being not crowded were easier to watch. As Emilienne did not care to be arrested and sent off as an undesirable, she presented herself at the hospital for the insane at Sainte-Anne. Fernand shortly joined her there.
(THE FOCAL BRAIN DISEASE GROUP.)
Left-sided hemiplegia and aphasia: Contrecoup and local lesions.
Case 103. (Lhermitte, June, 1916.)
A soldier of 23 was wounded in the left parietal region and showed a left-sided hemiplegia with aphasia. The speech difficulty, although very marked, retrograded almost completely, but the hemiplegia remained severe. This hemiplegia was a spastic one, of a classical nature, with Babinski sign and exaggeration of tendon reflexes. Lhermitte thinks that the left hemisphere was directly affected by the contusion, as in point of fact there was an actual loss of bony tissue, but that it would not be necessary to suppose the ipsilateral hemiplegia was due to an absence of pyramidal decussation. The transient aphasia was probably due to direct affection of the tissues on the left side of the brain; the permanent hemiplegia was doubtless due to a lesion of the opposite hemisphere produced by contrecoup. It appears that sometimes a surgeon may be led to superfluous surgical intervention in a case of such paradoxical hemiplegia, since the surgeon may believe that a bullet or shell fragment has traversed the brain substance to the opposite side of the skull, when as a matter of fact the brain parts have been injured merely by contrecoup.
Re such amnesia, it is of note that many head cases, even if they do not show amnesia, show a conspicuous euphoria and lack of understanding of the seriousness of the injury in question and of the necessary treatment. According to E. Meyer, there are constantly to be found in head cases disturbances of perception and lack of coÖrdination (especially for time), perseveration, difficulty in thinking and calculating.
Chart 5
COMMOTIO CEREBRI
| I. | Senses: Asymmetrical hyp- or anesthesia (with hyperalgesia and osseous hyperesthesia). |
| II. | Motility: Disorder, muscular or reflex. General or unilateral hyperexcitability. |
| III. | Vasomotor Control: Dermatographia. Cardiac, splanchnic disorder; also, Headaches, Vertigo. |
| IV. | Emotions: Disorder. |
| V. | Intake of Ideas: Disorder. Persistent lacunae of memory. |
| VI. | Intelligence: Disorder of recollective memory. Speech-disorder. Intellectual inertia. Overimagination (hallucinations, tremors). |
Mairet, PiÉron, Bouzansky.
Gunshot wound of head; alcoholism: Amnesia.
Case 104. (Kastan, January, 1916.)
A German soldier had a bullet pass through his right eye and lower jaw, leaving a fistulous opening from the mouth. He said that he was completely blind, but ophthalmological examination cast doubt upon the blindness. There had been immediately after the injury a number of severe attacks of dizziness, which lasted several hours; and another attack developed after he had come back from hospital, to which he had gone by reason of his pains.
He was to be arrested on account of a disciplinary crime and had ostensibly gone to his mother’s house, there to await arrest. The non-commissioned officer found him in a saloon. As soon as the phrase, “You are my prisoner!” was said, the soldier lost track of his surroundings. He had drunk a few glasses of beer but did not himself think he was drunk at the time. He was insulting and violent when asked to proceed with the officer, and a policeman was called in to take charge. He then lay down in the street and had to be put upon a wagon, still firing abusive phrases at his captors.
Upon examination, aside from the effects of the gunshot, excessive knee-jerks and tremors of the body were found. The eyebrows met but there was no other sign of bodily stigmata. There seems to have been no hereditary disease, or any history of severe alcoholism, though the man had been convicted previously of violence and theft. The amnesia is to be ascribed to effects of the head injury.
Bullet in brain: Crises; cortical blindness; vertigo; hallucinations.
Case 105. (Lereboullet and Mouzon, July, 1917.)
An invalided soldier, 40, was sent to be observed, Oct. 23, 1916, because he wanted his pension renewed. He had been retired a year before for diminution of binocular vision with impaired perspective of objects in the right half of the visual field. He had now become completely blind.
He had been wounded, March 12, 1915, in the Argonne, without losing consciousness. He was wounded at ten o’clock at night and waited until the next day to walk to the ambulance and was at this time able to see perfectly. Arriving at the ambulance he lost consciousness. He was trephined but remembers nothing about the trephining.
His memory grew better from his arrival at a hospital in the rear in April. An attempt was made to remove the bullet in May, 1915. Though the surgeon’s finger was pushed as far as the tentorium the patient did not lose consciousness or sight, but on leaving the operating room he fainted and, after a few days of restlessness and delirium, he became completely blind. There was a cerebral hernia difficult to reduce. Vision became a little better and light and persons could be distinguished at the time when he was retired. A month after the operation there was a convulsive crisis beginning in the left arm, affecting the legs and ending in unconsciousness. Several similar crises occurred in August, sometimes with and sometimes without loss of consciousness. Later these crises began to be limited to the left side and then to be ushered in by visual hallucinations. At home he was unable to care for, clothe or feed himself. The crises became more frequent. The visual hallucinations began to dominate.
This situation lasted to February, 1916, when the blindness which had been increasing since the onset of the hallucinations became complete. The crises now became less frequent and intense. Headaches not severe were exaggerated after seizures. The patient acted like a totally blind
Pallor, perspiration, shivering, irresponsiveness, clonic spasms of left arm followed. The patient always had a premonition permitting him to get into bed if he was sitting, for example, in his chair. Sometimes there was a dizzy sensation as if the body were being rotated to the left. This sensation did not occur at the beginning of the seizure and the patient fought against it, turning to the right. Sometimes he felt as if he were sliding at great speed down an inclined plane. Headaches and sleepiness followed, but there was never any complete loss of consciousness of memory.
The eye grounds proved normal and all the photomotor reflexes were normal, though there was no pupil reflex to pain. The patient could write readily to dictation printed letters. It would seem that these printed letters mean that he had visual memories, as he traced the characters as if from a design. Speech was monotonous with some stuttering; but his speech had always been of this sort according to information. He walked with difficulty, not merely on account of his visual but on account of his equilibration disorders. Outside of his seizures he always turned to the right and if left to himself standing he turned to the right. If asked to walk straight ahead, he always turned to the right. Silent and uncommunicative, he was amiable and sometimes even gay. He often had troublous dreams, sometimes seeing his relatives. He said he could bring up in his mind the faces of his relatives and even the appearance of the SalpÊtriÈre. Reflexes and sensations were normal. There was a traumatic rupture of the tympanum. Lumbar puncture showed a slight excess of albumin and 1.8 lymphocytes to the cubic millimeter. The Mauser bullet was found by X-ray in the left calcarine region with its base touching the median line, and
The case is one of cortical blindness. The seizures are explained by the vicinity of the right Rolandic region to the lesion. The rotatory vertigo is to be explained by the contact of the Mauser bullet with the tentorium and vermis of the cerebellum, which may also explain the difficulties in orientation that occurred between the crises. The visual hallucinations are doubtless due to lesion of the calcarine region.
Tunisian theopath with mystical hallucinations; gun-shot wound of occiput (bullet extracted): After the trauma, Lilliputian hallucinations and micro-megalopsia.
Case 106. (Laignel-Lavastine and Courbon, 1917.)
A. ben S. was sent to Villejuif with the diagnosis: “depression, feeling of impotence, discouragement,” having been found on the public street. He was indifferent, almost completely mute, and was at first considered not to understand French. In a fortnight, however, he was talking freely and was then found to be afflicted with hallucinations, melancholia, and delusions, apparently following trauma to the skull.
A. ben S. might have been about thirty years old, and was of a rich family, indigenous in Tunis, well educated in the Koran and Arabic literature.
Upon examination, this Tunisian gunner showed contraction of visual fields, poor color vision, and general hypalgesia. During examination, the man seized the needle and plunged it deeply under his skin, exclaiming that a prophet felt nothing and that he could be cut into bits without feeling pain.
It seems that he had had divine visions from early childhood. In his youth he had once gone to a mountain near his home and talked with Mohammed and Allah. Of course, Allah did not appear in human form, but he appeared like a ball or a wheel of fire, slowly turning. Mohammed was a tall man, with a long white beard, his eyes darting rays of fire, and his forehead bearing a gleaming bright body. Allah was heard talking to Mohammed. Orders were given concerning the sun and stars. Subterranean treasures were displayed, as well as Paradise full of yellow, blue, and green houris, transparent, such that, when food was taken, it could be seen going down their throats. Hell too was visible, and the devil very tall and black, an eye behind and another on top. There were also many genii—little men who climbed over the Tunisian’s body. Sometimes in dreams, Allah carried him to all countries of the earth. It was hard to tell
His further history was obscured by the fact that he wove delusional elements into his story. He said, for example, that he had been court-martialed, though there was no evidence that this was a fact. It is probable that after his wound the patient in a delirium felt that he was going to be shot. The visual hallucinations were very interesting, being Lilliputian. He would see three or four hundred Tunisian gunners walking along, knee-high or taller. Sometimes they all would stop and aim at him. He also showed micromegalopsia, real objects changing their height under his eyes. Both the Lilliputian hallucinations and the micromegalopsia dated from the trauma to the skull. There was no change whatever in the mystical delusions concerning Allah and Mohammed. These he had before the trauma.
Meningococcus meningitis with apparent recovery: Dementing psychosis.
Case 107. (Maixandeau, 1915.)
A soldier in the Heavy Artillery, 42, developed occipital headaches and Kernig’s sign, December 27, 1915.
December 31, at the HÔtel-Dieu, he showed myosis, slight photophobia, meningitic tÂche, temperature 39.6, pulse 84, heart sounds dull. Lumbar puncture: hemorrhagic fluid.
January 1, the headache was intense, neck stiffness increased, Kernig’s sign less marked; morning and afternoon temperature 39.2. Lumbar puncture yielded hypertensive cloudy fluid and 30 cubic centimeters of serum were administered.
This dose was repeated January 2 and January 3, on which date there was no headache.
January 4, Kernig’s sign and neck stiffness were diminished; fine rÂles at the bases without dulness. 30 cubic centimeters of electragol were injected intravenously.
January 5, Kernig and neck stiffness slight. Meningitic tÂche; exaggerated knee-jerks; unequal pupils; temp. 36.6 morning, 39.4 afternoon; respiration 36; pulse 120; no rÂles; splenic enlargement.
6, no headache or photophobia; constipation; fine rÂles, right base; spartein; meningococci found in hypertensive spinal fluid. 30 cc. serum.
7, more rÂles; exaggerated heart sounds; intestinal worms in stools.
8, temperature fell to 37; pulse to 90.
9, patient worse; involuntary stools; Kernig’s sign; stiff neck; fever. 30 cc. serum injected.
10, 20 cc. injected.
11, delirious all night; tetaniform stiffness of neck; more rÂles.
12, delirious, incoherent words, Cheyne-Stokes breathing.
13, less stiffness, Kernig almost absent; pupils normal; Romberg sign slightly developed; pulse 120.
14, a few rÂles at right base.
15, pains in elbows, knees and hands with joint swelling; moist rÂles; temp. 38.4; pulse 140. Digitalon.
16 and 17, serum erythema of thorax; edema of left knee; pulse 150; spartein 16.
17, ice pack over heart.
18, edema of knee diminished; no headache, delirium or pupillary sign.
19, improvement. Temperature normal thereafter.
20 and 21, fine rÂles. Then all symptoms disappeared.
Recovery was predicted, but on January 28 it was observed that the patient was untidy, made mistakes in dressing, such as trying to put his legs into the armholes of his shirt, and denied the most evident facts: His kÉpi on his head, he said it was not. Face drawn; skin yellow. Appearance of asthenia. Deep depression and hebetude. At this time the knee-jerks were exaggerated, pupils unequal, vermicular tremor of tongue; the patient walked on a broad base with tremulous legs suggesting contracture and weakness.
February 8, in a similar state the patient wandered about his room, moving his bed and chairs about, answering questions with an absent air. He had now been taught to be less untidy.
March 5, stiff neck and Kernig’s sign were distinct. He made believe he was on his farm. Ecchymosis of right upper eyelid: he had fallen (his sheep had pushed him over!). The improbability of this idea did not persuade him to think it had not happened. He walked after the manner of a tabetic.
In April he became bedridden, unable to walk, with marked stiffness and Kernig’s sign. He had at this time periods of excitement in which he would tear the bedclothes. He was invalided as demented.
Meningococcus meningitis.
Case 108. (Eschbach and Lacaze, November, 1915.)
During his eleven months captivity at GrafenwÖhr, Eschbach and Lacaze had the opportunity of observing the case of a soldier, 24, who sustained a shell-wound in the left lung and was made prisoner August 20, 1914, at Chateau Salins. He got well of his wound, but February 16, 1915, began to cry out and was restless in the night. He was found on the straw muttering words among which only the word, “Head, head,” could be distinguished. He was irresponsive, possibly deaf. Suddenly he had a convulsive crisis and whenever touched he would have jactitations and cry out. Otherwise, he was calm and stuporous. The pupils were widely dilated. In short, he showed a mental confusion associated with paroxysmal excitement due to cerebral and cutaneous hyperesthesia. The first symptoms had occurred the morning before, when he leaned his head against a wall and complained.
Lumbar puncture yielded intra- and extracellular meningococci. The patient was isolated. In the afternoon he became less agitated, kept his eyes closed, mumbled, repeated gestures, would spit in his hands, rub his hands together, rub his neck, shoulders and body, or else he would pass his hands over his forehead and through his hair. Occasionally he would seize the straw and draw it to him with all his strength. Once when asked, “What is your name?” he said, “Not true. Not true.” Hallucinations appeared to have been added to the situation. The neck was a little stiff to forced flexion. Temperature 37.8. Lumbar puncture under chloroform anesthesia; antimeningococcus serum was injected. Next day quieter; able to get up and walk. Slept, mumbled less, was able to answer simple questions, desired to urinate and finally succeeded.
February 19, no mental disorder. Headache and lassitude. Neck stiff, Kernig’s sign marked. Lumbar puncture yielded a fluid now puriform; antimeningococcus serum injected. February 20, lifting the head produced opisthotonos. Labial herpes. The fluid yielded, besides meningococci,
Shell-explosion: Meningitic syndrome, fourteen months.
Case 109. (Pitres and Marchand, November, 1916.)
A soldier sustained shell-shock at the distance of a meter at Saint-Hilaire, September 26, 1915. He lost consciousness and blood flowed from his ears. He arrived, September 28, at the neurological center in Bordeaux in a semistupor, knowing that he had been shocked and had lost consciousness. He groaned, cried out, and kept stroking his head with his right hand; lay on the right side; showed Kernig’s sign right, ptosis, and stiff neck. Headache was increased on moving and noises. Patient constantly asked for food, but refused to drink. Lumbar puncture yielded a yellowish fluid, due to laked blood. October 3, headache, ptosis, left internal strabismus, temperature 38.5. October 4, lumbar puncture, slightly blood-tinted fluid. October 5, improvement; gap in memory for period since shock. No strabismus, ptosis diminished, temperature normal, improvement continued. Kernig’s sign and headache persisted. He lay doubled up on the right side, eyes closed, right hand on pillow. Defense movements on touching the neck or occipital region. The condition of semistupor often passed off in the afternoon, when he could talk, write or play cards. He had always smoked, even at the beginning of his disease. Lumbar puncture yielded a normal fluid December 12, 1915. He was sent February 23, 1916, to a hospital in the country, but came back May 9.
It seems that several days after transfer he had had an attack of delirium in the night, having lost consciousness, and tried continually to get up out of bed, saying that he wanted to go to Verdun to fight. This spell lasted several hours and on the days following came mutism, refusal of food, and a state of stupor. Nutritive enemata were given. As he grew better he sometimes ate a great deal, sometimes nothing, even wanted poison from his family, and wrote to a comrade that he wanted to commit suicide.
May 9, he was clearer, told of seeing the shell, which he said he had not heard, nor did he know how he had gotten to a hospital. His head and spine had hurt him ever since the shock. He had had difficulty in urination for two days after the shock. He could not remember the delirious attack in the country hospital. He gave various data about his life, but not fully. He refused to lie on the left side, or to walk, because of pain. He could lift either leg from the bed, but hardly both. There was an irregular coarse tremor of the extremities. The right hand was weaker than the left; there were no reflex disorders; no change in the eye grounds. There was a patchy analgesia. May 26, stupor reappeared as before, with semimutism. June, the patient presented the appearance of a dementia praecox in stupor, with stereotyped gestures and attitudes, without catatonia. The patient was sent to a hospital for the insane at Cadillac. November 9, 1916, he returned to the neurological center, as mental and cerebral disorder had disappeared. There still persisted a difficulty in remembering facts since the shock and there was still a functional paresis of the legs.
We here deal with a case of a meningitic syndrome following shell-shock and lasting fourteen months.
Brain abscess in a syphilitic: Matutinal loss of knee-jerks.
Case 110. (Dumolard, Rebierre, Quellien, 1916.)
An unmarried subaltern officer, 30, entered an army neuropsychiatric center, April 8, 1915, looking exhausted and bearing a ticket “nervous asthenia, evacuated for neurological examination.” He said he had had scarlet fever at ten; strongly denied syphilis, of which he presented no trace; had not been excessively alcoholic and had had no nervous seizures. Detailed information showed that he had been a normal child. He left his two years’ military service with promotion and was a man of above the ordinary intelligence.
He was wounded in the right buttock with a shrapnel bullet about the end of September, 1914. He went back to his regiment two months later and had shared in a number of actions up to the time of his evacuation. He said he had been very tired for several weeks, and had finally been sent to the physician. There were pains in the kidney region and in the head, especially on the right side. The head felt empty. He could not sleep, but did not dream. Ideas were not distinct. Memory had become impaired. He could not keep his accounts right, and was afraid something might go wrong.
There was no pain or nervous or reflex disorder of any sort except for the knee-jerks and Achilles jerks (see below). A special examination proved complete normality of eyes. There was a slight hesitation in words, but no dysarthria. There was a slight tremor of the tongue and fingers.
As to the tendon reflexes, April 9, on waking, the knee-jerks were absent, but later in the day gradually came in evidence again. The Achilles jerks were also absent at first, but could be obtained after a prolonged examination and after percussion of the calf. In the afternoon, after exercise, the knee-jerks and Achilles jerks were easily demonstrable. The left Achilles jerk was always a little weaker than the right. Massage brought these jerks out to virtual normality. April
Lumbar puncture yielded a clear fluid with hyperalbuminosis, 20 cells per c.mm. (lymphocytes and mononuclear cells 95 per cent) and a positive W. R. Iodide of mercury treatment was given April 18.
April 23, the patient went into a coma, with trismus, stiff neck, Kernig’s sign, sluggish pupils, incontinence. He was transferred to a special hospital, showed on lumbar puncture, April 23, 85 per cent polynuclear leucocytes, and died April 27. The autopsy showed a yellowish, quasidiffluent softening of the size of a small egg in the first occipital gyrus on the right side. The authors comment on the fact that the only objective sign in this case was the variable tendon reflexes of the lower extremities,
Early recovery from a spinal cord lesion.
Case 111. (Mendelssohn, January, 1916.)
Mendelssohn reports a soldier, who was sent to a Russian hospital, April 12, 1915, with a diagnosis of chronic appendicitis. Operated on next day, the patient appeared to be passing through a normal convalescence, when ten days later, he had an intense headache and some trouble in vision, which disappeared the next day, only to be followed, two days later, by the patient’s complaint that he could no longer urinate or rise from bed.
In fact, Mendelssohn found a complete flaccid paraplegia with urinary retention, without fever or pain. Knee-jerks and Achilles jerks were absent, and there was a slight extension of the great toe on plantar stimulation. There was disorder of sensation, with heat sensibility abolished, painful points poorly localized, and position sense poor. Electric reactions normal. Pain on pressure in and about the lumbar vertebral region. Cerebrospinal fluid showed lymphocytosis and an excessive albuminosis.
This paraplegia lasted six weeks. At the end of May, the patient began to be able to move his toes and to lift his heel. Improvement was gradual and progressive. Early in June he could walk if supported. The weak knee-jerk then began to reappear and the urinary retention gradually disappeared.
This patient was not hysterical, although a bit emotional. Perhaps, according to Mendelssohn, an organic lesion was grafted on a neurosis. Perhaps the spinal lesion was infectious. At any rate, a presumably organic paraplegia had recovered in two months and a half.
Shell-explosion: Meningeal hemorrhage: Pneumococcus meningitis.
Case 112. (Guillain and BarrÉ, August, 1917.)
