Part 13

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 resistance, but did not respond to orders, commands, noises, or contact. In short, the patient was in the midst of a hallucinatory dream at his post in the trenches, undergoing a bombardment. He was placed in a chair; remained motionless for a few seconds, woke up, and answered questions. “Where am I? Oh, yes; I must have been sick because my head feels bad.” In answer to the question. “What did you see; what was there?”, he said, “I don’t remember anything. I never remember. I don’t know.” The patient was dull and weak after the spell.

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.

IV. PHARMACOPSYCHOSES

(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 reason to state, according to Lépine, that if we throw in cases in which alcoholism was a partial factor, more than half, or even more than two-thirds, of the mental cases had been strongly influenced by alcohol. Lépine thinks there may be effects like those of anaphylaxis. Certainly, the startling and sudden effects in so-called pathological intoxication, as in Case 86, suggest the critical and vehement effects seen in the sensitized anaphylactic subject.

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 proper. The value of mental tests would here be extreme. There seems to be no evident epilepsy, and the majority of the phenomena can perhaps best be explained by alcoholism. Possibly the case is one of so-called pathological intoxication. The patient’s own story that, although he had been always subject to drink, he had been less tolerant of alcohol since a fall from his horse, seems to be entirely consistent with the post-traumatic history of numerous cases, so that it would hardly be wise to consider that alcohol accounts for the whole story. We must raise then in succession the hypothesis of syphilis, feeblemindedness, alcoholism, and coarse brain disease, bearing in mind also early stammering. As to the utilization of such a man, it would appear that a supervision of him with absolute countermanding of alcohol in view of the decrease in tolerance of alcohol since the fall from his horse might perhaps preserve this man for some form of military service.

_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.