Part 32

2. Is the old syphilitic especially liable to break down under war conditions? According to Richards, Shaikewicz says that in the Russo-Japanese war paresis was noted especially among the officers and non-commissioned officers, and that it was undoubtedly hastened in its development by war conditions. Steida says that while ordinarily we find paresis developing twelve to twenty years after the primary sore of syphilis, in these cases it developed in five to ten years after the primary sore. Some of the cases progressed with unusual rapidity. It was also noticed that among soldiers from the front, under treatment, evidences of syphilis were present in 20%, while among the other soldiers under treatment, evidences of syphilis were present in 1.6%. Undoubtedly the old syphilitic is especially liable to break down under war conditions.

But, on the whole, the German authors in this war find no evidence favoring Steida’s claim of the hastened post-infective outbreak.

3. How did it come about that the efficient German system permitted this alcoholic and weakminded syphilitic to enter the army? As will be seen, he was a volunteer. In general, the German system has been supplied with army surgeons who have been trained, not by brief and “brush-up” courses, but by longer periods, sometimes two years in duration.

=Syphilis contracted before enlistment, “AGGRAVATED BY SERVICE.” Canadian case, courtesy of Dr. J. L. Todd, Canadian Board of Pension Commissioners.=

=Case D.= 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, dyspnea.

=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. (See Case E, “aggravated _on_ service.”)

1. In view of the fact that the majority of the cases here abstracted happen to be in common soldiers, is there any evidence bearing on relative incidence in officers and men? Quoting R. L. Richards:

“The percentage of paresis cases among officers alone is variously estimated from 50 per cent in the German army (Stier) to 58.9 per cent in the Austrian army (Drastich). Since paresis is a disease of more advanced life, it is but natural that the percentage of paresis among officers, non-commissioned officers, and older soldiers should be higher than among the whole military body, where the average age is, as we have seen, well below thirty years. Hence the above figures do not mean a greater prevalence of syphilis among those classes, but that we have no means of knowing how many of the others develop paresis. If anything it shows that these ‘soldiers by calling,’ have a more stable mental make-up, since they succumb chiefly to an exogenous toxin.”

Rayneau at the 19th Congress of French Alienists and Neurologists at Nantes in 1909, discussing the insane of the army from a medicolegal point of view, states that the most frequent mental disease amongst officers and soldiers is general paresis. At least, this disease is the most frequent basis of invaliding, retirement, or placing in the inactive list. He states that French and foreign statistics are at one upon this matter, quoting Christian as finding 32% among the soldiers interned at Charenton; Gamier at Dijon, 59%; Meilhon at Quimper, 42% and Talon at Marseilles, 33.8%. Grilli found 31 of 40 officers interned in Florence, Sienna and Milan victims of general paresis. Stier’s German statistics indicate about 50%. Rayneau himself found 16 of 20 officers paretic and 17 out of 27 subalterns and _gendarmes_.

The Neurological Society of Paris held a conference December 15, 1916, with the chiefs of the neurological and psychiatric military centres of France, and discussed a variety of questions concerning invaliding, incapacity, and compensation in neuroses and psychoses of war. Dupré dealt especially with the psychoses of war as caused by trauma, strain, infection, and intoxication. General paresis is regarded by Dupré as the most important of the dementias found in the army. The medicolegal point of view is, of course, that general paresis is necessarily related to an old syphilis, but its late development leads to misinterpretations as to its probable cause, both by the family and friends and even by magistrates. The war acts in the French nomenclature as an _agent revélateur_ or as an _agent accélérateur_. Although its cause is prior and exterior to the war, general paresis in a majority of cases is brought out (_revélé_) by the lack of adaptability of the general paretic to the novelty and difficulties of his surroundings and duties in war. Trauma, strain, and alcohol in a certain number of cases accelerate the progress of a general paresis. The aggravation of paresis is produced by these same factors, but especially by violent cerebral trauma. According to Dupré, the Val-de-Grace statistics show that the number of paretics has not been increased by the war. Medicolegally, the victim of general paresis, like the victim of traumatic or infectious chronic mental disorder, may be assigned an incapacity of from 50 to 100%, and these patients are invalided under _Réforme No. 1_,—a permanent invaliding.

Lépine of Lyons also discusses the compensation question in general paresis. Lépine thinks that, although syphilis is indispensable in paresis, yet the truth is that syphilis plus something else unknown to us is responsible for general paresis. This something else is neither a special kind of virus nor is it a particular kind of prepared soil alone. Trauma, physical, intellectual, and moral strain, and insomnia are the factors to which he calls special attention as adjuncts in the production of general paresis. As to the responsibility of the State for the production of general paresis, according to Lépine, the maximal responsibility should be 40% on account of the very considerable predisposition to paresis created by pre-existent syphilis.