An infantryman, 20, came to the Sixth Army Neurological Center, October 13, 1916, as a case of “choluria, due to shell explosion; epistaxis needs watching.” He was somnolent, had waked vomiting, pulse 108. Kernig’s sign, defensive movements of the legs on stimulation, with flexion of leg on thigh and of thigh on pelvis, plantar reflexes flexor. Puncture showed typical meningeal hemorrhage. Two days later, temperature 40, pulse 70, that is to say, a bradycardia in proportion to the fever. Vomiting, pulse persisted. Next day the patient was moaning and semi-delirious and showed stiff neck, Kernig’s sign, accentuation of vasomotor disorder, plantar response flexor with leg retracted, thigh flexion both homolateral and contralateral. The spinal fluid upon the next day, that is, four days after his arrival at the clinic, showed a purulent fluid in which there was an excess of albumin, no sugar, diplococci extracellular (proving on culture to be pneumococci and able to kill a mouse in twenty-four hours).
As a rule such hemorrhages remain aseptic, and in fact meningeal hemorrhage is said by Guillain and BarrÉ to have, as a rule, a favorable prognosis. The above described case was the only one of infected meningeal hemorrhage that had occurred in the Sixth Army Neurological Center.
ANTEBELLUM cortex lesion: right hemiplegia; recovery. Struck by shrapnel on right shoulder: Athetosis.
Case 113. (Batten, January, 1916.)
A British soldier, aged 27, showed a somewhat remarkable phenomenon. It appears that at five years of age, this man had had poliomyelitis, affecting the left leg. At 20 years of age, he had had pneumonia, and this had been followed by a paralysis of the right arm and leg with a loss of speech. The man recovered from this illness, although he never quite regained full control of the right hand. It is evident that this lack of control was not marked, else the man would not have been enlisted, and it is Dr. Batten’s opinion that at all events he could not have shown pathological movements of the right hand at the time of enlistment.
However this may be, in October, 1914, the soldier was struck on the right shoulder with shrapnel. Apparently he was not wounded, but thereafter he was not able to use the right arm well, and in two months’ time he had become unable to manipulate his rifle. On January 13, 1915, he was sent home. The remnants of the old poliomyelitis of the left leg were shown in a general weakness of that leg as compared with the right. The movements of the right hand were those seen in athetosis. The movements were independent of volition. The patient had difficulty in releasing his grasp. He improved rapidly during the six weeks he was in hospital, although the movements of the right hand never became entirely normal.
In this case, according to Batten,
Hysterical versus thalamic hemianesthesia.
Case 114. (LÉri, October, 1916.)
A soldier, 40, had been suffering for a number of months with pains in the left side of the trunk and feelings of weakness in the left arm and leg. In the summer of 1915 he was on leave and while walking, fell, lay down, and found he could hardly move his left arm and leg. Two or three weeks later he got up, walking with a stick. After some time in hospital, he was sent back to the trenches, a little weak.
He had shortly, however, to be examined neurologically again. He could hardly raise the left leg and his passive resistance was poor on this side. The left side was almost completely anesthetic to all forms of stimulus, although an intense faradic current yielded a feeling like that of a fly. Nor was the tactile sensation absolutely nil, as it could be got with a flat finger on the upper arm and thigh. Cold and heat sensations not well localized. The hemianesthesia was sharply limited at the median line and affected the buccal, lingual and nasal mucosa. Deep sensibility was almost abolished on the left side. Stereognostic sense was lost and the sense of position was lost absolutely for hand and foot.
The patient said that he heard less well on the left side. There was also a slight contraction of the left visual field. The reflexes were lively, but equal on both sides. A diagnosis of hysterical hemianesthesia was apparently called for, but psychoelectric treatment failed. The plantar reflex was, in fact, completely absent on the left side, as well as the corneal reflex. The faradic current failed to produce as marked a dilatation of the pupil on the left side as on the right. The forehead wrinkles were less marked on the left side. The mouth deviated slightly to the right. The left nasolabial fold was a little less marked. The tongue did not deviate, but was a little narrow on the left side. The palate deviated a little to the left. The left side of the trunk seemed a little less developed than the right, and the scapula stuck a little less closely to the body on the left side, when the arms were raised. The left buttock was a little narrower than the right
Shell-explosion: Syndrome suggesting multiple sclerosis.
Case 115. (Pitres and Marchand, November, 1916.)
A soldier, 40, carriage painter, underwent shell-shock at Voquois, May 2, 1915, following ten hours’ bombardment. At the time he felt tinglings. The bombardment had just ceased when he fainted suddenly while repairing a telegraph line. There was no loss of consciousness. He could not move his arms or legs, was able to spit, and did not suffer at all except for the tingling. He was evacuated to the interior, where the diagnosis of psychopathic double paraplegia, Kernig’s sign, zones of anesthesia in the legs, was made. He was immediately treated with gray oil, and got an injection of neosalvarsan, and iodides. He grew slowly better. He could lift a leg from the bed, but then both legs began to tremble. The arms had recovered their movement, before the legs, but always trembled in movement.
November, 1915, he was able to get up; two months later, he walked alone.
At the neurological center, which he entered December 17, his gaze was fixed and there was a slight exophthalmos. The folds of the face were smoothed out. The nose was deep set (as a result of a fall at the age of eight). In the upright position he could not remain still, but trembled markedly on the left side, so that he had to make a few steps to keep his balance. He was unable to stand on his left leg. He walked on a broad base, in little steps, and rather unsteadily on account of tremors augmenting upon movement. General muscular weakness; left hand slightly weaker than right. He could not lift both legs more than 20 cm. from the bed and in the process they both trembled, trembling together. There was also intention-tremor of the arms, a little less marked than that of the legs, of an irregular rhythm. The arms trembled as a whole. In a state of rest there was no tremor. There was a slight muscular stiffness and the patient himself felt difficulty in relaxing. Patellar reflexes absent,
We here deal with a syndrome in part that of a multiple sclerosis, that is, the intention-tremor, gait disturbance, muscular rigidity, and weakness.
Re multiple sclerosis, LÉpine remarks that there are numerous army cases of pseudo multiple sclerosis which are actually hysterical or hystero-traumatic cases of hypertonus and tremor. The true cases of multiple sclerosis, according to LÉpine, are of interest inasmuch as they are usually found in officers. These men have apparently at first but a slight motor disorder, quite compatible with desk work. We have usually under-rated the cortical element in multiple sclerosis. Spells of confusion, delusional ideas, sometimes grandiose, start up without warning in these cases. To be sure, alcohol and syphilis sometimes also enter these cases etiologically. Any case of localized tremor ought to be carefully examined psychically, and such cases in general ought not to be given responsibility.
Coexistence of hysterical and organic symptoms in two cases of mine explosion.
Cases 116 and 117. (Smyly, April, 1917.)
A soldier was blown up by a mine and rendered unconscious. Upon recovery of consciousness, he was dumb, unable to work, very nervous, paralyzed as to left arm and leg. The paralysis improved so that in the hospital at home the patient became able to get about. However, he threw his legs about in an unusual fashion. Several months later, the patient was much improved.
Shortly, however, there was a relapse. Transferred to a hospital for chronic cases, the patient was unable to walk without assistance on account of complete paralysis of the leg. Insomnia, general tremor, and a bad stuttering developed, with a habit of starting in terror at the slightest noise.
Hypnotic treatment was followed by almost complete disappearance of the tremor. The patient began to sleep six or seven hours a night; nervousness diminished, and the stuttering slowly improved; but neither the paralysis nor the anesthesia of the left leg was affected by suggestion. The leg remained cold, livid, anesthetic, and flaccidly paralyzed to the hip. Though a slight improvement has since been produced by faradization, the patient still can walk only with assistance.
A man was injured in 1906 by the fall of a heavy weight on his back. In 1914 he went to France 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.
Since return home the patient had gone from one hospital to another, for the most part unable to walk, suffering from agonizing pain in the head and eyes, unable to sleep, and in the night subject to horrible waking dreams.
Chart 6
MINOR SIGNS OF ORGANIC HEMIPLEGIA
(LHERMITTE)
| I. | Hyperextension of forearm (hypotonia). |
| II. | Platysma sign: Contraction absent on paralyzed side. |
| III. | Babinski’s flexion of thigh on pelvis (spontaneous, upon suddenly throwing seated subject into dorsal decubitus). |
| IV. | Hoover’s sign: Complementary opposition (on request to raise paralyzed arm, presses opposite arm strongly against mattress). |
| V. | Heilbronner’s sign of the broad thigh (hypotonia). |
| VI. | Rossolimo’s sign: flexion of toes on slight percussion of sole. |
| VII. | Mendel-Bechterew sign: flexion of small toes on percussion with hammer of dorsal surface of cuboid bone. |
| VIII. | Oppenheim’s sign (extension of great toe on deep friction of calf muscles); or Schaefer, or Gordon (on pinching tendo Achillis). |
| IX. | Marie-Foix sign: withdrawal of lower leg on transverse pressure of tarsus or forced flexion of toes, even when leg is incapable of voluntary movement. |
At first able only to bring himself to an upright position and to rush a few steps, he later acquired considerable control of his feet and legs through crutches. The insomnia persisted.
Smyly regards this case, like Case 116, as more neurological than mental.
Re organic neurology, much of great value has been reported.
Sargent and Holmes say that, contrary to expectation, there have been few war cases of bad sequelae of cerebral injuries, such as insanity and epilepsy. During early stages, after infection of the head wounds, there is dulness and amnesia, irritability and childishness,—symptoms which disappear during and after repair of the wounds. Mental disorder requiring internment is surprisingly rare. During 12 months only eight cases were transferred from the head hospital in a year to the Napsbury war hospital, where cases of insanity attributable to the service are sent; and in but two of these could the persisting mental symptoms be attributed to head injury.
Col. F. W. Mott confirms the opinion of Col. Sargent and Col. Holmes, remarking that from all the London County Council Asylums, only one case of insanity associated with gunshot head wound had been admitted, and that this was one of a Belgian who died from septic infection of the cerebral ventricles. Yet all cases of insanity in invalided soldiers belonging to the London County Council area (about one-seventh of the population of the United Kingdom) are transferred to these asylums.
Again Sargent and Holmes point out that both generalized and Jacksonian epileptiform seizures are comparatively rare in patients suffering from recent head wounds; even convulsions in later stages have been as yet less common than was feared. Thus, after evacuation to England, fits occurred in 37 (6 per cent) of 610 cases with complete notes, and in only eleven of these 37 cases were the convulsions frequent. Sargent and Holmes remark, however, that the practice of giving bromides regularly to all serious cranial injuries until the wound is healed, and for some months afterwards, seems
As for other neurological complications aside from septic infection and hernia formation, there are a few subjective symptoms that may necessitate the invaliding of soldiers. The most common of these is headache, usually in the form of a feeling of weight, pressure, or throbbing in the head, which headache is increased by noise, fatigue, exertion, or emotion. Attacks of dizziness also occur, and nervousness or deficient control over emotions and feelings. Changes of temperament are found in some soldiers, who become depressed, moody, irritable, or emotional, and unable to concentrate attention.
Foix, under the direction of P. Marie, worked upon aphasia in 100 cases, reporting results at a surgical and neurological meeting, May 24, 1916, in Paris. Only lesions on the left side of the brain have produced important and lasting speech disorder, although lesions on the left side may leave behind them a little dysarthria or difficulty in finding words in conversation. It is, of course, hard to tell speech disorder from stupor or clouding of consciousness. Foix notes certain specialties in speech defect according to which region of the left brain is affected.
First: Prefrontal lesions produce a transient dysarthria, lasting but a few weeks, and right-sided prefrontal lesions produce just as much disorder.
Occipital lesions produce no speech disorder.
Second: Patients with right-sided hemianopsia due to lesions of occipital regions were not aphasic and could read or write perfectly. Lesions of the left visual centers certainly do not affect reading. If, however, the injury is not to the
Third: Central convolutional lesion produces a variety of disorders according to the site and extent of the lesion. There is no aphasia with the crural monoplegia due to superior paracentral disorder. But slight aphasic disorder accompanies the brachial monoplegia of middle central lesion, though writing, reading, and calculation are slightly affected, and the more so the more the lesion extends posteriorly to the stereognostic regions. The lower down in the precentral region the lesion appears, the more likely is the Broca syndrome to be observed. But if the hemiplegia is chiefly a brachial monoplegia, the aphasic disorder may remain slight, involving reading, writing, understanding of words, the spoken word, articulation, and calculation.
Fourth: Lesions of the lateral-frontal region produce more or less marked aphasic disorder, just as do those of the inferior part of the precentral gyrus. This aphasia is more apt to occur when the wound is deep. However, no case of permanent aphasia has been observed in cases of lesion of the lateral-frontal region (termed in Foix’s nomenclature, the precentral region, but referring to the tissues in front of the precentral (or ascending frontal) gyrus of the more familiar nomenclature). Almost absolute, or absolute, anarthria follows the wound, and the patient is hemiplegic. This hemiplegia may last from ten days to two or three months. After a time there is no longer more than a slight dysarthria, and writing becomes good again; reading remains, perhaps, a little difficult. A complete or almost complete cure is the rule.
Fifth: When the retrocentral region is injured, various aphasic syndromes appear. The retrocentral region is the parietal-temporal lobe except the superior part of the parietal lobe and the anterior part of the temporal lobe, which latter two regions when injured do not allow any marked aphasic disorder. Lesions of the middle or posterior temporal region are particularly important for speech, and produce more marked disorder than lesions of the angular gyrus or the
To sum up, cases with central lesions (precentral and postcentral gyrus) have hemiplegia and a Broca aphasia without much tendency to cure. Cases with lesions anterior to the central convolutions have a transient anarthria and their recovery is ordinarily complete. Cases with retrocentral lesions have an aphasia suggestive of Wernicke’s aphasia, and ordinarily leave behind them extensive defects in intelligence and language. These cases should be taken account of from the standpoint of compensation, since they are much worse off for work than many cases with amputations; and though their disorder looks slight, it quite interferes with working at a trade. From the point of view of military effectiveness, the retrocentral cases are not very good soldiers, and especially not good officers, as they do not understand commands completely.
Neuropsychiatric phenomena in rabies.
Case 118. (Grenier de Cardenal, Legrand, Benoit, September, 1917.)
A farmer, 34, mobilized in veterinary work, fell sick at a station for sick horses, April 25, 1917. He breakfasted well, drank coffee, and went to the abreuvoir at eleven o’clock. He told his mates that he felt bad in his head. He fainted over a table at the eating house, refused to eat or drink. At noon he went out into the court, vomited and went to lie down. A physician thought he was suffering from angina because of the pronounced dysphagia. He entered the hospital at eleven o’clock at night on the 25th. He was found next morning on his back, with a fixed and haggard look, crimson face, masseter and phalangeal spasm at times. Respiration irregular, interrupted by moans. The pulse would go up to 120 during agitation and then go down to 50 as soon as the patient lay down again. Pupils slightly dilated and unequal. As the patient came from a sick horse dÉpÔt, the first question was that of tetanus, suggested somewhat by the jactitation of the limbs and the trismus. A violent headache began and the patient cried out, “My head! My head!” Painful vomiting movements, with very slight bilious material. Convulsive movements increased. The pulse was slow. The diagnosis “meningitis” was suggested, despite the absence of fever and the absence of Kernig’s sign. Lumbar puncture gave limpid fluid with a normal lymphocytosis, without increase of albumin or reducing substance. The bacteriological smear and culture were negative.
Soon another sort of symptoms appeared. The patient would rise, cry out, threaten his neighbors. He was calmed with morphine. There were periods of excitement alternating with periods of calmness, during which he would reply sharply but accurately, being somewhat vexed by the questions, and would walk up and down without offering a word. When a glass of water was offered to him, as soon as his glance met the glass his eyes expressed fear. He drew back in repulsion
He was sent that evening to the neuropsychiatry center, walking jerkily and as if slightly drunk, with a number of small gesticulations and murmurings. He was immediately isolated, undressed himself and went to bed. He did not move in his bed, and seemed to sleep. The next day he got up, dressed and had a small spell of excitement, but was quiet enough on the medical visit, though the floor was soiled with urine and vomitus and the clothing was in disorder. He now had a pronounced phase, deep sunk eyes, drawn features and anxious look; dilated pupils and an expression of mixed fear and anger. His breathing was hard and he kept his hand on his heart. He was oriented. He suddenly rose and said, “I am thirsty.” A glass of milk was given him. He hesitated a moment, plunged his mouth and hands into it and aspirated the drink without making any swallowing movements. He pushed away the glass, spat a little, and vomited a small quantity of a black liquid. Then followed an anxious crisis, and he fell upon his side, absolutely immobile, without breathing for a few seconds. Again in the sitting posture, he was taken with contractions of the limbs and face. The tendon reflexes were at this time normal.
A quarter of an hour later the attendant found him dead, in the sitting posture, leaning against the wall, mouth open, arms dependent, hands extended, pupils dilated—a death in syncope. The brain was found congested. There was a slight effusion of blood over the posterior aspect of the brain. There were no hemorrhages or softenings in the brain substance. The muscles were of a dark red to black. The adherent lungs were very slightly congested at the base. The stomach contained a quarter of a liter of black, inodorous fluid in which there was much bile and little blood. There were numerous small hemorrhages of the mucosa near the great curvature. The spleen was large, the liver congested. The Pasteur Institute confirmed the diagnosis of rabies. There is no history of the man’s having been bitten by a dog.
Tetanus: Psychosis.
Case 119. (LumiÈre and Astier, 1917.)
A soldier wounded May 18, 1916, was given antitetanic serum May 26th. The wounds healed, but on June 16, that is, 29 days after the trauma, contractures began, at first localized. There had been numerous wounds of legs and scrotum by shell fragments and the contractures were limited to the right leg and scrotum. There was no trismus or any lumbar symptom.
During the next few days the contractures became general, the temperature rose, a shell fragment was found by X-ray at the root of the thigh and was surgically extracted. B. tetani was found upon inoculation of media with material from the shell fragment. Persulphide of soda and antitetanic serum 90 cc. in three days were given intravenously. The temperature fell and the general health was greatly improved. July 6, hallucinations and terrors, worse at night, set in. The man believed himself surrounded by flames, that daggers were being plunged into his old wounds, that his hair was being pulled. These symptoms lasted a fortnight only, whereupon the patient recovered.
This case and six others accompanied by cerebral disturbances all recovered, and all the patients retained a perfect memory of their delirium and of their hallucinations.
The chronological distribution of these cases was odd. One case was found early in the war; then no other cases of cerebral disorder presented themselves until the group observed at the end of 1916. Besides flames and daggers, zoÖpsia was several times observed. One of the cases showed these symptoms without having been given antitetanic serum.
Re tetanus in the war, see in the Collection Horizon a book by Courtois-Suffit and Giroux on Les formes anormales du tÉtanos.
Tetanus fruste versus hysteria.
Case 120. (Claude and Lhermitte, 1915.)
Claude and Lhermitte describe a condition of tetanos fruste. The neck was absolutely rigid. The patient had not been wounded in any way and, being regarded as a pure neuropath, was sent to the Centre Neurologique at Bourges.
The differential diagnosis lay between true tetanus and the hysterical pseudotetanus or pseudomeningitis. In pseudotetanus there is a contracture of the superficial and deep neck muscles, especially the trapezii, sternomastoid, and deep muscles. The condition somewhat suggests that of acute meningitis or tetanus, and especially suggests tetanus because it is often associated with masseter contracture (hysterical trismus). The head is immobile, stiff, and inclined backward; eyes directed above, throat slightly prominent. Upon attempts to move the head, intense pain occurs. The pain and contracture sometimes even suggest a suboccipital Pott’s disease. This form of hysterical pseudotetanus is of sudden onset, as a rule following burial in a trench or else contusion, or a slight wound in the cervical region. Pressure on the spinous processes produces no pain, nor does a blow upon the head; and an X-ray examination will definitely eliminate the hypothesis of Pott’s disease.
To return to the Claude-Lhermitte case of limited true tetanus: It showed marked modifications in the tendon and bone reflexes. Upon percussion of the zygoma, of the occiput, or of the clavicle, there was a marked further contraction in the contractured muscles. Although there was no apparent spasticity in the legs, there was an ankle clonus and a bilateral patella clonus, combined with a distinct exaggeration of all bone and tendon reflexes. In such cases also there is hyperexcitability of the nerves and muscles to faradic and galvanic currents.
An officer’s letter concerning local tetanus.
Case 121. (Turrell, January, 1917.)
The following letter from an officer who had had local tetanus and was treated by Turrell by ionization Dec. 6 and 7, 1915, by diathermia Dec. 7 to 22, and occasionally by static breeze ionization and chlorine ion to relieve contractions from Dec. 29, 1915, to Feb. 4, 1916. The tetanus was in the muscles of the legs. Of course diathermia is a purely symptomatic treatment and does not replace antitoxin serum or other specific treatment; thus its effect in relieving the contractions of local tetanus is precisely like its effect in the treatment of sciatic neuritis or lumbago.
November 15, 1916.
