Part 20

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 him. He also said that he was a rich nobleman, a cavalry captain with a servant (asked to be given his pressed clothes and his cigarettes), and was being pursued. He rode his pillow as if it were his horse, and hid it in the horse’s stable, namely, the bed. He ate nothing, as he thought everything was poisoned; smeared himself with faeces and drank urine as “strawberry punch.”

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 foreign words, somewhat improperly used. After a time he began to sit about dully and at times to run about and throw himself into and out of bed, or strike rhythmically with his shoes on the floor, or draw his shoulders together, making grimaces, rolling his eyes and breathing deeply. He said he had to make these movements involuntarily if he were in some way excited. But the peculiar conduct also often occurred without any emotional prod. His emotions were variable, but on the whole indifferent and not always quite suitable.

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 all the soldier’s life, but why should he be specially favored? Was he not to be called sooner or later to hold a high rank? He confessed, in fact, that he was to be the King of France, and, like Joan of Arc, was to save his country. Now the soldier began to understand the hidden significance of his surroundings. Everything around him was symbolic, thus, white, of purity, order and royalty; red, of anarchy, disorder and atheism. Some white ship which he saw outstripping some darker ship showed him how the kingdom of France was arriving once more. In fact, there was a symbolism in the whites and yolks of eggs, and the proportion of yolk to white was as one to five. He made talismans to exorcise bad spirits.

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.