Part 19

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 eyes. There was a marked diminution in the memory. Heart was in the 5th space on the nipple line, pulse 110; Wassermann reaction negative; red blood cells, 3,520,000, white cells, 6500; albuminuria, hematuria, leucocytes, and urethral cells in the urine. The temperature had now become normal. The lateral lobes of the thyroid were slightly larger than normal, but not painful. Sella turcica was unchanged upon X-ray. Exploratory puncture of a tumor showed much free fat, without fatty acid crystals and with some fat cells. The cells could not be cultivated in test tube. The authors believe it doubtful whether this instance of Dercum’s disease is related with the shell explosion.

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.

VIII.[5] SCHIZOPHRENOSES

(DEMENTIA PRAECOX GROUP)

[5] VII. Geriopsychoses (senile-senescent group) not represented in war cases (see page).

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 in things, and lying indifferently, with a blanket over him.

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.