“Dear Major Turrell,
“I have been meaning to write to you for some time, as I knew you would be interested to hear how I was getting on. Your letter has just been received, and I am only too happy to give you any information I can with regard to my leg. I was wounded in the left leg on October 13, 1915, by high explosive shell, and arrived at Oxford on October 22. There was no operation as the surgeon in charge did not consider it advisable to remove the pieces of shell: my leg seemed to be getting better, and after about a month I was able to hobble round with sticks. My foot at this time used to swell a great deal towards night, and the foot seemed then to gradually stiffen up with violent pains at intervals, this gradually spread up the whole leg to about the knee, and I was compelled to take to my bed again. The pain at times was very bad, similar to a very bad attack of cramps, and then my leg became rigid and stiff, and at other times used to get horrible jumps and it was impossible to keep it still, and whenever the doctor or nurse looked at it it used to stiffen up at once. The night seemed to be the worst, and consequently I got very little sleep. I often had to get up in the middle of the night on crutches to try and obtain relief, my leg was so cramped and sore. It was about this time that you first visited me and prescribed a course of electric treatment for my leg, and I shall never be able to thank you enough for the relief it gave me. I cannot remember the names of the different treatments, but the first one—diathermy, or heat pads—certainly relieved the pain, and after the first two or three visits to you I got immense relief. I never looked back after this, and, although the progress was slow, I gradually lost all pain and was able to get sleep at night. The nervous jumps slowly disappeared and my leg became gradually normal except for contraction of the tendons. I was unable to straighten my ankle or knee, and it was thought at one time that my tendo Achillis would have to be severed. Gradually the knee straightened and I was able to get my heel to the ground. I was for some time on crutches, and was able to leave the hospital on February 5, 1916, walking with sticks.… I am now able to walk comfortably, but am unable to flex the ankle more than at right angle to my leg. The circulation is not very good, and I feel anything tight round my calf. I am still getting Boards, and have not been passed fit for overseas yet.”
(THE SYMPTOMATIC, NON-NERVOUS, GROUP)
Dysentery: Psychosis.
Case 122. (Loewy, November, 1915.)
Out of a large number of dysentery patients, many of whom had very serious symptoms, but one of Loewy’s patients became psychotic. Loewy in fact had discharged this one as normal, and he had been put on the wagon train (no opium or alcohol) to go to a sanatorium. As the fighting shifted, the sanatorium site changed and could not be reached with the wagon. Finally, the wagon train met the battalion once more and Loewy was told that the man was “dying.” At this time he was afebrile, without collapse symptoms, with a strong and normally frequent pulse, and with few signs of exhaustion. Yet the guard had thought that he looked moribund. Both upper eyelids were drawn rigidly up but conveyed a different impression from that in maniacal or anxious conditions. The expression was that of staring astonishment, helplessness, and apathetic lack of orientation. The patient recognized Loewy, spoke to him as “Herr Doctor,” said he was doing quite well; he was found to be well oriented. There was no fabricating tendency even as to the number of stools (although Loewy had noted such in bad dysenteries of the Shiga-Kruse type). He was apparently hard of hearing, as if at the beginning of a typhoid fever. He showed a retardation in his intake of ideas, and his voice in answering sounded absent-minded. There was an expression of absent-mindedness, and the patient seemed markedly unconcerned about his health, the direction of the journey, the terrible rain, etc. These phenomena are attributed by Loewy to attention disorder.
The patient had been out of reach of fire for days. Loewy reports the case as one of beginning amentia or as an exhausted state resembling a Korsakow condition, recalling one of emotional hyperesthetic weakness (Bonhoeffer).
Typhoid fever: Hysteria.
Case 123. (Sterz, December, 1914.)
A soldier entering hospital for typhoid fever, October 2, 1914, was discharged to another hospital and again, November 10, to a hospital for nervous disease. The typhoid was serious and complicated by delirium. After defervescence, the patient was weak and could not stand or walk, especially on account of pains and weakness in the left leg. Sometimes he had had pains in the sacrum and left hip. He complained of tinnitus, deafness, dizziness, headache. He said he had fallen from a cart, had been sick for three months, since which time he had been under medical treatment for his present condition. He had, he said, been given a small pension.
The gait disorder sometimes amounted to a real astasia-abasia. The left leg became stiff and was dragged behind. There was a paresis demonstrable in dorsal decubitus, of the left side, especially of the leg, without atrophy. There was a hypesthesia of the whole left side of the body, with the exception of the head. Hyperesthesia of the left leg, hip and upper sacrum. The left corneal reflex was diminished. Moody, hypochondriacal, lachrymose. The general attitude of the patient was affected and theatrical. Paradoxical innervations were frequently found on test. There was no neurological disorder except for the absence of the right Achilles jerk.
The absence of this Achilles jerk may be regarded as a residuum of the previous accident. The localization of the pains points to a neurotic lumbosacral plexus disorder on the left side. Superimposed upon this picture are the hysterical phenomena. The typhoid fever and its attendant neuritis are therefore to be interpreted as the liberating factor for a severe hysteria in a subject already disposed to such symptoms through previous accident.
Dementia praecox versus post-typhoidal encephalitis.
Case 124. (Nordman, June, 1916.)
A butcher, 29 (aunt insane, sister melancholy, one child stillborn, deformed), had had several days convulsions at eight; went through military service without incident; was at the Marne and was evacuated October 19, 1914, with typhoid fever,—a severe fever with a delirium prolonged into the last weeks. Three months convalescent leave was given, passed at Paris with the man’s aunt, but he had become strange. One day he wanted to strangle neighbors of German origin; another day departed for Dunkirk and then returned, having lost all his documents.
February, 1915, he went back to the front, did strange things and was soon evacuated to Tarascon. In April he went back to his dÉpÔt; May 18, to the hospital at Rennes for erythema. June 15, he was given 15 days in prison for setting off a cannon too quickly and then running off through the fields. August 11, he was interned at Rennes for stealing a priest’s cap. September 12, two months convalescence. December 10, headaches. Back to Rennes January 14, February 18, Val-de-GrÂce, then Maison Blanche.
Here he was found sometimes sad, immobile; at other times laughing and singing. He was very irritable on small occasion. Once on leave he had a fugue with complete amnesia, though alcohol may account for the latter. His memory was vague, especially for his crimes and for recent events. He was emotional, indifferent even in the presence of his wife or aunt. Sexual indifference. He often complained of his head, saying that he felt it blocked and that he could not think. The headache was frontal and would last several hours. The man would, however, not complain spontaneously. He was physically, in general, negative.
This case might possibly be due to a post-typhoidal encephalitis, but Nordman believes rather that it is a case of dementia praecox. Perhaps the convulsions at eight produced a slight brain lesion, brought to an issue by the typhoid fever.
Paratyphoid fever: Psychosis outlasting fever.
Case 125. (Merklen, December, 1915.)
A Breton farmer, 34, had paratyphoid alpha. Admitted to hospital September 3, 1915, he had headache, anorexia, asthenia, coated tongue and tense abdomen, algosuria; later, abdominal swelling, borborygmi in the right iliac fossa, rose spots, dicrotism, albuminuria, bronchitic rales. The disease was severe, and was complicated by sacral decubitus and ran a month.
At first somnolent, September 8th the patient went into a state of mental excitement with agitation and delirium. He got out of bed, cried out, sang, talked to his neighbors, complained that his papers (colis) had been stolen, as well as his watch and tobacco; that his horses’ hoofs had been injured, and the like.
He grew calmer in a few days, and now no longer tried to get up, remaining inert in his bed. The occupation delirium persisted—he was not being paid what he owed, and the like. He had hallucinations; looked for scissors, and one day said, “Here they are!” At intervals he appeared lucid and responded appropriately to questions.
The fever dropped and the paratyphoid disease appeared past, but the mental state remained for three weeks without change, having the same periods of lucidity when he would be regarded as cured, but falling again forthwith into his post oniric ideas. He was soon sent to a convalescent hospital and was not wholly well for another month.
Psychopathic taint brought out by paratyphoid fever.
Case 126. (Merklen, December, 1915.)
A soldier, 31, was a victim of paratyphoid alpha, entering hospital October 21, 1915, with the usual symptomatology: fever, asthenia, headache, abdominal swelling, tongue coated and red along its edges, diarrhoea. After admission he passed into a deep toxic state.
He woke up in the night with a cry, got up afraid, and refused to go back into his own bed. He was mute, except for curses addressed to the nurses. After two hours he went to bed and to sleep. Next day he sat quietly with a depressed look, occasionally groaning deeply, talking in brief phrases about his anxiety, wanting his wife telephoned to, saying that he would not see his children, was going into the four planks, and the like.
This situation lasted about a week. He became afraid of medicines and thought he had been poisoned, saying that he would rather be shot than poisoned and complaining that, though he had served France for fourteen months, they now wanted to kill him. In the night time he was agitated. He gave vent to cries, and threats, but this delirious state rapidly decreased and he became calm the night of September 27th. The upper extremities showed a tendency to catatonia. From this time forth, during the remaining month, the patient was immobile, mute, fearful, and mistrusting, depressed and always wore a cunning look. His disorientation decreased and he passed good nights. He would answer questions by groaning. He would say, “They think I am a Tartar.” The end of the mental disorder coincided with the cure of the paratyphoid fever. According to Merklen, the paratyphoid bacillus in these cases serves to bring out a psychopathic taint. This particular patient had always been of a sad demeanor, uncommunicative, very impressionable and emotional. Two other cases had always been somewhat below normal.
Diphtheria: Post-diphtheritic symptoms.
Case 127. (Marchand, 1917.)
A farmer, 37, was evacuated March 20, 1916, for diphtheria. April 1, paralysis of tongue and uvula, impairment of vision. These symptoms rapidly improved, but paralysis of the legs appeared and then of the arms. This paralysis lasted until he was sent to the neurological center June 28 for post-diphtheritic paralysis, wherein it was found that voluntary movements of the legs could be performed, though painfully and of slight extent, that walking was impossible, that there was a considerable atrophy of legs and arms, that the knee-jerks, Achilles jerks and plantar reflexes were absent. There was complaint of pains in the legs and over nerve trunks.
Improvement followed, the atrophy gradually passed away, and the voluntary movements of the legs became more extensive; but by October the reflexes had not yet reappeared. Yet the patient had begun to walk on crutches and soon was able to get on with canes only. The improvement did not continue. He did not raise his heels and dragged his toes. There was now a clonic tremor of the legs as soon as the weight of the body was put on them. During movements of legs carried on in dorsal decubitus there was found an irregular tremor of the legs with twisting of the trunk. The muscular strength was well preserved. There was a slight muscular atrophy. The tendon reflexes had now come back, though the right Achilles jerk was weak and the plantar reflexes were absent. There was a hypalgesia of the legs which ceased sharply at the middle of the thighs. There was a slight hypoacusia on the left side. Visual fields normal. The patient complained of feelings in the inside of his bones. Electrical reactions normal.
Diphtheria: Hysterical paraparesis.
Case 128. (Marchand, 1917.)
A soldier, 24, was evacuated June 24, 1915, from Roussy for diphtheria and was treated by serum, receiving 80 cc. in 8 injections. A few days later there was a paralysis of the uvula with regurgitation of liquids from the nose; but patient was able to go on convalescence July 21. A few days later, however, he noticed that his legs were weak. Vertigo, vomiting and painful walking followed, and his convalescence was increased a month. The paralysis got progressively worse. September 10, he went by automobile to Libourne where he stayed two months. He arrived at the Neurological Center at Bordeaux November 9 with diagnosis “polyneuritis of legs.” He could not walk and could hardly flex thighs on pelvis or legs on thighs. Voluntary movements of extension and flexion of feet and toes were limited. There was neither atrophy, pain nor reflex disorder. Both legs were analgesic, as was also the abdomen up to the umbilicus. There was complaint of dorsolumbar pains and of stomach trouble and lack of appetite; vomiting after meals frequent, pulse 120.
January 3, the patient was able to lift his legs a few centimeters above the bed but not together. There was now a slight muscular atrophy especially on the left side. Knee-jerks lively, analgesia limited to legs, no vomiting, pulse rapid.
The patient was sent to a hospital in the country May 8 to July 8. He was now much better. His legs were able to support his body but he could not walk. Slight atrophy of left leg. There was hypalgesia now in the feet and legs below the knee. There was no pain on pressure over the nerve trunks. The electric reactions normal. The patient could now walk on crutches. He was invalided on the temporary basis, December 12, 1916.
It does not appear that in this case the hysterical paralysis was preceded by polyneuritis.
Malaria: Amnesia.
Case 129. (De Brun, November, 1917.)
A soldier lost all memory of his hospital stay in Salonica and the voyage home. He could only remember a little about the hospital at Bandol. There is a period of transition to full memory in malarial cases characterized by sure memory, vague on certain points, alternating with phases of almost complete amnesia. The soldier in question had very inexact memories of the Bandol Hospital, and could only remember about his fevers, that they began about noon and terminated about four o’clock. Twice he had been found in his shirt, walking, unconscious, in the passageway of the hospital. Having obtained leave for convalescence, three months after his memory gap began, he went to Paris, and probably had attacks at home. He vaguely remembered afterward being carried by automobile to the Pasteur Hospital, December 1. There he remained to the end of March, 1917, without preserving anything but the vaguest memories of an intermediary period of more than six months. The memory in these malarial cases often remains permanently altered and there may even be a retrograde amnesia, carrying back to facts prior to the gap and an anterograde amnesia relative to facts after the main gap.
Thus, there is in the febrile period a retrograde amnesia and in the post-febrile period a retrograde or anterograde amnesia. One group of subjects are severe cerebral cases, and the memory gap appears to run back to a period of true mental confusion. But there is another group of patients who preserve throughout the febrile period an absolute consciousness of all acts, and yet the memory gap is just as sharp and definite as in the confusional cases.
Malaria: Korsakow syndrome.
Case 130. (Carlill, April, 1917.)
A stoker, 45, was admitted to the Royal Naval Hospital, Haslar, November 6, 1916, from the Fifteenth General Hospital in Alexandria, to which he had come from a hospital in Bombay about three weeks before. At Alexandria he was anemic and showed an edema of legs which had been present for six weeks. Cylindruria; no albuminuria. At Haslar there was no cylindruria and no edema, and nothing but weakness, gouty arthritis of left wrist, right ear and left great toe. Red cells 4,650,000, leucocytes 10,000 (52 per cent polymorphonuclear, 46 per cent lymphocytes). He was rather dull mentally. December 10th, Dr. Fildes found malarial organisms in the blood on the occasion of a hyperpyrexia (104°). Quinine was given. December 14th, he was transferred neurological. According to the patient’s own story, he was born June 10, 1868, lived in Fulham, had a daughter aged 12 years, had recently seen his wife at the hospital: all this seemed plausible enough.
Later, however, he said that the year was 1899, that King Edward was king, that the war was between England and some field forces, etc. This well-nourished, pale, simple-looking stoker spoke quietly and politely; told about intermittent fever; about being eight years on the active list, becoming a reservist and being called up for the war. He read intelligently, could do sums, but did not know the name of the hospital and was confused about the war. He recognized that his memory was not as it should be; constantly stroked his moustache and chin. He was happy and contented.
The gait was normal, systolic blood pressure 140 mm.; no evidence of alcoholism. Blood, January 15, 1917, contained 5,050,000 reds, 10,300 leucocytes (63 per cent polymorphonuclear, 37 per cent lymphocytes). There was a bilateral absence of the ankle-jerks, repeatedly confirmed at subsequent examinations. Wassermann reaction was negative. Puncture fluid contained no cells.
Instead of living at Fulham, this stoker lived at Portsmouth, and had not been seen by his wife for four years. He had done 18 years’ active service and had last sent his wife a letter from the Sailors’ Home at Bombay, November, 1916. They had been married 21 years. He caused astonishment with his wife and friends by announcing that Lord Roberts and General Buller were in command at the battle of the Falklands. He continued to say that he lived at Fulham. He was discharged home, January 22. It seems as if he were living through the period of the Boer war.
Carlill considers that alcoholism may be ruled out, and there is no likelihood that the gout was the cause of the neuritis. He believes that the neuritis was probably malarial. Possibly the illness suffered in Bombay may have been beriberi or it may have been malarial nephritis.
A complication of malaria.
Case 131. (Blin, August, 1916.)
A Senegalese corporal of machine gunners, 21 (early life normal save for sore throats and coughing), was a robust, well-developed man of 75 kilos when he entered the hospital at Konakry, February 15, 1916. He was given the diagnosis: malarial anterior spinal paralysis.
It seems that he had joined a Colonial regiment, April 8, 1915, attended classes as a recruit, left Bordeaux November 1 for Dakar, arriving there November 11. He stayed there some sixteen days, during which time he slept without mosquito-netting. November 16, he left for Konakry, and had his first febrile symptoms November 27, with vomiting, headache, and prostration. His temperature ran as high as 41, but by December had fallen to normal, after quinine.
The corporal was sent away, cured, to his company at Kouronesa, December 6. There was more fever, headache, and vomiting during the railway trip. Quinine again relieved the fever, but a bloody diarrhoea set in so that it was only at the end of January that he could go on service.
February 6, another attack of fever, with shivering and perspiration, lasted for some three hours. He could hardly stand by himself and had to be helped in walking. Next day, another spell of three hours of fever; definite paralysis set in, affecting both legs. February 8 the arms were attacked by paralysis which, unlike that of the legs, was a progressive one, attacking first the shoulders, then the elbows, the wrists, and finally the hands. All the body muscles were in a state of flaccid paralysis, as well as the muscles of the face. The patient was now afebrile. February 9 there was a slight speech defect; the tongue was slightly paralyzed, and swallowing became painful. The jaw movements remained normal. The muscles of the face were intact and the patient could whistle, move his lips, and move his eyeballs normally. Vision normal. The pupils were fixed in dilatation, more widely on the left side. There was a slight
By February 14, when the patient was sent to the Bellay Hospital, muscular atrophy had made its appearance. No plasmodia could now be found in the blood, which showed 71 per cent polynuclear leukocytes, 20 per cent mononuclears, 9 per cent lymphocytes.
This state lasted til February 25. Despite the fact that the patient ate well, emaciation rapidly progressed. The buttock showed a very few signs of decubitus. Upon this date there was pain from a marked orchitis of the left side, the cause for which remains unknown (no history of gonorrhoea; catheter used for the last time, February 15). The temperature which attended the orchitis came down in three days; the patient’s appetite was singularly good, but the muscular atrophy increased. The speech defect meantime disappeared, and the patient swallowed more readily.
March 7 a slight and hardly perceptible movement could be noted in the fingers of the left hand. Two days later, similar movements appeared in the right. March 11 he could spread his fingers in a kind of creeping movement. Next day slight movements were possible with the legs, and March 13 the knees were movable. March 14 the patient could lift his head from the pillow. The range of movement now increased all over the body. According to the patient, those parts were the first to regain power that had been attacked last. This certainly seemed to be the case with respect to the left upper limb, in which first the hand and wrist, then the elbow and shoulder, successively recovered power. The legs regained their power in the same way proximad. March 17 the patient could sit up and grasp objects with the left hand. The cremaster and plantar reflexes appeared,—the former, more on the right; the latter, more on the left. The left pupil remained in wider dilatation than the right.
The treatment was by quinin and potassium iodide, with massage. The patient was apparently on the highroad to complete recovery, and left for France March 21, weighing 63 kilos.
Trench-foot: Acroparesthesia.
Case 132. (Cottet, September, 1917.)
A fantassin, 36, carpenter by trade, went into the trenches October, 1914, and had two attacks of trench-foot, first in January, 1915, when there was a painful swelling of the foot and secondly in July, 1916, when there were some bullae on the dorsal aspect of the feet. These were not serious and the fantassin did not report sick.
He was wounded, August 27, 1916, by shell fragment on the right elbow, was evacuated to the ambulance where the fragment was extracted and then to a hospital which he left cured with a seven days’ leave. Although he had not suffered in any way from his feet while in hospital, and had not been exposed to cold, the bullae reappeared on the feet just as they had been in July. They in fact now formed a sort of exanthem occupying symmetrically the dorsal surfaces of the toes. The bullae contained serum. They were confluent, varying from pin head to a nut in size, were as a rule round, but sometimes irregular. The eruption went on to a cure rapidly and on the twelfth day the bullae had dried up. This patient had hypesthesia up to the knees, hypesthesia of the dorsal surfaces of the feet, hyperesthesia of the plantar surfaces and ankles, hypesthesia of the forearm and the elbow and of the dorsal surfaces of the hands with possibly exaggerated sensibility of the palma surfaces. Hypesthesia of the face was limited to a small part of the right ear. The reflexes were normal and there was no atrophy. The name “paresthetic trench acrotrophodynia” was given to it.
In a service of eighty beds Cottet found within two months fifteen instances of these acroparesthetic disorders regarded as neuritic changes in trench-foot of a latent and lasting character which would have remained unobserved unless there were disorders of sensibility. In fact similar disorders of sensibility may be found without any history of gelure des pieds, forming a latent type of neuritic alteration hardly noticed by the patient himself. In twenty-six cases Cottet found sixteen with hypesthesia of the ears and of the nose.