Marie remarked that, although there had been thousands of head cases at the Salpétrière, there had not been a single case of general paresis. Dupré agreed with Marie that trauma was not a frequent etiological factor; strain and alcohol were more important. The Society agreed that in exceptional cases, where an encephalic trauma could be regarded as accelerating or aggravating the disease, the degree of incapacity might be set at from 10 to 30 per cent.

=Syphilis contracted before enlistment, “AGGRAVATED ON SERVICE.” Canadian case, courtesy of Dr. J. L. Todd, Canadian Board of Pension Commissioners.=

=Case E.= A laboring man, 44, acquired syphilis at a time unknown. Ten months after enlistment this man developed symptoms on the firing line. He was inattentive, irrational, incoherent. The diagnosis was then “mania.”

There were, however, scars at angle of mouth and on lower lip. Occipital glands were palpable, fine tremor of hands. The W. R. was +++.

Later the patient became violent, destructive, untidy, disoriented. Auditory hallucinations are recorded.

He was “boarded” for discharge five months after the first symptoms. The board agreed that these symptoms would have appeared in civil life. In view of a difference of opinion as to the part played by stress of service, his condition was set down as “_aggravated on service_” (not, it will be noted, _by_ service, see Case D).

1. Under what conditions should pensions be awarded for disability resulting from venereal diseases? According to a personal communication from Dr. J. L. Todd, Chairman of the Board of Pension Commissioners for Canada, pensions are awarded for all disabilities appearing _during_ service, unless they can be shown certainly to be due to the men’s own fault and negligence. It would appear that _during_ service covers both aggravations _by_ and _on_ service. There remains some doubt as to whether contraction of venereal disease constitutes negligence.

2. What have been conditions in the small inactive American army of the past? Richards has made a study of statistics at the Government Hospital for the Insane, Washington.

“The leading features of this mental disease were well exemplified in our cases the past year. They formed 7.5 per cent of the total number. They averaged forty years of age, and Ziehen says 80 per cent of all cases are in the fourth or fifth decade of life. They averaged ten and a half years’ service, which would indicate that the military life was their calling. Only one had any serious hereditary defect. Stigmata of degeneration were infrequent, averaging only two for each case. 66 per cent had good schooling, considering their opportunities. Physical signs were frequent in each case. Only one showed normal light reaction. Ziehen says the light reaction is retained in only 20 per cent of the cases. Patellar reflex was absent in one case and normal or exaggerated in five. The speech defect was slight in four cases. Other physical signs were present in the usual proportions. Memory defects existed in all the cases. In four the onset was with excitement. One began with a character change as the most marked feature. In only two were the transfer diagnoses correct. One, beginning as a quiet dementia, was diagnosticated paralysis agitans, because of a marked tremor. One was excited and euphoric and was called a manic-depressive psychosis. One with an obscure onset was diagnosticated as a neurasthenic. The other one was first observed in this hospital. The physical signs should have led to a correct diagnosis in each of these cases.”

=Duration of neurosyphilitic process important _re_ compensation. Canadian case, courtesy of Dr. C. B. Farrar, Psychiatrist, Military Hospitals Commission.=

=Case F.= 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 of examiners. This board reported that:

“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.

=Can PARETIC NEUROSYPHILIS (“general paresis”) be lighted up by the stress of military service without injury or disease? A possible example from P. Marie, Chatelin and Patrikios of Paris.=

=Case G.= 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 were found.

The serum and fluid W. R. were positive, albumin in fluid, 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.

1. 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.

2. What is the duty of the military authorities relative to so called traumatic paresis? Medicolegally speaking, Froissart, quoted by Rayneau, states that a victim of traumatic paresis _may or may not_ have presented mental disorders before the accident, that is, that the paretic symptoms may develop out of a clear sky as a result of the accident. The accident itself must be of a serious nature. The accident must be followed by phenomena pointing to brain injury of traumatic nature. These phenomena need not be characteristic symptoms of general paresis at the outset. The period elapsing between the trauma and the supervening condition of paresis must be occupied without notable interruption, at first by phenomena of a purely traumatic nature, later by signs indicating the onset and evolution of general paresis.