Bullet injury of spine; bronchopneumonia: État criblÉ of spinal cord.
Case 133. (Roussy, June, 1916.)
As to the development of eschars, Roussy reports the case of a lieutenant wounded September 25, 1915. There was a penetrating wound of the interscapular region. The bullet had entered on the posterior aspect of the right scapular region and had emerged at the level of the first dorsal vertebra. October 1, a neurological examination showed flaccid paraplegia, knee-jerks normal, Achilles jerk weak on the right, plantar reflexes flexor, cremasteric reflex absent on the right, and both abdominal reflexes absent. There were pains in the legs and arms. There was retention of urine with overflow. A slight dulness on the right; temperature from 38 to 39 degrees.
Four weeks later the knee-jerks had become very weak, and the Achilles jerks were now absent. There was an extensive diffuse atrophy of the lower leg and thigh muscles, and a hypesthesia of pronounced degree had developed throughout the legs, over the buttocks, and in the lumbar region. Anal and vesical sphincters relaxed; dejections voluminous; sacral decubitus as well as healed eschars. December 5, the patient was transferred to the Army neurological center; temperature rose; there was much expectoration; paracentesis yielded no fluid; pneumococcus in the sputum. Cystitis had developed despite extreme care. Extensive edema of the legs developed. There was increased dulness on the right side, coughing and dyspnea. Death, January 17.
The autopsy showed a bronchial pneumonia of the right lower lobe, confluent, imitating a lobar pneumonia. The left lung also showed extensive confluent bronchopneumonia at the base as well as disseminated areas and edema of the middle and apical portions. Infectious splenitis, large fatty liver, swollen kidneys, no pyonephritis.
The spinous processes of the 6th and 7th cervical vertebrae
According to Roussy, these patients injured in the spinal region are particularly sensitive to cold and support transfer badly even when the disease is short. Such patients should be evacuated to the interior after the shortest delay possible. Sometimes these patients show rib fractures; these are in the posterior portions of the ribs and are due to the fall of the man when struck. It might be possible even that the spinal lesions should through the action of the sympathetic nervous system favor lung infection.
Shell-explosion: Hystero-organic symptoms; decubitus; radicular sensory disorder.
Case 134. (Heitz, May, 1915.)
A soldier, 32, was bowled over in a first-line trench by the bursting of a shell that he did not see coming, September 14, 1914. He regained consciousness only in the middle of the night, finding himself half covered with water. He was taken up by the stretcher-bearers at eleven in the morning. Paralysis in the legs was then absolute. There were pains in the legs and in the back, but there was no evident lesion. Knee-jerks, plantar reflexes, and abdominal reflexes absent; cremasteric reflex absent on the left, weak on the right. Tactile sensations, on the contrary, were almost intact except for a slight diminution over the feet and the external aspects of the lower legs. Sensitiveness to pin-prick, however, was abolished throughout both lower extremities, and diminished in the abdomen and back up to two or three centimeters above the level of the umbilicus; that is, including the territory of the first lumbar and the last three dorsal roots. Sensibility to heat was abolished in the feet, the external aspect of the lower legs, and the posterior aspect of the thighs, but was preserved in the second and third lumbar territory, in the anterior aspect of the thighs, as well as in the region below the umbilicus. Micturition was impossible. Constipation the first few days yielded spontaneously September 20. There were signs in the bases of both lungs, corresponding with a suffocating feeling. September 22, he was evacuated, almost well, without signs of pulmonary congestion, having regained the power of urination and some capacity to move the legs sidewise. February, 1915, after evacuation to a hospital at Vic, he showed sacral decubitus, soon reaching the size of a hand, as well as trochanteric decubitus; traces of albumin in the urine, sacral and sciatic pains (recalcitrant to morphine).
He began to improve December 25. Camphorated oil and the sitting posture relieved the pulmonary congestion;
It is difficult to consider this case only functional in view of the decubitus, to say nothing of the radicular distribution of the sensory disorder. Heitz brings this and the previously given case (No. 1) into relation with Elliot’s case of transient paraplegia (see Case 210) and Ravaut (see Case 201).
Shell-shock (windage?); typhoid fever; “neuritis” actually hysterical.
Case 135. (Roussy, April, 1915.)
A Colonial soldier was sent back from the front, September 12, 1914, for nervous disorder due to the shock of the windage of a bullet. He had not lost consciousness. Under observation at his station, he got typhoid fever, and was cared for at Paris from the beginning of October. About October 15 he began to feel pains in his left shoulder, neck, and arm. The diagnosis, neuritis, was made and was strongly borne in upon the patient, so that upon the cure of his typhoid, he went out on two months’ leave with a complete impotence and much pain of the left arm. At the end of his relief, he was evacuated to Villejuif. January 24, it was found that he had no somatic phenomena whatever, despite the fact that the left arm and a part of the forearm was powerless, and so painful that the patient cried out when his arm was moved. There were a few cracklings in the scapulo-humeral joint.
Hot air and reËducation cured the man in less than two months (March 20), though the disorder had lasted for four months. The patient had been retired for hysteria before the war and had re-enlisted.
Bullet wound of pleura: Reflex hemiplegia and double ulnar syndrome.
Case 136. (Phocas and Gutmann, May, 1915.)
A soldier, 26, was wounded in the enfilading of an Argonne trench December 17, 1914. He felt the bullet like an electrical shock, and fell. He had been leaning forward at the time and suddenly felt the left half of his body go paralyzed and his mouth pulled to one side. He did not lose consciousness, and spat up a good deal of blood five minutes after falling. He lay in the trench all night, unable to move his left leg except by the aid of his right. He was evacuated next day. There was a five-franc piece wound at the upper border of the left scapula, four finger-breadths from the median line. There were a few lung signs which rapidly cleared up. December 28, the hemiplegia was better, although neurological examination showed weakness of left upper extremity, abolition of deep reflexes, and certain skin changes of the left hand with edema (main succulent), decreased resistance of muscles of lower extremity to passive motion, especially of adductors and flexors, exaggerated polykinetic left knee-jerk, ankle clonus, Babinski reflex, abdominal and cremasteric reflexes absent on left, platysma paralysis left, with complete paralysis in the inferior distribution of the facialis; whistling impossible. Also the left eye could not be closed singly. Synergic movements of the lower part of the paralyzed face when the right hand of the patient was grasped.
There were also sensorimotor disorders in the ulnar distribution on both sides, with complete anesthesia to pin prick. There was also an area of hyperesthesia of the anterior and postero-internal aspect of the right forearm from below the elbow to the wrist. The tendon reflexes were weak but distinct on the right side. The left arm had feelings of pain, with Élancements and formication from the shoulder to the fingers on the ulnar distribution. There was, of course, also, local hyperesthesia due to the wound of the thorax.
Lumbar puncture showed a fluid normal in all respects. We deal with a hemiplegia of organic nature, associated with the bilateral ulnar syndrome. The hemiplegia followed the trauma immediately. When the ulnar phenomena appeared is unknown.
The lung complications cleared. The pains disappeared; motion returned up to the level of the facialis. The patient got up and three months later went on convalescence, still presenting Babinski, exaggerated knee-jerk and weak arm reflexes on the left side. The bilateral ulnar syndrome had disappeared six weeks after the patient entered hospital. Phocas and Gutmann cite a considerable literature on nerve complications of pleural trauma, among them syncopes of grave prognosis; a relatively frequent pleural epilepsy (forty-five per cent fatal) or epileptic status (seventy per cent fatal); and the rare hemiplegia. Accidents and death have followed exploratory puncture of the pleura. Air embolism is probably not the cause. Phocas and Gutmann prefer the theory of a reflex disorder starting from the pleura.
Hysterical tachypnoea.
Case 137. (Gaillard, December, 1915.)
A man, 23, came to the LariboisiÈre November 29, 1915, in a hurry to show evidence that he had been invalided for valvular lesion of the heart. In point of fact, the interne found a murmur at the base. Yet there were things in the military papers suggesting caution. The patient next morning showed no malaise, dyspnoea, or any evidence of serious disorder. The contractions of the thorax beat in time with contractions of the alae of the nose, about 112 per minute. Here, then, was a cardiopulmonary patient. The heart impulse was exaggerated; the patient could not or would not stop breathing to aid the auscultation, but almost absolutely normal sounds could be heard at the apex and the base. A valvular lesion could be excluded. The lungs were perfectly normal. The patient was requested to stop his gymnastics, which might have succeeded elsewhere but could not at the LariboisiÈre!
How could the man have established the synchronism of pulse and respiration and synchronous tachypnoea and tachycardia? Why should he persist in this form of sport, since he had already been invalided? The family history was not especially suggestive (father albuminuric, died at 59; mother well, probably tuberculous). Scarlet fever at eight; occupation, tourneur. After four months of service there was gastric disorder followed by typhoid fever (despite vaccination, according to the patient). Convalescent leave at Paris, during which leave he had swollen legs and albuminuria. May, 1915, gastric difficulty; valvular lesion determined; examination; invalided. At home, a variety of complaints, for which treatment was unsuccessful.
During further examination it was noted that in auscultation the head of the examiner was lifted, as if there were hypertrophy of the heart or an aortic aneurysm. The synchronism was less exact on December 2; 112 beats to 128 respiration. Was this man a simulator? Had he become
Soldier’s heart.
Case 138. (Parkinson, July, 1916.)
A corporal, 21, who had been a miner and entirely well up to enlistment in August, 1914, went to France in 1915. In June, came shortness of breath and palpitation on exertion; later, precordial pain (fifth space, between nipple and median line) and giddiness on walking. Like all cases of true so-called “soldier’s heart,” this soldier had no physical signs indicative of heart disease, yet reported sick for cardiac symptoms on exertion. In this particular case, as in about half of forty cases reported by Parkinson, there had been no disability in civil life.
August, 1915, the soldier was admitted to the casualty clearing station, where the apex beat was found in fifth intercostal space internal to the left nipple line. The first sound was duplicated in all areas. The second sound was duplicated, though not loudly, at the base. After nine months’ treatment, this man went back to light duty with slight symptoms.
According to Parkinson, the absence of abnormal physical signs in the heart of a soldier should not prevent his discharge from the army if under training or on active service he shows breathlessness and precordial pain whenever he undergoes exertion well borne by his fellows. A simple exertion test, such as climbing 25 to 50 steps, reproduces the symptoms in such a patient. The rate of the heart at rest is a little higher than that of normal men, though the increase on exertion is greater. Nevertheless, it has been proved that the increase of rate on exertion bears no relation to the symptoms elicited and is therefore without value in judging the functional efficiency of the heart.
Soldier’s heart?
Case 139. (Parkinson, July, 1916.)
A sergeant, 36, had been in the army from 17 to 29, but in 1908 he had acute rheumatism and was discharged from the army. He then became a furnace man and had shortness of breath and palpitation on severe exertion with syncope three times.
He re-enlisted in August, 1914, and had an attack of orthopnea and edema after exposure at a review. However, he improved and went to France in May, 1915, where he again had symptoms; namely, precordial pain and breathlessness on severe exertion. One day while carrying telephone wire under fire, the sergeant felt a sudden pain in the region of the apex beat, shooting down the right arm. “I thought I was shot.” He fell down, very short of breath. His left arm remained sore and weak. Two days later came a similar attack, this time with unconsciousness, and the left arm was now useless. Two days later he was admitted to hospital, where slight breathlessness but no pain and no enlargement of cardiac dulness could be found. No further details are available but it seems clear that this man is unfit for duty. According to Parkinson, it is probable that the infection indicates the presence of some degree of myocardial disease.
Strain and shell-shock: Acceleration of diabetes mellitus.
Case 140. (Karplus, February, 1915.)
An infantryman, aged 22, previously healthy and from a healthy family, was struck by a shell fragment in the forehead and lay for several hours unconscious. He did not vomit. He had a number of furuncles on his body and his urine, upon examination, showed a severe diabetes mellitus which increased despite treatment. Upon an attempt to withdraw carbohydrate, the sugar suddenly sank from six to four per cent. Acetone at the same time increased. An abrasion had been noticed by the patient a few days before the shell explosion on the spot rubbed by the tornister. The patient said that since his accident he had had to urinate every night several times and was often very thirsty, neither of which tendencies had he had before. A month before he became merod he had had an injury of the hand produced by a shell fragment. He had undergone tremendous strain.
The chances are that the excitement and the strain had more to do with the diabetes mellitus than the shell explosion.
Dercum’s disease.
Case 141. (Hollande and Marchand, March, 1917.)
An adjutant in a chasseur battalion was buried by a shell explosion, which killed his lieutenant beside him, January 5, 1915, at Hartmannsweilerkopf. Hematuria followed; ten days later, fever with anorexia, and the appearance of two or three lipomata on the anterior surface of the thighs. Remaining at his post, the adjutant took part in an attack, March 5; was evacuated on the 8th; “lipomatosis with febrile reactions.” He spent eight days at Bussang, and thence went to the hospital at Pont-de-Claix. Here marked albuminuria was noted; the lipomata increased in volume; others appeared in the arms. The patient was transferred to the Des-Genettes, where the diagnosis nephritis was added to the previous diagnosis, and a milk diet was prescribed. Convalescence of five months was proposed. The lipomata increased in volume and in number. The patient was then hospitalized at Avenue Berthelot, placed in the auxiliaries, and stationed eight months at his dÉpÔt.
When he was observed by Hollande and Marchand, four nut-sized tumors were found on the anterior surface of the left thigh; two smaller tumors: one of them painful to pressure, lay on the inner aspect, another the size of a small egg lay in the right thigh, and there were two others on the internal aspect and two on the external aspect of the thigh. A nut-sized tumor was found on the inner border of the right forearm, and below it another lenticular tumor. A nut-sized tumor was found on the left forearm below the elbow on the internal border. Small tumors were found on the buttocks. There were no tumors below the knees, in the upper arms, or on the thorax. There were 14 tumors in all. The smaller the tumor the more sensitive, and there was more pain when the tumor had just appeared and during the first days of its growth. There was no spontaneous pain; pain only upon a blow or pressure. Diminished knee-jerks, especially the right; no other neurological disorder, although the patient complained of often having something before his
Hyperthyroidism.
Case 142. (Tombleson, September, 1917.)
A private, 22, was selected by Col. Garrod for hypnotic treatment by Tombleson from among the hyperthyroid cases. He was admitted April 3, 1916, with a typical hyperthyroidism, with manual tremor, enlarged thyroid, pulse 120, blood pressure 136-40, and hemic murmur. Tombleson induced deep somnambulism at the first hypnotic sitting and suggested an increase of nerve strength and steadiness. The suggestions under somnambulism were repeated for ten days. An occasional added suggestion was given as to lessening of the thyroid. At the end of the ten days the patient declared himself quite well.
Eight of twenty consecutive functional cases treated by hypnotism by Tombleson were cases of hyperthyroidism and in virtually all of these an effect like the above was registered.
Shell-shock; thrown against wall, stunned, emotional: Paroxysmal heart crises six days later, observed for two months. Neurasthenia? Mild Graves’ disease?
Case 143. (Dejerine and Gascuel, December, 1914.)
An infantryman, 29, was sent to auxiliary hospital No. 274, for heart trouble, a little thin but looking vigorous enough (typhoid fever at 13 and some diseases of unknown nature and of brief duration while in military service).
September 24, a large calibre German shell burst and threw him against a wall, producing no wound or contusion. He was momentarily stunned, emotionally much affected, and noted at the time extreme palpitation. He was evacuated to Paris September 30, six days after the shock. His pulse was 130-134, regular, and the heart seemed not to be anomalous in any respect.
But there were paroxysmal crises in which the pulse rose to 180 and in which the patient fell into a state of great anxiety. The mouth temperature in the midst of such crises would always rise to 38°, and this temperature would outlast the rest of the seizure. The man was mentally depressed and apparently indifferent, preoccupied with his heart and his insomnia, but at the same time emotionally easily affected. In short, he was a neurasthenic. There was no change in mental state, tachycardia, or paroxysmal seizures in two months, except that he gained weight. Walking and climbing stairs produced dyspnoea. Urine was negative. According to Dejerine, such a case should be treated by psychotherapy.
Alquier, in discussion, called attention to the slight but distinct tremor in this case, dermographia, and spells of perspiration. He suggested that the case might be one of mild Graves’ disease.
Hyperthyroidism three months, following ten months’ service, at times under protracted shell fire.
Case 144. (Rothacker, January, 1916.)
A man in service ten months, under strong excitement and at times under protracted shell fire, complained of palpitation, insomnia, dizziness, and dyspnoea. Hospital notes showed that the left lobe of the thyroid was somewhat enlarged. Before the war his neck could not have been very thick; he had served his year out without difficulty. His mother is said to have suffered at one time from thick neck. According to the patient, he had never suffered with heart trouble. Heart not enlarged; blowing first sound over the apex. Graefe, Stellwag and MÖbius signs negative. Heart rapid, not irregular; pulse strong. There was fine tremor of the hands, as well as a tremor of the tongue. Knee-jerks increased.
The patient was at first sleepless and excited, but after three weeks in bed the heart murmur had disappeared. After three months, he was ordered to Ersatz with the left side of the neck measuring 20 as against 18 cm. on the right. There was a soft pulsating swelling of the thyroid. First sound over apex still impure; heart action now regular; pulse 64; blood pressure 120 Riva-Rocci; after test exercises, slight dyspnoea. No cyanosis. The outstretched hands were no longer very tremulous. The knee-jerks were still increased. The man had begun to sleep well. His neck was apparently much diminished in girth.
Here then was a case of Graves’ disease of acute development, brought out by nervous stress and excitement as well as by 10 months of war work and exposure to shell fire,—with approximate recovery after three months of rest.
Graves’ disease, forme fruste.
Case 145. (Babonneix and CÉlos, June, 1917.)
A farmer, 31, entered the Rosendael Hospital, Jan. 25, 1917. He had been two years in active service. The family history was negative except that one of his sisters had had dyspepsia. The patient denied venereal disease and alcoholism and had always been well. At the Battle of the Marne he was slightly wounded in the left knee. January, 1915, he was exposed to gas bombs and explosive shells. He was several days in the hospital spitting, or perhaps vomiting blood and was sent on a long convalescence. On returning to the front, he had to be sent back to hospital with a note, “not fit for service, nervous troubles and paroxysmal tachycardia.” In point of view he now showed a number of symptoms suggestive of Graves’ disease, such as a definite exophthalmia which, according to the patient, started up a short time after the shock and a tachycardia (110-120) with circulatory excitement, a tumultuous heart, neck arteries contracting, almost dancing in their contractions, together with a systolic murmur maximal in the pulmonary area, not retaining, variable,—in short, suggestive of an inorganic murmur. There was also a generalized rapid tremor and a variety of vasomotor disorders, such as blushing and paling, perspiration, exaggerated reflexes, emotionality, logorrhea, jactitation. There were also digestive troubles, regurgitation after meals and the patient had become thin and weak.
There was, however, no swelling of the thyroid gland nor any eye signs other than the exophthalmia. In short this case is doubtless one of the forme fruste of Graves’ disease. It seems to show that Graves’ disease may have a traumatic origin.
Somatic complication in a shell-shock hysteria (Trauma).
Case 146. (Oppenheim, February, 1915.)
Musketeer. No faulty heredity, but was always somewhat nervous. On October 26, a shell burst one meter in front of him, burying him under the anterior wall of the trench. He was dug out and taken to the field hospital, where he remained unconscious until the next morning. On October 29, he was taken to the reserve hospital. Severe pain in the head, entire scalp tender on pressure, especially in the left frontal region, left side upper lip swollen, bluish and discolored. Left tenth and sixth ribs broken. Fracture of skull(?). November 10, at eight o’clock at night, sudden attack of vomiting, and the patient was found in a faint in the water closet. Almost complete paralysis of speech and all of the four extremities. Consciousness obscured; no sensory disturbances. November 11, severe headache and vertigo. Speech somewhat more intelligible. Pulse, 60 to 68. “Evidently secondary hemorrhage in the brain.” November 12, to Augusta Hospital. November 20, admission to nerve hospital. Typical aphonia. Limitation of motion in all four extremities, but no paralysis—anergy. Reflexes normal. Unable to stand and walk. Sensibility preserved. Under suggestive treatment, curative gymnastics, as well as electrotherapeutics, the aphonia and abasia disappeared in a few days, but the patient continued to complain of headache and insomnia. December 16, an attack of nausea, headache, vomiting, loss of consciousness, followed by epistaxis, marked tachycardia. January 4, in his sleep he felt a prick in his left upper arm, as if he had pushed a sewing needle into the arm. X-ray examination showed a needle in the arm. This was extracted under local anesthesia.
(DEMENTIA PRAECOX GROUP)
The Sister’s ear boxed for blow to a German soldier’s pride: Diagnosis PSYCHOPATHIC CONSTITUTION! A true psychosis develops: hate of Prussia and the Junkertum: Diagnosis, DEMENTIA PRAECOX!!
Case 147. (Bonhoeffer.)
A sick soldier in a military hospital kept complaining of being waked up too early, and of poor food. His reactions looked like the irritable weakness of a psychopath. One day he went into a room where a woman was being examined, without knocking. When ordered out, he boxed the Sister’s ear.
He said himself, on transfer to the psychiatric clinic, that he had always been quarrelsome as a child with his brothers and sisters, subject to fainting spells, and poor and stubborn in military service,—all of which seemed to clinch the diagnosis of psychopathic constitution.
But he seemed to show a decided lack of autocritique. About boxing the Sister’s ear on her saying “Please go out,”—his idea was that he could not let a thing like that happen to him,—a German soldier and a patient! Moreover, “It should not be thought that perhaps I had a love affair with her! There was a cynicism about her.” The Sister had a strong sex impulse, he could see that by her nose: she was, so to speak, “hypochondriacal.” Both in speech and writing he used stilted phrases. The ego at last swelled to the point of his saying that he was an inhabitant of the World and hated Prussia and Prussian Junkertum.
Then came unmotivated states of excitement, with pressure of speech and motion, and eventually negativism. Accordingly, the diagnosis hebephrenia finally replaced that of psychopathic constitution.
Dementia praecox, arrested as spy.
Case 148. (Kastan, January, 1916.)
A German private, called to the colors, was supposed to take his civilian clothes to the post office along with his comrades on March 21, 1915. He did not get his package ready in time and was ordered to go with another troop. At an opportune moment, he left the barracks with the package of clothing. When later arrested, he said that he had gone by railroad to Dirschau; then he had visited Berlin. After this, he had walked to Bromberg, SchneidemÜhl, and Landsberg.
At last he had ridden back to KÜstrin. At KÜstrin some children told a railway official that the man was making drawings. There was a petroleum tank near by. Accordingly, he was arrested as a possible spy. He claimed that he was not a soldier.
In the clinic, he looked dull and smiled a good deal. It seems that, before being called to the colors, he had been very angry with his wife and had even threatened her. He now explained this anger as his wife’s fault. She had attacked him, he said. He said that he sometimes had attacks of weakness, which used to last two days at a time, but they had recently lasted for a shorter time. He said that his thoughts always wanted to be somewhere else. In fact, he had not performed military duty. His uniform had been gotten for him, but he had had no further orders. Sometimes in a fever or dream his head seemed to be as big as a room, as if there were no space for it. There was an itching in his legs, he said, which often fell asleep so he could not stand on them. He had had syphilis seven years before, after which he had been hoarse, forgetful, and anxious.
Examination showed perceptive power and knowledge to be good. He played the violin, but always the same tunes. He said that he had not worked in Berlin during the winter of 1914. He spoke as if he had been in another sanitarium, where he did nothing but dream by himself, taking no interest
He said that when he received the uniform he had a longing for clean underclothes. Requested to explain the meaning of the uniform, he remarked: “Why, many have these things on.”
Re dementia praecox, LÉpine states that in the French army instances of dementia praecox have been numerous in the interior, both at the time of mobilization and at the time of calling out sundry new classes. He notes that the courtmartial and invaliding experts have neither the leisure nor the experience necessary to keep these men from going into the army. The somewhat frequent remissions in dementia praecox make the task all the more difficult. To be sure, the stuporous and catatonic cases are not very much in evidence in the army; when such cases do occur, it is easy enough to evacuate the patients to a hospital for observation. Far more troublesome are cases of a less advanced or milder nature. Here are cases in which judgment is deficient, and in which quite unsystematic, incoherent, and transient delusional ideas occur. The patient looks quite normal to the non-psychiatric expert. Something odd happens which quite suddenly reveals the delusional ideas. For example, there is a fugue, or else the soldier goes to his superior and aggressively chides him for having troubled him the night before. These particular psychopaths are among the most dangerous to be found in the army.
Fugue, catatonic.
Case 149. (Boucherot, 1915-6.)
A gunner, aged 23, enlisted on the expiration of his regular period of service and was a good soldier, in excellent health, up to June, 1915. He then began to have a few vague ideas of persecution. In a short time these became more definite and he caused talk by requesting to go into another corps because his comrades did not like him. He told his brigadier that the soldiers were frightening him by magnetism. He had hallucinations of hearing people say, “He will get it.” He kept by himself, would not eat and stood motionless for long periods of time before his mess-tin. He was often found in a dreamy state of apathy. One day he left the cantonment without leave, wandered through fields, had coffee in a village and then started off in no special direction. The police took him without resistance the next day. He said, “My comrades are in politics; they are going to cheat me.” He was brought to Fismes and the ambulance surgeon said that he found he did not know what he was about. He was amnestic for the fugue, explaining that he went because he was frightened. It was hard to get him to eat.
July 14, he was evacuated to Fleury protesting arrogantly, but this phase of excitement passed and he became absolutely indifferent and disoriented. He became untidy in his person and in no way could his attention be attracted whether by mentioning his family or the war. He sometimes made ape-like grimaces and sometimes laughed causelessly. He was occasionally negativistic, but in general was perfectly compliant with the requirements of the hospital. Now and then he started off impulsively to escape but was brought back quite indifferent. Now and then he went into bizarre contortions on a medical visit or aped gestures of bystanders. He began then to go into stereotypical attitudes. This case is the only catatonic one found by Boucherot in his war group.
Desertion: Schizophrenic-looking behavior. Adjudged responsible.
Case 150. (Consiglio, 1915.)
An Italian private in the artillery, a telephone operator at the front, came up for desertion in the face of the enemy. It seems that he had often left his post, going off for a number of hours and drinking. At last he lost his position in the battery, went off and got drunk again, and was removed to a hospital and held as a neurasthenic and psychopathic patient. At the territorial hospital he was regarded as a melancholic. He still showed signs of alcoholism, was hallucinated, did a number of peculiar things, was impatient of medical examination, and was given a furlough of two months for convalescence. He apparently grew somewhat better in his father’s home, but went to a physician there and presented his certificate as a mental case. His behavior was so peculiar on subsequent arrest that he was sent for observation to Consiglio.
It appeared that he had been in military service from August, 1912, and had been imprisoned for a space of eight weeks for disobedience when he had been in military service for six months. He had been punished in the army nine times, once being given 70 days for lying. He was regarded as an undisciplined soldier but not as a nervous or mental case.
At hospital he was in a semi-stupor, claimed that he was forgetful, was apathetic concerning home and relatives, complained of pain in the head, and altogether preserved a strange and stolid attitude with occasional gestures, mimicry, and stereotyped reactions. As he had come to be operated upon, he looked about for the cannon that was to be used in the operation. Accordingly the question of dementia praecox might well be raised.
His indifference turned out actually to be assumed and pretentious. He preserved throughout an arrogant tone, and there were features in his voice that strongly suggested simulation.
According to Consiglio, we are dealing with an epileptic degenerate, addicted to alcohol, lying, and immorality. The question concerning responsibility was settled in the affirmative. Of course, it might be thought that the case was one of pathological intoxication, in which case, the man might be regarded as only semi-responsible. However, the phenomena of simulation, not merely in the observation hospital but also in the period of apparent depression and strange conduct immediately following his arrest for desertion, led to the decision that the man, despite his nervous abnormality, was responsible for his act. He was condemned to 20 years in prison.
Re dementia praecox, Buscaino and Coppola found a number of cases of dementia praecox amongst soldiers admitted to hospital during the period of mobilization; cases amongst men who had not yet been at the front. These mobilization cases, in fact, were as a rule either cases of dementia praecox, cases of a psychopathic constitution, or cases of alcoholism.
A disciplinary case: Schizophrenia, alcoholism.
Case 151. (Kastan, January, 1916.)
In October, 1914, a German soldier returned to his barracks late from a drinking bout. He insolently called for order, brandishing his arms, and when the captain rebuked him, he kept a cigar in his mouth. Examined in hospital (Allenberg), he was very reticent at first but wrote his name up over the bed with the additional word “Dead.” He answered, “I don’t know” to most questions. Although it was December, he said the season was summer. He was to be shot for disrespect, he said, but showed more disrespect at every remonstrance. “What is your regiment?” “I am no soldier at all, you know. I have already been discharged as unfit for service.” “Have you been in prison?” “I don’t know. My father often thrashed me.” Then suddenly, after a moment, “I was in prison five, seven, and two years, and my father was in prison four, six, and three years.” He said that he had drunk ether and urged the physician to try it, as one saw all sorts of beautiful pictures and figures and heard music.
Upon investigation, it was found that the man had been in a provincial sanatorium for some form of degenerative mental disease with excitement. He, at this time, had given a number of fantastic stories concerning his wanderings. For example, he said he had come from Australia, where he had eaten snipes and crows; that he was on his way home and would get there in half an hour (real distance 10 hours). Or again, he would roll his eyes, assume a false name and say that he had come from Morocco, or that he was the emperor and would not play soldier. When asked to repeat digits, he habitually omitted the last digit. He had been a poor scholar, and of a tricky and treacherous character.
Despite this history, he had behaved well in the army at first, though insolent to superiors. On July 5 he had a heavy drinking bout, and wrote next day to his mother that he was going to commit suicide. At this time he had been put for safe keeping in a cell, where he saw foxes making as if to bite
We are evidently here dealing with a psychopath of schizophrenic tendencies, strongly colored, however, by alcoholism. The patient’s father was a drunkard, and a brother and sister were insane.
Re schizophrenia in the German army, Saenger remarks that like paresis, so also latent dementia praecox becomes acute under war conditions. E. Meyer states that amongst 1126 officers admitted to his hospital, August 1, 1915, there were 352 that had either psychoses or neuroses, amongst which were 148 psychogenic cases (either psychopathic or hysterical), 128 with what he terms a congenital psychopathic diathesis, and 76 with traumatic neuroses. The cases of congenital diathesis were somewhat difficult to diagnose, since but 44 of these were clearly psychopathic and in the remainder the question of dementia praecox or of cyclothymic conditions arose.
Stier gives statistics for 1905 and 1906 in the German army, namely 35 per cent of dementia praecox cases. Under war conditions the army has developed far fewer cases: Bonhoeffer, 7 per cent; Meyer, 7.5 per cent; Hahn, 13 per cent. But although dementia praecox figures so much less frequently in the mobilized army than in the army of peace times (manic depressive psychosis is also less in evidence under war conditions), the psychopathic constitutions, hysterias, traumatic neuroses, and the like, run from 17.5 per cent (Stier, 1905-1906) to 54 per cent (Bonhoeffer), 37.5 (Meyer), 43 per cent (Hahn).
Schizophrenic symptoms. Aggravation by service.
Case 152. (De la Motte, August, 1915.)
A Landsturm recruit, 20, and somewhat peculiar in early life, got whipped by his comrades for getting back too late from leave. The next day he was commanded to carry a machine gun. He threw the gun down and made for the barracks. He was put under psychiatric observation, as he said he did not know what he was doing. His conduct seemed normal at first and he explained that he had heard noises and singing in his head,—pointing to the left ear where there was an otitis media. His skill, knowledge, and general experience seemed well in hand. However, he was not very communicative. Eventually a series of schizophrenic symptoms came to light. He had been hearing threatening voices of varying intensity for two years, sometimes a veil seemed to be before his eyes, sometimes he heard his thoughts, and felt that his whole personality was changing. He began to think that his facial traits were gradually turning into those of the physician. The hallucinations were so insistent that sometimes he did not know what he should do. He was evidently unfit for military service, and the decision was also made that the mental disease had been aggravated by service.
Re schizophrenia in the service, most authors point out that there was either patent or latent schizophrenia before mobilization. E. Meyer attempted to make a study of the influence of the war on psychopaths. He found that the ego of the psychopath remained relatively unaffected by the war. Naturally, the paretics and the seniles were unaffected. The grandiosity and self-centredness of the alcoholics remained as prominent as ever. Seventeen schizophrenic cases were studied, and some of these yielded entire apathy with respect to the war; others had the content of their delusions somewhat affected. Saaler remarks on the military tinge which dementia praecox assumes under war conditions. Dementia praecox and manic-depressive psychosis alike show war changes.
Shot himself in hand. Delusions.
Case 153. (Rouge, 1915.)
An infantryman, 26, left for the front August, 1914, was slightly wounded, recovered, went back to the front, and then is said, in March, 1915, to have shot himself in the hand. When up for military review a delusional state set in. It seems that he had been interned in several hospitals for examination, but escaped four or five times because physicians wanted to poison him and had partially succeeded.
He came to the Lemioux Custodial Institution, July 12, 1915. His brother, 15, was a voyou; his sister, 16, was an imbecile. The patient told about his military history and how he had shot himself in the left hand, to be with a certain woman, how attempts had been made to poison him, especially a certain man in Bordeaux, who wanted to possess the woman in the case. In point of fact, the physicians could not save him from this enemy.
The patient now became calm and indifferent, lived secluded and almost immobile. In November, however, he began to sit down and eat like others, making low, timorous answers, vague and confused. He smiled cheerfully on questioning, but had many sad ideas. He would smilingly say that he was going to die soon.
Re schizophrenia in the French army, Boucherot found eight cases amongst 107 soldiers admitted to Loiret in the first year of the war. He remarks upon the fact that the schizophrenic cases were often disciplinary. The group is a disciplinary group. Damaye remarks upon the difficulty of diagnosis betwixt feeblemindedness and dementia praecox as observed in the French army.
Volunteer: Dementia praecox.
Case 154. (Haury, 1915.)
N. enlisted voluntarily for three years in the Infantry, September 10, 1912, and immediately gave indications of abnormal mentality by his conduct. He made mistakes all day long. At reveille he had to be called several times, and when his corporal objected, he said, “It is cold; I don’t see why I must get up; I am free to remain in bed until 8 o’clock.” In reply to his corporal’s remonstrance about his continued latenesses, he once said, “I can’t get ready; I have no mirror to wash before.” This was rather surprising conduct from an intelligent printer-engraver, who had lived and gone to school in the town of Lyons. He was unable to make his own bed or to perform the simplest of exercises in the manual of arms. He was violent on several occasions, once attacking a comrade who had given him an order, and again when another had taken his place in the line. His reasoning faculties were those of a young child. He continued doing these strange things, and was finally discharged.
Re dementia praecox amongst American troops, Edgar King, before the war, concluded that some 5 to 8 per cent of the American cases of mental disease in the army belonged to the paranoid form of dementia praecox. King lays special emphasis upon dementia praecox, finding that more than one-half of the army admissions for mental disease belong to this group. He calls attention to the number of desertions and undesirables in the group. He found that 70 per cent of the cases showed some heredity.
Hysteria versus catatonia.
Case 155. (Bonhoeffer, 1916.)
A reservist, 31, was in the hospital about Christmas, 1914, for rheumatism, when suddenly he became excited and was sent to the CharitÉ Psychiatric Clinic. He was restless all night, moving about in bed, grinding his teeth, and continually getting up. He had a blank and astonished expression; his breathing was rapid and forced. There were no pyramidal tract symptoms, but muscular power was diminished,—more on the right than on the left. While the knee-jerks were being tested, the legs moved (seemingly psychogenic). Irregular hypalgetic zones were found, and pain was less well felt on the right side than on the left. Answers to questions on mental examination were made with the appearance of effort, the patient breathing deeply and rapidly, head drooping, forehead wrinkling, and eyes glancing about in an astonished way. “How many legs has a horse?” After long cogitation, the man counted slowly,—1, 2, 3, 4. “What’s your wife’s name?” “Marie—Marie, I think.”
In the interpretation of this case, the functional paresis and hypalgesia of the right side, the functional pseudoclonus obtained during the knee-jerk test, the mental situation,—rather suggestive of a hysterical pseudodementia or a “Ganser” dazed state,—make the probable diagnosis at first sight psychogenic. Left to himself, however, the patient assumed a stereotyped unchanging posture; he would suddenly cry out, without particular emotion, that he was to be shot or executed; there was a tendency to rhythmic repetition of certain answers to questions, with the suggestion of perseveration.
After a time, pronounced rhythmic, and then stereotyped, movements started in. Suddenly negativistic phenomena, with refusal of food and self-accusatory ideas set in; speech stopped altogether. Information from his relatives showed that he had been peculiar for some time and had for years occasionally said that he was going to be shot.
Here then, instead of a hysterical pseudodementia, was a case of hebephrenia or perhaps catatonia. Possibly there had been no pseudodementia, but actually an elementary disorder in the associative process. Possibly the defects which the patient early showed, in his responses, for example, were really genuine schizophrenic blocking.
According to Lewandowsky, almost all cases of neurasthenia, of hysteria, and of the so-called traumatic neuroses, stand out very clearly as functional. Bonhoeffer is far less certain that the diagnosis can be made readily in all cases. Antebellum conditions have not been continued in wartime; hysteria was a female affair antebellum, but under war conditions, it is found necessary to draw many differential diagnoses in the male betwixt schizophrenics, epileptics, and psychotics, on the one hand, and hysterics on the other.
Re the so-called Ganser symptom, Hesnard has dealt especially with the value of what he calls the symptom of “absurd answers,” finding the differential diagnosis between dementia praecox and simulation particularly difficult. Hesnard states that incoherence is very hard to simulate. The answers of the Ganser patient are not always incorrect, and not always absurd. The patient strikes one as intact except for the absurd answers; intimidation and other external conditions affect the symptom greatly. Drugs are refused by the Ganser patient.
“Hysteria”—actually dementia praecox.
Case 156. (Hoven, Henri, 1917.)
A shell burst about twenty-five meters away from a soldier, 21, but he continued in the military service thereafter for one month, having only one symptom, a trembling of the arm. This persisting, he was evacuated to Calais, then to Dury to the hospital for the insane where he stayed six months. He was transferred from Dury to the Belgian Hospital for the Insane at Chateaugiron on August 20, 1915. He remembered nothing of his stay at Dury, Calais, or of anything that happened after the shell-shock. He had no complaint and wanted to go back to the front. He was well oriented for time and space and had no disorders of association or perception. Besides the persistent, retrograde amnesia, he showed certain neurological disorders, occasional slight vertigo, a generalized tremor especially affecting the arms but disappearing almost completely at rest, lively tendon reflexes, intense dermographia and cardiac erethism. Diagnosis was made of acute, convulsional psychosis with agitation, convalescent phase.
During March he was quiet and worked about the hospital. In April the patient had a number of seizures of an hysterical nature. In June it was possible to evacuate him to full convalescence. He went back to the front and stayed there, but shortly developed catatonic signs with visual hallucinations and delusions of persecution of a non-systematized nature, such as poisoning, being magnetized, etc. He was at this time poorly oriented for time, assumed bizarre and theatrical attitudes, showed Ganser’s symptom, was oversuggestible and agitated and sleepless. Diagnosis of dementia praecox was now clear.
Hoven remarks that this case is important in that it suggests that a diagnosis of hysteria may easily be mistaken.
Influence of war experience on the content of hallucinations and delusions.
Case 157. (Gerver, 1915.)
In one of the divisional field hospitals Gerver examined a patient with a very vivid paranoic condition. The following were some of his hallucinations and delusions:
The patient asserted that everyone considered him a spy. Voices continually told him: “You are a spy.” “What? Spy? Caught? What?” “You will be shot by the Germans for espionage.” About three months before his present trouble, the patient had been wounded in left shoulder by a fragment of a large projectile. The wound healed and examination showed a big scar with attachments to the bone. The patient asserted that now he could not touch anything with his left hand, as there immediately go from it “some currents” to the Germans in the trenches and they at once begin shooting at the Russian position. Later, the patient could not even look in the direction of the German front, for all he had to do was to throw a glance in that direction and the Germans would at once begin a bombardment.
All these phenomena he explained as being due to the fact that the fragments of the large projectile which entered his shoulder were poisoned and charmed. Through these fragments there went currents from his hands to the Germans. The patient always supported his left hand with his right, in order not to touch anything with it. He slept only on his right side, so as not to touch the bed or floor with his left hand. During the examination and conversation the patient tried always to look downwards, so as not to throw a chance look in the direction of the German front and call out their fire.
An Iron Cross winner had a hysterical-looking attack (reminiscence of a bayoneted Gurkha). Later he begins to talk of “this damned war that is so vulgar” and of “atrocities, concrete and abstract”: Shortly the diagnosis, hebephrenia, had to be made.
Case 158. (Bonhoeffer, 1915.)
An Iron Cross winner, 21, in the field from August, 1914, to the middle of March, 1915, at first in France, later in Russia, finally went to hospital for rheumatism and sciatica. Three months later he had to be transferred to the CharitÉ in a state of delirious excitement.