The French invaliding process called _Réforme No. 1_ with pension is granted according to the governmental instructions only to officers, subalterns, and soldiers whose disease is due to trauma. In view of this governmental regulation, the military surgeon must write out certificates describing every cranial trauma, however slight, which might have a bearing on the development of paresis. However, he should not too readily admit trauma as a cause of paresis. If a long period of quietude, a period in which the trauma itself seems to have undergone a complete recovery, supervenes, then general paresis should not be reported by the surgeon.

Lépine has recently noted the following features as desirable in board reports concerning paretics: nature of trauma, length of service, fatigue endured, insomnia, date of infection, treatment, W. R.

=Can “gassing” light up a paresis? Example from de Massary of Issy-les-Moulineaux.=

=Case H.= A soldier, 35, was sent to the _Centre Neurologique_ with a hospital ticket reading:

“Neurasthenia, general weakness following intoxication by gas.”

The soldier was thought at first to be a neurasthenic. But he soon showed signs of more pronounced mental trouble. The voice was suspicious. There was a slight irregularity of pupils.

An epileptiform attack occurred, followed by aggravation of symptoms.

Lumbar puncture showed pleocytosis. The W. R. of the serum proved positive.

Yet the evident =neurosyphilis=, possibly =paretic= (de Massary’s diagnosis), was preceded by a neurasthenia and the neurasthenia was preceded by “gassing.”

De Massary believes the patient _and his family_ would perhaps be justified in believing the condition produced by the injury. De Massary is not clear as to the financial deserts of the patient. It is not a manifest case of aggravation of antebellum symptoms, even if it be neuropathologically an instance of acquired loss of resistance to pre-existent spirochetes in body or brain.

1. What adjuvant factors have been recognized in military paresis? Aside from syphilis, Rayneau finds that alcoholism, malaria, sunstroke and various intoxications serve as causes for paresis. Rayneau points out that the apparent integrity of the mind in general paresis may be such that they last in the army some time and have their oddities ascribed to misconduct or breaches of discipline. In fact the Legrande du Saulle called this early period in general paresis the _medicolegal period_, showing, as it so often does, thefts, outrages against decency, frauds, assaults, exhibitionism and the like. To be sure these acts are absurd and infantile and not difficult to recognize as of psychotic origin.

=Syphilis may bring out epilepsy in a subject having taint. Case from Bonhoeffer, 1915.=

=Case I.=[28] 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 had been somewhat of a drinker. His sister had suffered from convulsions 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 for the lost period.

This retrograde amnesia is uncommon in epilepsy and suggests organic disease. No sign of organic disease was found on neurological examination. The patient had no 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.

As to the amnesia, it is of interest that alcohol should long before have been able to cause amnesia in this man in the same way as does now the syphilitic epilepsy.

1. In view of the fact that this _Landwehr_ man appears to have acquired syphilis while on campaign, what is the responsibility of the government for treatment? The Canadian authorities, as stated under Case E, are in doubt whether contraction of venereal disease constitutes negligence on the part of the soldier. It would appear to us that where a government does not take suitable steps to prevent the acquisition of syphilis by the soldiers, the government must assume a measure of responsibility for the syphilis incurred. The government’s responsibility would be still greater in equity, it would appear, if commercial opportunities for the acquisition of syphilis are maintained under more or less close government supervision or (even as has been claimed for certain encampments on our own Mexican border) if shelter for illicit sex relations is afforded within the limits of a military camp. In a certain community, “E,” for example, it is claimed by Exner,[29] the district for prostitutes was “situated within the lines of military camps and protected and ‘regulated’ by the military authorities.”

But even if the government has no legal responsibility in this regard, it would be well to consider the ultimate results of the syphilis that will probably be acquired by great numbers of soldiers under campaign conditions. Aside from the ravages of syphilis outside the nervous system, it is well known, as Weygandt intimates for German conditions, that the aftermath of war will be a high proportion of cases of neurosyphilis.

Weygandt remarks in his review of the influence of the war upon psychiatry, that the opportunity for syphilitic infection in the campaign is considerable. In the war of 1870, the conditions in this regard were extremely unfavorable, and writing in 1915, Weygandt remarks that at present there should be a prophylaxis against syphilitic infection by the soldiers, which prophylaxis should be the most energetic possible. Continence on the part of the soldiers and the isolation of infected women, with examination by specialists, have been advocated by Neisser and by Mendel. In the ’80’s a great number of cases of locomotor ataxia developed in Germany, which were due to syphilis acquired by the soldiers and officers in the war of 1870.

=Syphilis in a psychopathic subject. Convulsions 5 days after Dixmude. Case from Bonhoeffer, 1915.=

=Case J.=[30] 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, and absences, post-convulsive headaches, and mild bad humor.