The attack began suddenly. He thought he was in the field telephoning with his captain, trembled, threatened to injure people about him, said he could not hold the position with the few men he had, and the like. Next day he quieted down and became oriented for time and place. He explained that he had seen a Gurkha coming upon him with a mallet, by way of revenge upon him because he had stuck his bayonet in the Gurkha’s breast. Behind a little hill he had seen Frenchmen and Englishmen, from which he drew the conclusion there was going to be an attack that night. A little cloud of dust he thought was enemy cavalry. In point of fact, he said he had once on patrol stuck a Gurkha through and the Gurkha’s eyes had since followed him in his mind. He had seen him crawling along the ground one evening and heard his step. The patient had imperfect insight into these hallucinations when questioned about them during the daytime, and still talked somewhat as if the experience was a real one.
At first the situation seemed probably one of hysterical delusion, for which the Gurkha experience served as material. In point of fact, further observation in the clinic showed that the diagnosis of hysteria was wrong. He was induced to write out his experience in a style quite like his conversation; and there was a queer tendency in his writing to the use of
He frequently said he wanted to get into the field again, giving vent to superficial phrases, such as “atrocities, concrete and abstract,” and “this damned war that is so vulgar.” Yet a few minutes later he would say he wanted to go to war at Amsterdam as Amsterdam had pleased him very much. He said he now had a good many thoughts and ideas which formerly he had not had. He had not been promoted, he said, because he had once angered an officer in another company.
His field hospital history told of certain oddities, such as his lying stiffly in bed heedless of what was going on about him, falling into causeless depression, failing to sleep, and wandering about.
As to previous life, only his own data were available. He had been a moderate scholar, had been rather irritable and thought a peculiar character. In the ward, he showed baseless antipathy to certain patients and said they were well. He seemed to have no insight into his condition, yet wrote in a letter that the insane state in which he was had very much “augmented his mental organism.” The diagnosis of early hebephrenic disorder could now be considered established.
Occipital trauma. Mystical visual hallucinations and explanatory delusions.
Case 159. (Claude, Lhermitte, Vigouroux, 1917.)
A soldier, 33, single, was wounded in the right occipital region by a shell burst September 25, 1915. There was no sign of focal lesion, but a trephining operation was done, which healed perfectly. No disturbance of vision ensued. The soldier was sent to convalesce two months after having been examined by P. Marie at the SalpÊtriÈre. He went back to his regimental station and was put into the auxiliary service April 26, 1916.
In the early days of September, that is to say, a year after his injury, he had a vision. Above the church cross at Chantenay, where he then was, he saw a rainbow-colored bird, passing slowly in the sky. He lowered his eyes and the apparition followed and was projected on the white walls around him. After some time it disappeared. The soldier himself wondered whether his brain injury might not have something to do with the vision, but none of his comrades wounded in the head had had any such vision. So then he thought of tobacco, of which he was a moderate user, and stopped smoking, but the vision returned in the same intensity four months later. On examining the bird’s face carefully, he found that it was the Holy Virgin’s. In dreams he also had analogous visions and in the dreams the Holy Virgin spoke to him, but what she said he did not remember. The bird’s head did not speak to him. The soldier was now convinced that it really was the Holy Virgin who had visited him in the form of a bird. He remembered that he had asked Notre Dame de Lourdes to protect him on the day when he was injured. He had, in fact, eaten a bit of cheese that day upon which he had inscribed a prayer to the Holy Virgin.
Sometimes he saw a red globe shining like a church lamp; sometimes white or black ladies descending from the sky; sometimes other visions. Now the Holy Virgin was to direct
Were there auditory hallucinations? If so, they were only episodic and took no part in either the construction or the fixation of the man’s delusional system. Thus, a voice once said to him, “All is not lost. You will be ——.” May 25, 1917, he entered the neurological center at Bourges.
As to the interpretation of this case, it seems that the patient’s mother had crises of depression which at one time caused her to be interned in the CharitÉ. The contributors of this case do not believe that there can be any causal link set up between the mystical delusions and the brain injury.
As an auxiliary the soldier has a right to twenty per cent compensation for his head wound with loss of substance without bulging of the dura mater. Of course, as an insane person he must be retired. The aggravating or accelerating part played by fatigue, emotion and cranial trauma must, from the standpoint of compensation, be taken into account.
Shell-shock dementia praecox.
Case 160. (Weygandt, 1915.)
A subaltern who had been in the service since 1909 was on patrol under shell fire from the enemy, but shortly thereafter came with his detachment into the zone of the German fire. Six men, two steps away from him, were killed by a shell. The officer remained stationary with the rest of his detachment until darkness set in, then returned, made his report in due order, but thereafter tremors set in over his whole body and he lost consciousness. He was carried to the hospital and on the way met his best friend whom he did not recognize. Arrived at the hospital he was unable to give answers to questions or obey requests for two or three hours. He thought he was hearing calls, commands and a dull drÖhnen. If an automobile passed he was frightened and cried, “Auto! Auto!” He remained subject to inhibition, anxiety and insomnia for a long time; pulse accelerated; visual fields somewhat contracted for red. Face asymmetrically innervated and dermatographia. Sent to the reserve hospital, he was still apprehensive, especially at night, but in the course of a few days became perfectly tranquil. Only if he took part in the singing of war songs did he feel transient sensations in his knees.
Here is a case of psychic shock with many traits, such as inhibition and hallucinations, suggestive of dementia praecox. The Abderhalden reactions (cortex, white matter, testes, not thyroid) all, according to Weygandt, are suggestive also of dementia praecox.
Shell-shock dementia praecox.
Case 161. (Dupuoy, 1916.)
A machine gunner, 23, was the sole survivor, March 18, 1915, of the explosion of a large calibre shell in a block house containing ten men. He worked himself out of the dÉbris and came to Dupuoy’s attention in September, when an extension of leave was asked for him.
There were two groups of symptoms; persistent headache, painful hyperacousia, vertigo, tremulous walk, cervical spinal column stiff and painful both spontaneously and to pressure, muscular weakness, tremor of hands, hypesthesia of extremities especially upper, exaggeration of tendon and bone reflexes with tendency to ankle clonus and patellar clonus, sterno sign lively, frequent nosebleeds (two to four times a week), profound sweating, unequal pupils.
On the mental side it was clear that the man’s character had changed, according to information supplied by the mother. Aprosexia, impairment of memory, recollective and retentive, inability to give age, birth date and similar data. Words came with difficulty. Some disorder of comprehension; stereotyped replies; negativism; indifference; he would sit hours in a chair or on a bed silent and inactive. Fixed attitudes; dull glance; eyelids half closed. In short, it seemed as if this patient was a case of catatonic dementia praecox.
Re dementia praecox and shell-shock, Stansfield remarks upon the similarity of certain symptoms found in Shell-shock to those of dementia praecox; for example, apathy, retardation, amnesia and speech defect. According to Stansfield, one often gets the impression in a Shell-shock case as though the trench and shell fire stress had merely brought out a latent dementia praecox.
Re his new “sterno” sign (sternomastoid contraction on percussion of neck at level of third dorsal vertebra), Dupouy claims it negative in normal subjects, positive in concussion, meningitis, and general paresis.
Shell-shock; fatigue; fugue; delusions. Recovery.
Case 162. (Rouge, 1915.)
A sergeant, 40, had had nineteen years of service and had been married five months when he was recalled to the colors when war broke out, and sent to the front. March, 1915, he was exposed to bomb explosions during a very intense bombardment. He then got into the way of saying that he was akin to everybody. April 20, he was evacuated on the score of general fatigue, rejoined the company May 17, left his comrades at the end of June, and was taken up as a deserter by the police, who, observing his state, brought him to a hospital. He there showed “cerebral overexcitement” with “incoherence and nervousness.” In two or three days he was much better. He was evacuated on the sixth day to the hospital at Vichy.
There was amnesia for the fugue and he could remember no further back than the extraction of a tooth at the Vichy hospital. In fact, he attributed the fugue to this dental operation. His wife took him home, but he soon threatened her with a revolver; got better in the night and next day went about apparently normal, buying things, however, extravagantly. His delusional state began once more, and two days later he was brought to Limoux. It seems that, while in Mauretania, he had formerly shown signs of mental disorder, having a mania for wireless and airplane inventions and the like. A cousin-german had also been in a hospital for the insane twice, recovering each time. There was a lingual and manual tremor. The man had not been recently alcoholic. He was a little irritable and showed a little megalomania, but worked hard and made himself useful. He went out, recovered, November 12, 1915.
Analysis indicated that this sergeant received a moral shock as a consequence of his fatigue and the shell fire, which emerged in a spell of confusion. It may be that his predisposition had something to do also with this spell and the fatigue. In any event, it seems as if the latter phenomena were not all assignable to war stress.
(THE MANIC-DEPRESSIVE GROUP)
A maniacal volunteer.
Case 163. (Boucherot, 1915-6.)
An Alsatian became the object of much attention when he enlisted at the outbreak of the war in the infantry at the age of 59. He was interviewed and soon became more than naturally exuberant. The peculiar things he did soon brought him to Fleury in a gay and expansive mood, singing and talking as hail fellow with everyone he met.
The next day he grew more excited, disrobed and threw his things out of the window, filled his bed with excrement and wanted to smear the orderly therewith. He took other attendants for old friends and wanted to kiss them. His language and ideas were incoherent. He broke glass.
This situation of alternate joy and anger lasted one month, leaving him in an excitable, unruly state. He wrote many prolix letters to the prefects and the ministers, insisting on the discharge of certain patients and offering plans for the defense of France. He got better and finally, in October, 1914, was invalided home still slightly exalted.
Re the cyclothymias, Montembault remarks that manias have been less numerous than melancholias in the present war, whereas in 1870, manias were more common than melancholias. Morselli likewise remarks upon the rarity of manias amongst the Italian soldiers. Butenko reports upon the maniacal cases amongst the Russians and how the men wish to enter the ranks, the women the nurse corps. E. Meyer, for Germany, found 4 per cent manic-depressives. Birnbaum quotes from Bonhoeffer (3 per cent) and Hahn (2 per cent) for war times as against Stier’s 9.5 per cent of cyclothymic cases in the antebellum period, 1905-1906.
Fugue: melancholia.
Case 164. (Logre, 1916.)
Logre classifies as a melancholic fugue the adventures of a man who had been depressed for some days, had stopped talking and eating, and ran away suddenly in the middle of an attack of anxious agitation. He was very anxious over the health of his daughter, whom he thought to be severely ill. It was, in fact, to go to Paimpol that he deserted, but he deserted with his arms and without any money. He went off on foot “in the Brittany direction.” He had gone 50 kilometers, the next day, and was picked up near Chateau-Thierry by two gendarmes, who fell upon him, seeing his regalia, and cried, “Give yourself up!” He replied in a firm voice, “No, I shall not give myself up!” and seizing his gun he made at one of the gendarmes. There was a fight. The gendarme declared in his report that he judged it opportune to retreat behind a tree. The soldier, knowing his trench lore very well, barricaded himself behind a pile of beets. There he would have held the gendarmes in check for some time if another had not succeeded by a dÉtour through some woods, in catching him. He gave himself up after firing several ineffective shots, but not without getting a bullet in his left thigh himself. With the charge of desertion and attempt to murder, he was handed over for mental examination. He was, in fact, a melancholic patient, subject to attacks of anxiety, and requiring long observation at a neuropsychiatric center for diagnosis.
Chavigny observed numerous victims of melancholia characterized by war terror. He remarks a somewhat curious fact that, whereas the melancholics were numerous and their mental states related to the war, on the other hand, the paretics were rather apt to be maniacal than melancholic. Soukhanoff, however, remarks on the occurrence of depression in a great number of types of psychosis, as was found in the Russo-Japanese war. Soukhanoff found frequent instances of schizophrenia, wherein the melancholia tends to conceal the actual dementia praecox. Soukhanoff predicted that depression will figure largely in the war.
Apples in No-Man’s-Land.
Case 165. (Weygandt, 1915.)
A soldier in November, 1914, suddenly climbed out of the trench and began to pick apples from an apple-tree between the firing lines. The idea was to get a bag of apples for his comrades, but he began to pelt the French trenches with apples. He was called back and on account of his strange conduct sent to hospital. Here he was at times given to pressure of speech and restlessness; he would climb the posts of the sleeping room and then loudly declare he wanted to get back to the trenches; he did not want to go back to Germany alive; did not want to live over to-morrow; was guilty of a sin; had a spot of sin, Schand, on his heart. Sometimes he refused food and said anything else tasted better. It seemed he had formerly talked about the Iron Cross.
After being transported to Germany, he was at first a little negativistic and apparently blocked. He talked about his experiences and said he wanted to go to Russia. He explained the episode of the apples on the basis that they were all really hungry and that he had sought to encourage his comrades who were unused to war. He had noticed the French all shot too high.
Physically there was a somewhat uneven innervation of the face, unilateral epicanthus and an areflexia of pharynx. Now and then the man was very irritable, but in general he was in an elevated frame of mind.
Weygandt interprets this case as one of hypomania, remarking that war influences may serve to bring out preËxisting manic depressive tendencies.
Re differential development of mania and depression, see remarks under Cases 163 (Boucherot) and 164 (Logre).
Four months in trenches: Depression; war hallucinations, arteriosclerosis (aged 38).
Case 166. (Gerver, 1915.)
A Russian reservist, a private, 38, went into the trenches, March, 1915. Without taking part in any battles or sustaining any injury, he four months later became depressed and had to be evacuated to a hospital and thence to the interior, little changed for the better.
He was an ill-nourished man, of middle height, with pallid skin and membranes; arteries sclerotic; face, eyelids, and tongue finely tremulous; hands tremulous; slight dermatographia; exaggerated tendon reflexes; pulse 100.
He seemed disoriented for time and place; looked weary; walked with back bent over; spoke in whispers, and appeared somewhat unclear. Thinking was slow and difficult.
He occasionally shuddered and looked to one side, said he was afraid, and was constantly troubled by thoughts of fire. The Germans were pursuing him; he could hear their voices and footsteps. He himself was doomed, and his family also; he felt he was the cause of all the domestic woe. His own heart was dying away; he had fits of anguish and causeless fear, and was under the constant expectation of death.
One day, he escaped from the hospital and went to the chief physician’s tent, where he lay on the ground. When he was found and asked why he was there, he begged the physician to save him from the Germans. The man was not alcoholic and had no previous history of mental disease.
Re early arteriosclerosis, Maitland in the second interim report of the British Association Committee on Fatigue in Warfare, speaks of the many Serbians, who, after six years of nearly continuous Balkan war, show a marked arteriosclerosis. Maitland remarks that the line officers were already showing (1916) a growing delicacy of perception as to the “breaking point.” Men that do not break may return from the lines, pale, with low blood pressure, and a faiblesse irritable, shown by restlessness of hands and feet.
War stress: Manic-depressive psychosis.
Case 167. (Dumesnil, 1915-6.)
A naval officer, 22, transferred from sea service, went into Belgium, November, 1914, in a Fusilleur brigade of marines and there greatly distinguished himself, growing very weary and enervated, however, about the middle of April, 1915. His attitude to the men altered: he sometimes struck them; gently, though, according to his account. They must do in ten seconds what they really could not do under ten minutes. The officer, in fact, had lost all notion of time. He went about agitatedly, contradicted his superior officers and was troubled because, as he said, they often were men of inexperience as compared to himself. He grew irritated, too, because there were Free Masons in the army and when he was sent to the asylum in July, 1915, said it was the doing of the Free Masons. He did not seem to have any hallucinations. His ideas and sentiments were very labile, and a bit confused, and not all his interpretations dealt with Free Masons and occultism. August 5, however, the phase of calmness was again followed by agitation; he broke things and laughed explosively. August 10, another attack occurred, with destructiveness. During the next few days there were alternate phases of depression and excitation. He was negativistic, resistive and struck attendants.
Re war stress and psychoses, Morselli finds the acute cases on psychopathic soil. First in the list, he places the neurasthenias and psychasthenias, and second, the hysterias, two groups which, more than the remainder, may be said to constitute the so-called Shell-shock group. Third, he found depressions ranging over into a delusional state with suicidal ideas; fourth, a species of stupor, occasionally catatonic, recalling dementia praecox; fifth, transient hallucinatory states; sixth, confusions (Meynert’s amentia?); last, manias.
The above case of Dumesnil appears to be a pure case of manic-depressive psychosis developing on the war basis, but perhaps merely comes from a latent cyclothymia.
Predisposition; war stress: Melancholia.
Case 168. (Dumesnil, 1915-6.)
A farmer, 30, was mobilized August 2, 1914, and was wounded in the hand September 27. He went back to his dÉpÔt in December and stayed there until March, 1915, when he was sent to Dunkirk. Before leaving the dÉpÔt he said that he had heard soldiers declaring that he was not doing his duty, that he was going to be court-martialed, that life was at an end for him. At Dunkirk he said these same soldiers continued to say the same things about him, forming a band about him, led off by a subaltern officer who meant to frighten him and to make him talk. One night sulphur was thrown at him for poisoning purposes; he complained of this to a sergeant and declared he did not understand why he should be thus pursued. After the bombardment of Dunkirk the hallucinations grew more intense. He was sent to hospital and was so harried by the voices that he wanted to throw himself down a staircase but was caught in time. At the hospital for the insane he complained that his thoughts were being heard and loudly repeated; he was made to make incoÖrdinate movements; was treated as a spy. He thought he must be a German or they would not treat him so. He waited for death as he wanted to be executed at once.
This man’s father was alcoholic. He himself at the age of fourteen had had a period of neurasthenia with some sort of nervous seizure for a period of five months. At 28 he had a rheumatic seizure which kept him in bed fifty days. A daughter born to his wife had died a few days after birth.
Dumesnil’s analysis is melancholia with delusions of persecution, due to war stress in a predisposed person.
Re melancholia and the war stress, see remarks under Case 167. Re manic-depressive psychosis in the Russians, Khoroshko found 9.4 per cent of manic-depressive cases, the same percentage of epilepsies, 10 per cent of paretics, and 20.4 per cent of schizophrenic cases amongst a group of 318 neuro-psychiatric cases. Almost all his manic-depressive cases had been patently so antebellum.
Depression; low blood pressure. Pituitrin.
Case 169. (Green, 1917.)
A private, 22, was sent back from Germany as insane. He had been in the asylum at Giessen seven months, and a prisoner in all fifteen months.
August 16, 1916, he was admitted to Mott’s wards at Maudsley in a markedly depressed and lethargic condition. He had improved somewhat in October, but still had periods of depression. He was put on thyroid extract (Green’s treatment was in doses measuring from gr. ¼ to gr. 1, t.d.s.; according to Green, the effect of thyroid extract is more rapid when coupled with pituitrin). In December he was given pituitrin extract gr. 2, t.d.s. In January, 1917, he was no longer depressed or lethargic. He complained of pain in his back, found to be due to a bullet. This was removed.
Re prisoners, Imboden found amongst 20,000 French soldiers taken prisoner at Verdun after the severest drum fire and strain, only five neurotic cases (data of MÖrchen), and Wilmanns found but five neurotic cases amongst 80,000 prisoners. Lust reviewed 20,000 war prisoners in Germany and found singularly few instances of neurosis. Shunkoff notes, however, that there are a number of psychotic cases amongst the prisoners because the mentally diseased who do not disturb the military routine are kept in the line. Bonhoeffer found amongst Serbians taken prisoners by Germany, emaciation, atrophy, heart disease, and frequently tuberculosis. (See Case 166.) Bonhoeffer noted the absence of psychoses amongst these Serbians, drawing the general conclusion that campaign stress was unable to bring out psychoses. But, although the exhaustion psychoses are not found, there are exhaustion neuroses or states of acute nervous exhaustion, characterized by somnolence and depression, followed by a mild degree of overemotionality. vum Busch states that interned German civilians have gone into psychosis frequently. It is said that one in 10,000 war prisoners in Germany has committed suicide. Bishop Bury found at Ruhleben 60 or 70 cases of psychosis.
Hallucination in the field (surprise by BOCHES); scalp wound: Three psychopathic phases—(a) over-emotionality, (b) obsessions, (c) loss of feeling of reality (victim a “constitutional intimiste”).
Case 170. (Laignel-Lavastine and Courbon, July, 1917.)
A cashier, 31 (of rather weak constitution but without hereditary or acquired mental taint—a religious man and for religious reasons chaste, always given to metaphysical speculation and introspection, but on the other hand, much interested in sports and very sympathetic with English manners), was about to go to live in the country on the advice of his physician when the war broke out. He was called to the colors and shortly lost his tendency to bronchitis, put on flesh, and felt delighted with his situation.
After almost two years of effective service, June 2, 1916, when his troop was cautiously advancing into a trench at the end of which they might be taken by surprise, suddenly the officer cried, “Sauve qui peut! The Boches are on us!” The patient remembered seeing Germans emerge from every side, remembered his fear, how he had turned about and crossed over a palisade, and then no more until he found a scalp wound being staunched by his comrades in the trench. He put on his own dressing and followed his comrades on foot.
He quickly got well of his scalp-wound but remained in hospital, very weak, extremely impressionable, jumping at every noise. He got somewhat better with the rest in bed, though even a month after his hallucination, he had a spell of insomnia, thinking about his future and the possibility of a relapse, and having war dreams from which he would awake in a sweat. Once on awaking, he distinctly heard a voice saying, “Well, Charles?” This hallucination occurred five times, under exactly the same circumstances, except that once it was in the daylight. Adrenalin was given, 1:1000, 10
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. There were fears that the ceiling would fall; there were scruples concerning the past; there were fearful premonitions for the future (such as, that any bomb he might pick up would burst). According to Laignel-Lavastine and Courbon, there may have been a predisposition in the vegetative system of this subject, or even a basis in his tuberculosis, of which, in fact, the X-ray showed still some slight evidences. The obsessions appeared at night, at a time, namely, when the vital rhythm is passing from a sympathotonic period over into a vagotonic period, at a time when the organic sensations are apt to swim to the fore. According to this analysis, these somatic sensations, precisely those that the battlefield had also brought out, brought out again the other emotions which he had felt on service. It was always the emotions first developed in military service that were revived in the disease. In the third phase, the physical condition of the patient had grown much better pari passu with disappearance of the obsessions and the onset of the personality disorder. The adrenalin raised arterial tension, and going down to the sympathetic caused the anxiety and war emotions linked therewith to disappear; but the adrenalin treatment,
Re neurasthenia, LÉpine notes that there are transient and relatively permanent cases. The term is often used to cover graver disorders, such as various melancholias and anxieties. As a rule, in France, the neurasthenics are evacuated for fatigue. There have been a number of cases in officers, who find themselves unable to make decisions on the minute and to remember military facts, or perhaps are unable to make any physical or intelligent effort whatever. 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. There is a group of young men who have never been physically strong, bowled over at last by some small event, such as a diarrhoea, and unable to carry on. Such men, perhaps, are likely to have some traces of an old tuberculosis, an adrenal insufficiency, or insufficient hepatic function. Martinet has found them hypotensive and rather poorly aerated. There is another group of neurasthenics (Maurice of Fleury) that are old arthritics, with increased tension. These cases are not found at the front because conditions there rather tend to reduce the trouble; but they are found doing office work in the interior. Besides these cases of the “cultivated” group, LÉpine also finds a number of neurasthenics amongst the peasants, in whom anxious ideas may lead to hypochondria.
Fugue, hysterical.
Case 171. (Milian, May, 1915.)
The fugue of an adjutant who left his regimental relief post at Palameix Farm and was found several days later with his family at Castelsarrasin, was reconstructed from partial records as follows:
November 27, 1914, after a night in the trenches, when two shells burst near him, the adjutant turned up at the relief post with wild eyes and a complaint of fatigue, and of an old wound and headaches. The wound he had gotten in a fight which gained him his grade of adjutant. The physician prescribed rest. He sat down by the stove, silent and dejected, and at about four o’clock, in the presence of the medical assistant, made preparations to go, leaving sack and saber behind, but taking outer garments and revolver case. On the way from the farm, he met comrades and told them he had been evacuated to his dÉpÔt on the colonel’s order, and walked with them, Indian file, in the midst of falling shells, the others talking but the adjutant himself silent. At nightfall, he said, “Good evening,” and parted from them. Of his further course to his home, all recollection was lost by the adjutant; in fact, he did not remember anything beyond the Palameix Farm, where he had seen a comrade wounded in the head. He got home November 29th, at eight in the morning. He had most of his money with him, having traveled by train some distance without a ticket; moreover, without asking for a ticket, and without having eaten. When the ticketman in his home town asked him whether he was back from the war, he looked at him vaguely and went out without replying; nor did he reply to a newspaper man on the road home. This was the more strange as he was ordinarily an affable person.
He had a convulsive crisis at home, after which he was exhausted and apparently unable to move or reply. A physician said that he had had a cerebral shock. When the police arrived, two hours later, he was apparently delirious, saying
In point of fact, he had had, at the age of 17, analogous crises, as was certified by RÉgis, who had cared for him from 1907 to 1909 for hysteria with sudden somnambulistic attacks and amnesia.
While in prison after his arrest, he also had hysterical crises with agitation, flushed face, hard attempts to vomit, respiratory disorder due to interference in the throat (globus hystericus), and delirious phenomena (“Germans had followed him home”).
After his birth his mother had had two miscarriages and a stillborn child. The adjutant was declared irresponsible and acquitted. This is apparently an instance of hysteria without stigmata.
Hysterical Adventist.
Case 172. (De la Motte, August, 1915.)
An engineer, 31, in the Landwehr at the outset of the campaign, was first put on sentry service in Berlin on the ground that he was an Adventist. He was later put into the military service and had difficulty because he did not want to serve on Sunday. He was shoved from one company to another. He refused to be inoculated and was arrested therefor. In the prison, he began to hear God’s voice calling to him distinctly to tell his fellow-men that the end of this was going to be the end of all things. Back in the barracks, he again heard a voice—“Come forth!”—“Go!” He went! He had his revelations then published in the form of tracts, and held Bible readings day and night among his friends in Bremen—looking for the signs of the times in the Bible sayings. One of his fellow Adventists finally warned the police, and the military authorities put him under psychiatric observation. He proved to have numerous stigmata of hysteria. He talked freely about his visions, and was aware that he was punishable.
Here, then, was a case of hysterical psychosis, liberated by military service.
Fugue, psychoneurotic.
Case 173. (Logre.)
The question, Is this escape really a fugue? is brought up not only in epileptic, alcoholic, and melancholic cases, but also in cases suggestive of psychoneurosis. A son of an insane person was subject to what may be called a phobic or obsessive fugue. The case may be called one of morbid cowardice and was observed in a soldier in the trenches. In point of fact, the man had always been an anxious and fearsome person, given to phobias. He had night terrors and fear of diseases and death. He was agoraphobic in adolescence, and had to have a policeman or passerby go with him through a public place. He had had also suicidal and homicidal obsessions, and periods of psychoneurotic anxiety.
This man’s sojourn at the front put his morbid personality to a cruel test. He was soon known by all in the trenches as a froussard. He had a terrible fear of the guns, jumped, grew pale, trembled, complained of palpitations, lumps in the throat, etc. He was the laughing-stock of his comrades; but according to the patient himself, he was more afraid of his own emotion than of the shells, although his comrades couldn’t understand it. He was employed as a kitchenman, in a post not much exposed. A more resolute comrade helped him to escape, escaping also himself, thus bringing up the problem of fugue Á deux. Limited responsibility was decided for the case, although the fugue had been aided by his morbid anxiety. Of course, his place was not in the trenches at all. He was condemned to two years in prison. After his sentence, he was given a chance to rehabilitate himself by sending him again to the trenches, but he had to be evacuated a few weeks later on account of his increasing emotionality.
Shell-shy; war bride pregnant: Fugue with amnesia and mutism.
Case 174. (Myers, January, 1916.)
A rifleman, 30 years old, was brought to a casualty clearing station, looking like an imbecile, with a history of having wandered about aimlessly, not knowing where he was or what he was doing. On questioning, he remained absolutely speechless and terrified. Four days later, in conversation with Major Myers, he was got to speak in a faint voice about his wife, home, and occupation, saying that the month was October (when it was actually August) and that he had been in France two months, when it was actually twelve. He described emotionally certain trench scenes, and then thought of his wife sewing.
Hypnotized, he remembered going into a dug-out after running away from shells; he was made to talk in a loud voice. Next day, during hypnosis, proper orientation for time reappeared. He was got to write an ordinary soldier’s letter to his wife. The following day he was active, making beds, but was mute (there was a case of mutism in the same ward). Under hypnosis speech returned. He had gone to a horse show, and upon his return, something hit his back; shells had begun to fall. Found hiding in a shack, he was carried to a hospital in an ambulance. After this hypnotic treatment, the power of speech was maintained, although his voice became faint or failed whenever he was asked about the incidents described above. Next day he waked speaking normally, nudging his neighbor and asking, “Is it me that’s talking?” He had before appeared dull and depressed, but now appeared an intelligent, agreeable, and garrulous fellow. It appears that his wife was a war bride and he had heard some months since that she was pregnant. He had been troubled, thinking she was in money difficulties and kept thinking about a friend whose wife had lost her first baby. Recovery appears to be complete except for occasional headaches, and the patient is now serving in his reserve battalion.
A neurasthenic volunteer.
Case 175. (E. Smith, June, 1916.)
A man who volunteered for service at the outbreak of the war (he had recently been an inmate of a sanatorium) was sent back to England as neurasthenic after three trying months at the front. The case sheet read that he was subject to dazed conditions. In hospital he suffered from insomnia, and before his slight periods of sleep he constantly had visions of two comrades who had been terribly lacerated at his side. These hallucinations in their reality aroused in him a fear that he was insane.
There were also terrifying dreams, beginning with episodes at the front and ending with sex experiences. These dreams were ended by seminal emissions. These formed a second cause for the patient’s belief that he was insane, as he said he remembered literature read as a boy concerning spermatorrhoea.
In the treatment of this case the writings of psychologists who had studied hypnagogic experiences were used and the absence of hallucinations during waking hours was stressed. The remembered literature regarding spermatorrhoea was discounted by the rational explanation of his state.
He seemed to be getting on well when a trivial accident caused a relapse. While he was saying goodby to his wife, who had visited him, she was taken ill, and he went home with her. He was punished for being late in returning to the hospital. Although no moral stigma attaches to confinements in barracks in most soldiers’ minds, in this man a depression was produced and suicidal talk followed. It seems that his father had been sent to jail when he was a child, and he felt he had been tainted by his father in such wise that his “criming” was due to heredity. With the removal of this misconception he became more rational and immensely improved.
Five months’ war experience: Neurasthenia in subject without heredity or soil.
Case 176. (Jolly, January, 1916.)
A 38-year old soldier is Jolly’s example of a neurasthenia produced in a person without previous neurasthenic traits or hereditary factors. This soldier had been a moderately good student and never ill. He went into the battle line in December, 1914, and came out in May, 1915, on account of exhaustion. The case is not wholly convincing since the patient had a shrapnel injury of the skull, described as of so inconsiderable a degree that he was not put on the sick list on its account. The patient finally arrived at the Nuremberg Hospital, complaining of pressure in the head, as if there was a band around the head, and dizziness. He wept a good deal saying that the sight of the dead had frightened him. Sleep was restless and there were unpleasant dreams of the battle field. Intelligence was not in any degree disturbed. The supra-orbital points were sensitive to pressure. The tongue showed a marked tremor and was coated; the mechanical excitability of the muscles was increased; and there was reddening of the skin on stroking. There was a fine tremor of the extended fingers, less tremor of the head and of the body at large. Knee-jerks normal. Nutrition well preserved. Partial recovery in the hospital.
Importance of arterial hypotension in the diagnosis of psychasthenia.
Case 177. (Crouzon, March, 1915.)
A man of 32 (never well, with general weakness, ideas of consumption and vacuous thinking following a good recovery from bronchitis at 28, unsuccessful in business, subject to weaknesses) had had eighteen months antebellum of what might be called psychasthenia. There were spells of loss of consciousness without convulsions, and probably of hysterical nature. There had been for two years insomnia and a general hypobulic slowing down of work.
In military service the crises became more frequent, coming two or three times a week. Tuberculosis could not be shown, nor was there any organic lesion of the nervous system. The arterial tension (Potain sphygmomanometer) stood at 11.
According to Crouzon, arterial hypotension is an objective sign tending to assure the organic nature of a psychasthenia. Whereas simple neurasthenics are hypertensive, others have long been recognized as hypotensive; but heart experts have recognized this asthenic hypotension more than psychiatrists or neurologists. In differential diagnosis it is necessary to consider and exclude the early hypotensions of pulmonary tuberculosis and those of Addison’s disease. This hypotension is most frequently observed in constitutional neurasthenics and psychasthenics. Hypertensive drugs, adrenalin, tincture of colchicum, have produced a transitory improvement in a number of cases, but the amelioration has halted with the stoppage of the drugs.
Re hypotensive and hypertensive cases, see remarks of LÉpine under Case 176. See also Case 169, illustrating some contentions of Green, from Mott’s clinic.
Service in France and Salonica: Psychasthenia.
Case 178. (Eder, March, 1916.)
A man, 29, after some months’ service (three months in France and later in Salonica) was invalided for backache, insomnia, and enuresis. It seems that this married man had never done any work after leaving school at 18, having substantial private means. He had been married for 3½ years, had a son, and was, according to Eder, perhaps morbidly attached to his wife and child. He had been a sportsman and was selected for sniping work in France. The son of a shipbuilder, he had always planned all kinds of ships and engines, never to be used. After seeing the world, he was about to enter his father’s business when he had to take care of his father in a nervous breakdown. After a second attack, the man never entered business.
February 6, 1916, wide-spread patchy analgesia and lumbar hyperesthesia were found. He thought sluggishly, being restless and holding attention poorly. He began twenty letters, destroying each after finishing a few lines. He was shy and felt that everybody was looking at him. He became speechless if he had to address his commanding officer. He had an obsession to mark each flagstone and touch each post, and various counting and arranging obsessions.
The Horme (Jung) was elusive. A dream: “I was in a cargo boat in the river; we were steering straight into ferry and harbor. The pilot rang down ‘Full speed to stern’; I pushed him out of the way, and rang down ‘Full speed ahead, two points to starboard.’ We went straight past ferry and harbor without accident.” Again, a few days later, “In a motor car, came to some rocks which sprang up in front of me. The machine broke down. I abandoned it and clambered over the rocks. It was tough work. My object was a ship. I got to the ship, took hold of the wrench, and signalled ‘Let go.’” Herein, according to Eder, are certain obvious symbolic conversions.
Antebellum attacks, with dizziness: Fainting on horseback. Neurasthenia.
Case 179. (Binswanger, July, 1915.)
A harness-maker, 37, a corporal, was called to the colors on the second day of mobilization. He was attacked by a slight dizziness in the evening (see previous history below). He went into the field on August 7 and had repeated attacks of dizziness, despite which he took part in several skirmishes. He could not ride on horseback, since dizziness, ringing in the ears, headaches, and trembling of the whole body would develop. October 27 a severe fainting attack came while he was sitting on a horse. He woke ten hours later, vomited several times and felt dazed. Two weeks later hearing in the right ear began to be impaired. During several transfers from hospital to hospital near the East front, there were two more severe attacks of dizziness and vomiting. Brought back to Germany, the patient finally came to the Jena Hospital, May 20.
The estimate of this case depends somewhat on the previous history. He appears to have come from a healthy family, was married, and had two healthy children. His bodily and mental development had been normal; he had been an unusually good scholar, but he stammered from his tenth year without apparent reason. He had had treatment in an institution for stammerers at 17, achieving a complete cure in six weeks. His military service was as a cavalryman, 1897-1900, after which he had married. There was no excess in alcohol; he was not a smoker. From his own account, he had always been somewhat nervous, had trembled easily, and had fallen to stammering when excited. In 1913 there had occurred, after physical exertion, three violent attacks of fainting, with dizziness, vomiting, and excessive perspiration, each attack lasting from two to three hours. However, from that time to just before the war, he had been free from attacks.
On examination at the Jena Hospital, the patient complained of general weariness, a feeling of pressure in the back
The man was slenderly built, of medium height, in moderate nutrition; pale of face and mucosae; pulse small, regular, and 114. Neurologically, the deep reflexes were generally increased, and the skin reflexes decreased. Percussion on the back of the head elicited marked pain. There were no pressure points. The movements of the arms were free; there was a marked tremor of both hands, more marked on the right. The left grasp was 45, the right, 20, by the dynamometer.
When lying upon his back, the patient could move his legs, but he moved them only slowly and with tremor. The heel-to-knee test was successfully executed despite the tremor; nor could it be demonstrated that there was a genuine ataxia. Placed upon his feet, he would collapse, nor could he be made to walk at all. With trunk supported, he was able to make only a few unsuccessful attempts to drag the feet forward.
Associated with this apparent paralysis, the sensitiveness to touch had entirely ceased in the legs, as well as sensitiveness to pain. The zone of analgesia, however, was more extensive than the anesthesia, spreading upwards three or four cm. farther in front. Ticking of the watch could not be heard even at the meatus of the right ear, although hearing of the left ear was entirely normal; bone transmission on the left side. Whispers could be heard close to the meatus. On speaking, the patient stammered in starting sentences.
He looked extremely anxious during the first few days in the Jena wards, claiming that he could not raise himself. When his trunk was raised, he would let himself sink feebly back into dorsal decubitus. However, when believing himself unobserved, he was found to be able to move himself in bed somewhat quickly. He was able to get a box from beneath the bed, to open the drawer of the night-stand, and to take remarkable care of his moustachios. He complained
Treatment at first consisted of cold packs of the legs twice a day, salt-water baths, active and passive exercises of the legs in the position of dorsal decubitus. The patient declaimed against this treatment. There was slight improvement after a week of treatment. He was then able to raise himself in bed, seat himself on the edge of the bed, and stand without support, all the time, however, groaning and moaning. After a few moments, he would fall back on the bed, complaining of violent headache and dizziness. While standing, both legs trembled.
Antityphoid inoculation: Neurasthenia.
Case 180. (Consiglio, 1917.)
A corporal, 39, began to be sleepless and weary, with headache, pains in the back, and dizziness. He was homesick. Upon hospital examination he was very variable in mood, rather hostile in attitude, and at the same time suggestible. He was so confident of being sent home that he anticipated the diagnosis by sending his belongings back to Sicily at the time he was transferred to hospital from his regiment.
After a month’s rest and psychotherapy, the man’s general condition was greatly improved; he was no longer sleepless and had no longer any sign of neurotic disorder. He still maintained that his memory was weak, although in point of fact his memory was very good and quick. He could narrate all the facts about his neurasthenic state. The man’s complaints were out of all proportion to any demonstrable somatic disorder. He was discharged, cured, to be put to work at shoemaking, with the diagnosis, neurasthenia. This neurasthenic state developed after antityphoid injection.
Re the occasional curious effects of antityphoid injection, see Case 65.
Neurasthenia (monosymptomatic: Sympathy with the enemy).
Case 181. (Steiner, October, 1915.)
A non-commissioned reserve officer, 26, in civil life a merchant, had a strong hereditary taint, having been also in peace times very nervous and on that account obliged to give up his studies. At the age of 14, he had seen a man fall down from a roof and was much excited about it.
At the beginning of mobilization he suffered a functional aphonia for a few days. He could not let his men shoot at the enemy because of an idea that occurred forcibly to him: that the enemy’s soldiers had wives and children! He felt badly on this account. Later he had a constant taste of blood in his mouth and a smell of corpses in his nose. Toward nightfall all these symptoms would change for the worse, and the symptoms would become especially bad whenever he had anything to do with the wounded. He tended to weep much and was easily frightened and had also various physical symptoms of neurasthenia.
Re the amazing sympathy with the enemy, see Case 229 (Binswanger) and Case 554 (Arinstein), in which chloroform lifted from a German and a Russian consciousness respectively opposite emotional tendencies.
Shell-shock CLAUSTROPHOBIA: Preferred shell exposure to shell-proof tunnel.
Case 182. (Steiner, October, 1915.)
A colleague of Steiner, an army physician, 35 years of age, with strong hereditary taint, having two sick sisters (one dementia praecox), had been incapacitated for work through a neurasthenia a few months before mobilization. However, at first he felt very well, marching through Belgium and into Northern France.
On the night of the 17th of October, 1914, a shell struck the house next where he was and startled him up out of sleep. After that, especially at nightfall, upon entering a cellar he would have the feeling of the ceiling falling down, and he would go restlessly from one space to another. Afterwards, any closed room, however secure or distant from the front and free from shells, would give him the feeling of the ceiling about to fall down. He could no longer sit quietly anywhere, but walked about and avoided the company of others.
A characteristic observation is the following as described by the physician himself: There was an absolutely shell-proof tunnel running to the position at the front where he was on duty. It took about 25 minutes to go through the tunnel, but on account of his feelings he could not bring himself to use this tunnel but walked over the exposed hill which was frequently shelled. Curiously enough, after the appearance of the first symptoms, a shell exploded nearby without any marked psychical effect. This happened about noon. The obsessions were stronger in the evening. Objectively, there were neurasthenic symptoms of a bodily nature; there was vasomotor excitability. He was depressed, wept easily, and showed lack of decision; he had tormenting thoughts that he had not fulfilled his duty.
(GROUP OF VARIOUS PSYCHOPATHIAS)
A case of Pathological Lying occurring in a soldier.
Case 183. (Henderson, July, 1917.)
No. 27369, a private, attached to the 15th Battalion Durham Light Infantry, was admitted Oct. 14, 1916, to Lord Derby War Hospital from Netley.
September 11, 1916, he had been admitted to Number 3 General Hospital, France, in a noisy, excited, insolent state: said he saw spirits of the dead; heard his sister urging him to lead a better life. Admitted to Netley early in October, 1916: now said he was a spiritualist, a Frenchman, had a quarrel with parents and enlisted in British Army, in army service; went to France August 12, 1914, was wounded at Loos, September, 1915, returned to front in February, 1916, “shell-shocked” June 1, 1916; lost consciousness after this—did not know where he was until July 22, 1916, when he had been arrested as deserter.
Admitted to Lord Derby Hospital October 14, 1916,—quiet, orderly, coÖperative: desired to return to his regiment. He now gave a history: Enlisted British Army 1908, went to France, August, 1914, wounded February, 1915, at Neuve Chapelle; recovered; then attached to 45th Durham Light Infantry; blown up July 22, 1916, came to August 5, 1916, in hospital in Boulogne; then back to his regiment—but month later left without leave to pay off old score on a former comrade who had insulted his sister—arrested later by military police; put under observation in 65th Field Ambulance. No deterioration noted, school knowledge fairly well retained; no hallucinations or delusions (maintained he was a spiritualist, also that following shell-shock had suffered from insomnia and seemed to hear sister’s voice). Physically—small, well nourished, effeminate looking.
Oct. 23, 1916, he broke parole, but a month later returned to hospital under arrest. The police reported he had been
Story in hospital on return:—Born in France, did well in school, entered military academy at Paris. Quarreled with father—ran away to sea. Adopted by a French lady at Pembroke Dock. On account of drunken habits, quarreled again; joined army at Bristol, 1908. Went to France in August, 1914; January, 1915, invalided home because of “trench feet”—discharged as unfit. ReËnlisted June, 1915, in Durham Light Infantry. January, 1916, again ordered to France. Blown up on Somme, July, 1916, by shell—remembered nothing until brought to No. 3 General Hospital. He remembers being accused of desertion but sentence was not passed, as he was held by the medical officer to have been irresponsible (as a matter of fact he was, at that time, considered to be a case of dementia praecox.)
Said that during twenty-five days, due to drunkenness, his friends had taken him to Manchester with them; arrested by police as he attempted to get back to hospital. He was now accused of wilfully lying and, confronted with his police record, at first denied it, but later gave following approximately true story:
Born, England, 1890; early life of a roving disposition, good at school, liked books of adventure. Drank early. Ran away at sixteen; was returned home. Ran away again—convicted of drunkenness. Three-year sentence to reformatory in 1910 for stealing: escaped. Rearrested for stealing in 1911: released in 1913, enlisted in army and deserted. Arrested in January, 1914, for stealing; sentenced to three years: released to rejoin army in June, 1915. Arrested as deserter: imprisoned but released in January, 1916; left for France. August, 1916, “shell-shocked,” sent to Field Ambulance No. 3, General Hospital, Netley, and Lord Derby War Hospital. Court-martialed for desertion: nothing came of it on account of medical evidence.
After breaking his hospital parole, he masqueraded in district as “R. le Auldere,” “Le Marchal” and imposed on various persons.
Psychopath almost Bolshevik.
Case 184. (Hoven, 1917.)
A sergeant, accountant in civil life (father insane, mother pulmonary, grandfather alcoholic, cousin insane; patient himself anemic as a boy, victim of chronic gastritis and gonorrhea), was evacuated from the front to Chateaugiron in March, 1916. It appeared that instead of watching over his men as a sergeant should, he gave utterance to baroque theories of the divine right, the influence of the grace of God on man, and the end of the war. He went so far as to ask leave to transmit to the Inventions Bureau of the War Ministry an invention with respect to the problem of locomotion, and he sent to the King of Belgium a manuscript to the effect that he had received from heaven a mission to reËstablish the world’s balance. He was, in fact, the victim of delusions of a mystical nature with visual hallucinations. To explain his mission, he wrote, “It was my duty to take supreme command of war operations.… I have the power, the right and the duty to give the following order … general armistice … peace will be symbolized by the house undivided and will be constituted by general Christian religious unity … as a consequence of what we shall say they will give up our territory to us of their own accord.”
This case of paranoia apparently took its coloring in part from the war situation itself.
Hysterical mutism: Persistent delusional psychosis.
Case 185. (Dumesnil, 1915.)
A sergeant, aged 23, evacuated from the front to a hospital for the insane, had been mute, though not deaf, since February 28, 1915. If asked to cry out he grew black in the face and could utter only a raucous scream which made everyone jump. He wrote very frequently, stating in February that as he was still a sergeant and had no hope of advancement, he cared nothing more for life. “The idea of death got anchored in my head.” In this state of mind, on the afternoon of the 27th two bombs came. “I saw the first one coming and cried out a warning. Coming back I saw the second one. The bombs were coming rather softly. From this moment on and up to the time when they burst, I thought I had gone, that I had been carried off and crushed. I was quite astounded at finding myself covered with earth and stones … but I could not talk any more, I could just say in a low voice ‘Papa,’ and the next day in an ambulance I could not talk at all.”
There was complete pharyngeal anesthesia. The man had been a foundling and was clearly a degenerate. He had always been of a depressed disposition and given to thoughts about his misfortunes. Over and above the mutism gradually ideas of persecution and revindication developed (such as that he merited adjutant’s rank and was being mocked and treated as a simulator). He drew up a long letter to the War Ministry in which he stated his desire to be sent back to the front. He complained to the police about a hospital sergeant and offered a duel in an elaborate and inflammatory style, “with whatever weapons shall please you, either sabre of 1845, revolver of 1902 or bayonet of 1886 or the chassepot. One of us two must disappear.” He had become dangerous enough to be interned and in hospital remained mute with the same ideas of persecution and revindication, the same alternate phases of calmness and excitation. According to Dumesnil: hysterical mutism with persecutory delusional psychosis.
A peasant’s psychopathic inferiority brought out by the war.
Case 186. (Bennati, October, 1916.)
An Italian peasant began to feel sick on being called to arms. Antebellum he had been an even-tempered, good-natured man, according to his own story, satisfied even with stale food, and always enjoying his sleep. He had been in the war about a month, doing construction work, sentry duty, and chores. Though he lived in the trenches under damp conditions, there had really not been much excessive war strain. He shortly developed migraine and war-weariness, as well as middle-ear disease.
A number of times he heard shooting nearby, and was subject in his sentry duty to a good deal of anxiety and painful associations. On sentry duty he had digestive disorder, vomited, and became intolerably weary; in point of fact, a fever, regarded as malarial, then developed, together with diarrhea.
Upon hospital observation, he was found fatigued, given to terrible dreams, tremulous in the fingers, with skin reflexes a little excessive, and the Moebius phenomenon. The thyroid was somewhat swollen. The pulse stood at 80. The Mannkopf sign was well marked, as well as that of Thomayer (80-120), and Erben (120-87). The oculocardiac reflex was prominent.
Psychopathic episodes.
Case 187. (Pellacani, April, 1917.)
A Neapolitan, 26 (neuropathic stock: mother epileptic, brother psychopathic; patient had previous criminal record; married and then appeared to behave himself for several years; had always been excitable and of violent temper), after but one severe day in the trenches, woke and found his night clothes soaked in urine. Another time, his comrade had awakened him because he was gnashing his teeth in his sleep. Again, his grief became very violent at learning of his wife’s infidelity, and during the night he bit his finger. He thereafter suffered from severe headaches, dizziness and vertigo though without falling. He was granted a furlough, but the condition was aggravated on account of his wife’s abandonment of him, and one day, finding her with her lover, he threw himself at them, wounding her severely in the face: he did not remember this impulse later. Many hours later, on awakening in prison with his wounded hand, he recalled the entire episode. He showed a confused and excited condition, which, however, quickly diminished. He became lucid and tranquil, though easily aroused. He cried at the thought of his daughter, whom he wanted to save. Insomnia, instability of reaction, habitual migraine, and dizziness. Tremors of the fingers and of the eyelids. Exaggerated reflexes. Very striking cutaneous analgesia.
Maniacal and hysterical delinquent.
Case 188. (Buscaino and Coppola, January, 1916.)
An Italian soldier, 25, a foundling, was always off and on in a military prison. At a tavern one night the man unsheathed his sword and threw three bottles at the host. Bystanders overpowered him and carried him to the local police station. Handcuffs were put on to stop the mania. His pupils were dilated and he was sweating profusely. Alcohol could absolutely be excluded from the history of this incident.
Observed in clinic, the patient was rather silent, but on the whole normal and without delusions or hallucinations. It seems that he had committed a number of crimes in the army that were always excused on account of his mental state. He had been strongly alcoholic, although not at the time of the incident mentioned. He was covered with tattooings of an obscene and violent nature.
He showed pharyngeal and conjunctival anesthesia and concentric limitation of the visual fields of unusual degree, and a remarkable hypalgesia. The knee-jerks were lively. The man was, in point of fact, sent back to military service, with, however, the suggestion of reform school.
Psychopathic delinquent.
Case 189. (Buscaino and Coppola, January, 1916.)
An Italian, 20 (family history negative), was described by officers as of an odd disposition, at times thoughtful and again chattering and presumptuous, and often very vulgar in talk and manner. He had tried several trades, with little success.
While in the army he discharged his gun three times, claiming to have heard noises in a nearby field. On account of the inopportune repeated discharges, he was condemned to the barracks for ten days. The following day, instead of returning to the barracks, he abandoned his musket, cartridge box and uniform, and, returning to town, left for Leghorn. Being sent to prison, he began to scream that he was thirsty. He tore his jacket into strips with his teeth, and making a noose of it, attempted to hang himself.
On being transferred to the military hospital, he was often very restless, screaming and making a great uproar. On being questioned, he answered indifferently and had a vacant stare. During his stay at the clinic, patient was always quiet. Once, however, he had a spell of intense psycho-motor agitation, brought on without any known cause and followed by a short period of bewilderment, lasting altogether half an hour.
Patient had insomnia and his visual fields showed concentric contraction for white. He was sent to a military convalescent hospital.
Psychopathic excitement.
Case 190. (Buscaino and Coppola, January, 1916.)
An Italian soldier, 22 (father and brother both committed to insane asylums), since his enlistment had been conducting himself strangely, being impulsive, undisciplined and unbalanced. He had been in Libia from January to August, 1913, and was returned to Italy on account of persistent severe headaches. A month later he was returned to a regiment in camp.
September 23, 1914, the patient, who had been reproved by a superior officer to whom he had given a disrespectful answer, began to be excitable. He was calm during the day, but acted in a sullen and gloomy way and kept entirely to himself, avoiding even his most intimate friends. When, however, he suddenly recalled his punishment of the morning, he began to race around the yard and finally threw himself upon the ground, remaining there in a cowering and squatting position. At the beginning of the attack he was possessed of a paroxysm of fury, which made a great impression upon those present: eyes agape, face swollen and distorted. He resisted being transferred to the hospital and a furious struggle followed. He tried to bite and scratch everyone. It required ten persons to carry him by his hands and feet safely to the hospital, where he arrived in a state of great excitement and rage.
At the clinic, during the period of observation, he was always tranquil, rather silent, gloomy, somewhat hostile; said he did not remember why he was brought there. Often he was not able to sleep, especially during the first few days of his stay. Has had painful headaches and feeling of dizziness. Several times he showed a tendency to be untruthful. Bodily examination revealed the absence of conjunctival and pharyngeal reflexes. W. R. of serum was negative.
Patient was sent to an interior hospital for convalescence.
Desertion: Dromomania.
Case 191. (Consiglio, 1917.)
An Italian private, 19, came up for desertion in the face of the enemy. He had had a good record during a year of military service and his army conduct in the war was regarded as very good.
He felt sad and preoccupied for a number of days, but all of a sudden “some indomitable force” thrust the idea into him to go out into the country a distance of some 20 kilometers from the front, with the definite object of praying in a certain church. It seems that this same impulse had occurred to him several times before but not so forcibly. These prayers were to be said in memory of some sad events in his life.
Upon examination he was found in a sad and self-accusatory state, much discouraged with ideas of his guilt, unworthiness, and ruin. He had a variety of gloomy fears and obsessions, all of which contributed to the dromomania that culminated in desertion.
As to his previous history, he had had a depressive psychosis two years before, but the delusions at that time were of persecution. He had also suffered from typhoid fever a few weeks thereafter.
Suppressed homosexuality.
Case 192. (R. P. Smith, October, 1916.)
A man, 32 years, of high intellectual attainments and unblemished moral character—a teacher—enlisted as a private. He apparently found his associates in camp very uncongenial and undesirable. He grew physically tired, then mentally tired and unable to concentrate attention. He began to neglect his uniform, could not keep his equipment in order, became introspective and depressed. The drums he heard seemed to point to his funeral. There was but one thing to do in his opinion: that was to humiliate himself by committing sodomy. He thought of committing suicide.
Upon discharge from military duty, he began to show improvement. Smith regards this case as one of suppressed homosexuality.
Of the cases in which change or excessive work is the precipitating cause, four out of six of Smith’s cases were men.
Re homosexuality in the Italian army, Lattes has made a special study. The effeminate homosexual is decidedly unfit for the army, being unable to stand the war stress. Homosexuals diminish army morale. The cases of functional effeminacy with normal physique are likewise unfortunate for the morale of active units, though they may be employed in garrison duty and office work. The medical decision in these cases may prove difficult unless a broad interpretation of the concept “psychopathic” is allowed to prevail.
Psychopathic: suicidal, then self-mutilative.
Case 193. (MacCurdy, July, 1917.)
An English soldier as a child had night terrors and fear of the dark; as a youth wanted to throw himself down from heights; took delight in seeing animals killed; was shy with both sexes; was never able to run great distances; was taken from school at the age of fifteen for weakness, and had always been subject to headaches, somewhat improved by lenses.
During training sharp pains appeared in the left groin that grew better when the man lay down. These pains were regarded as hysterical. Thereafter began shortness of breath, pain above the heart, with palpitations and occasional attacks of dizziness. After a short sick leave he insisted upon going to the front, though his superior officer thought it unwise, and, after a period of seventeen months training, was finally sent to France in September, 1916.
He was at first somewhat afraid of shells and, though he soon got used to the shells, the horror of the war grew on him, with pity for the Germans as much as for the British. He became depressed over his weakness and when his commanding officer committed suicide got obsessed with the idea of committing suicide himself. He went so far as to drive a knife into his upper lip and to smash a looking-glass to avoid seeing himself. After a long spell of trench duty he had to be sent home incapacitated.
In hospital in England he was depressed and suicidal. He began to want to mutilate himself, yet found that a slight pain and the drawing of blood was all that he really craved. Of course, he had been a failure, but now he rationalized the failure by a comfortable conviction that he should never have been sent to the front. He complained of memory and attention disorder, insisted that he was physically incapable of outdoor exercise, complained of headache if he stayed indoors. He said he wanted to go back to the front; knew, however, that he could not, and even refused to consider the possibility of getting well to work at home. At the time of report he argued there was nothing left but suicide.
Bombardment: Psychasthenia?
Case 194. (Laignel-Lavastine and Courbon, July, 1917.)
A twenty-year old engineering student of high grade and without hereditary taint, a scientific and non-introspective man of a brilliant and gay disposition, not very religious, without special sexual abnormality, was mobilized in class 1914, was put into the artillery, and was soon appointed marÉchal des logis. He left for the front April, 1915, yet had to be evacuated in November. One afternoon, at the end of a bombardment, he rose from a recumbent attitude and immediately felt a dreamy, bizarre feeling, as if a fog lay between him and his surroundings. Next day, after a good night, he woke in the same state. Everything was bizarre and novel despite the fact that he recognized men and things. A physician ordered rest and after a few days evacuated him.
He was cared for in various hospitals, but the psychasthenia increased. He felt a terrible and causeless anguish, with precordial constriction. He felt as if he were about to be executed. His fears appeared after seeing some turning object, such as a wheel or a cane twirling. Gradually this fear was transformed into a genital excitation, though lascivious pictures did not excite him. Seeing anything turning gave him a voluptuous feeling in proportion to the speed of the rotation. It seems that all sexual interest had been at a standstill for several months in the early part of his disease, when suddenly this new aberration appeared. It seems that a portion of the man’s work in the artillery caused him to use screws and cogwheels every day. Attacks of vertigo occurred, with the appearance of an infinity of small, colorless spheres turning over one another, the whole forming a sort of animated system of rotation. In the night this system was luminous and somewhat like what one feels on compressing the globes of the eye. There was a retraction of the visual field. The man would be found in the dream state, especially after waking in the morning or when some novel kind of act was being performed. He
The authors somewhat doubtfully term this case one of a quiet psychasthenia, but in discussion still further talk arose as to the diagnosis.
Re psychasthenics, LÉpine notes that the lack of any out-standing symptoms in many psychasthenics allows them to stay in the army longer than would epileptics or hysterics of the same degree of disease. The line officers tend to consider them exaggerators or simulators. The fact that they besiege the line officers and the physicians with their troubles may add to the impression of falsification. The basis of the psychasthenia is often also, genuinely enough, a fear. LÉpine divides the military cases into anxiety neuroses and hypochondrias. The anxiety cases are hypotensive and given to tachycardia. They have very labile vasomotors. When it comes to the necessary exclusion of malingering, it is the history, with its hereditary and collateral taint, that tells the tale. A history in the patient himself of alcoholism, typhoid fever, syphilis, or especially cranial trauma may play a part. An agoraphobic may actually be in general a courageous man except for his crises of anxiety about open spaces.
As to the hypochondriacs, fear of syphilis must be noted. Akin to the syphilophobics are a group of pseudo genitourinary cases that fear effects of an old gonorrhoea. See Case 195 (Colin and Lautier) below.
Gonorrhoea: NOSOPHOBIA, depression, suicidal attempt. Recovery, thirteen months.
Case 195. (Colin and Lautier, July, 1917.)
A munition worker came to Villejuif, December 6, 1915, with cord marks on his neck and conjunctival ecchymoses. He had tried to hang himself.
Non-alcoholic, he had, however, long since shown signs of imbalance; his father had died insane, in an institution. When the man came in, he wept and groaned and made vague complaints of having contracted a venereal disease, insisting that his genital organs were purple.
After a few days, he grew less anxious and told how he was married and how his wife had made life a hell for him, giving herself up to drink and becoming a sloven; how several months since he had contracted gonorrhoea; how though told that the condition was cured, he had found filaments in the urine and had tried a variety of drugs, spending most of his money; how he found more and more filaments, thought himself incurable and unable to live with his wife; how at last, desperate, he had tried to hang himself.
He got well quickly, though his convalescence was interrupted by several periods of depression a few days in duration, with anxiety and tears. February, 1916, he was discharged well.
He returned four months later; he was still occupied with his disease, still going to physicians and buying drugs. It took six months more before the man could be discharged from the service, at the end of 1916.
This man appears to be a hereditarily predisposed subject, who simply affixed his delusional ideas to a disease which had begun some time before the mental trouble itself. The family plight is important and practically constant in this group of cases. The fear lest the disease shall be revealed by the physician to the family is deep-grounded and impossible to overcome by mere statements concerning professional secrecy. The impulse to suicide is extraordinarily keen.
A soldier (neuropathic taint) after hardships for two days stumbles over a corpse; unconsciousness: Stupor; episodes of fright with war hallucinations; look of premature old age; paresis; anesthesia.
Case 196. (Lattes and Goria, 1917.)
An Italian soldier (a shoemaker with an epileptic mother and two nervous brothers; himself always irritable and for long periods melancholic; at 15 condemned to nine years in prison for homicide in a quarrel) took part in a number of attacks at the beginning of the war. His company was heavily engaged in October, 1915, and there was no sleep two nights, and only a bit of cold food. He was dazed.
October 24, the company had to advance at night in the rain and under a heavy rifle fire. The shoemaker stumbled over a corpse, fell, and lost consciousness for a time that he thought was very long. He woke up in a camp hospital, remembering all the experiences he had undergone up to the time of losing consciousness. He now fell into a state of torpor, occasionally jumping out of bed and shouting with fear, hurling himself at non-existent persons, assuming a position of defence, and suddenly awaking in anxiety.
October 29, he was transferred to a second hospital, and October 30, in a third hospital, was examined and found well and strongly built, but looking prematurely old. He was inactive, depressed, and stuporous looking. He fell to weeping often and rarely gave any answer to questions. Sometimes he refused food. There was a slight paresis of the left arm, and the left pupil was smaller than the right; both pupils reacted poorly to light. The larynx and cornea did not respond to stimulation. Skin reflexes were poor, and the plantar reflex lacking. The left side about the shoulder and hip showed large patches of anesthesia to touch, pain and heat; but deep sensibility was present in these areas. He slept well at night. Status unchanged for two weeks. He was experimentally sent to the guardhouse, but was soon back in hospital with the same symptoms as ever.
