Part 21

There were two groups of symptoms; persistent headache, painful hyperacousia, vertigo, tremulous walk, cervical spinal column stiff and painful both spontaneously and to pressure, muscular weakness, tremor of hands, hypesthesia of extremities especially upper, exaggeration of tendon and bone reflexes with tendency to ankle clonus and patellar clonus, sterno sign lively, frequent nosebleeds (two to four times a week), profound sweating, unequal pupils.

On the mental side it was clear that the man’s character had changed, according to information supplied by the mother. Aprosexia, impairment of memory, recollective and retentive, inability to give age, birth date and similar data. Words came with difficulty. Some disorder of comprehension; stereotyped replies; negativism; indifference; he would sit hours in a chair or on a bed silent and inactive. Fixed attitudes; dull glance; eyelids half closed. In short, it seemed as if this patient was a case of catatonic dementia praecox.

_Re_ dementia praecox and shell-shock, Stansfield remarks upon the similarity of certain symptoms found in Shell-shock to those of dementia praecox; for example, apathy, retardation, amnesia and speech defect. According to Stansfield, one often gets the impression in a Shell-shock case as though the trench and shell fire stress had merely brought out a latent dementia praecox.

_Re_ his new “sterno” sign (sternomastoid contraction on percussion of neck at level of third dorsal vertebra), Dupouy claims it negative in normal subjects, positive in concussion, meningitis, and general paresis.

Shell-shock; fatigue; fugue; delusions. Recovery.

=Case 162.= (ROUGE, 1915.)

A sergeant, 40, had had nineteen years of service and had been married five months when he was recalled to the colors when war broke out, and sent to the front. March, 1915, he was exposed to bomb explosions during a very intense bombardment. He then got into the way of saying that he was akin to everybody. April 20, he was evacuated on the score of general fatigue, rejoined the company May 17, left his comrades at the end of June, and was taken up as a deserter by the police, who, observing his state, brought him to a hospital. He there showed “cerebral overexcitement” with “incoherence and nervousness.” In two or three days he was much better. He was evacuated on the sixth day to the hospital at Vichy.

There was amnesia for the fugue and he could remember no further back than the extraction of a tooth at the Vichy hospital. In fact, he attributed the fugue to this dental operation. His wife took him home, but he soon threatened her with a revolver; got better in the night and next day went about apparently normal, buying things, however, extravagantly. His delusional state began once more, and two days later he was brought to Limoux. It seems that, while in Mauretania, he had formerly shown signs of mental disorder, having a mania for wireless and airplane inventions and the like. A cousin-german had also been in a hospital for the insane twice, recovering each time. There was a lingual and manual tremor. The man had not been recently alcoholic. He was a little irritable and showed a little megalomania, but worked hard and made himself useful. He went out, recovered, November 12, 1915.

Analysis indicated that this sergeant received a moral shock as a consequence of his fatigue and the shell fire, which emerged in a spell of confusion. It may be that his predisposition had something to do also with this spell and the fatigue. In any event, it seems as if the latter phenomena were not all assignable to war stress.

IX. CYCLOTHYMOSES

(THE MANIC-DEPRESSIVE GROUP)

A maniacal volunteer.

=Case 163.= (BOUCHEROT, 1915-6.)

An Alsatian became the object of much attention when he enlisted at the outbreak of the war in the infantry at the age of 59. He was interviewed and soon became more than naturally exuberant. The peculiar things he did soon brought him to Fleury in a gay and expansive mood, singing and talking as hail fellow with everyone he met.

The next day he grew more excited, disrobed and threw his things out of the window, filled his bed with excrement and wanted to smear the orderly therewith. He took other attendants for old friends and wanted to kiss them. His language and ideas were incoherent. He broke glass.

This situation of alternate joy and anger lasted one month, leaving him in an excitable, unruly state. He wrote many prolix letters to the prefects and the ministers, insisting on the discharge of certain patients and offering plans for the defense of France. He got better and finally, in October, 1914, was invalided home still slightly exalted.

_Re_ the cyclothymias, Montembault remarks that manias have been less numerous than melancholias in the present war, whereas in 1870, manias were more common than melancholias. Morselli likewise remarks upon the rarity of manias amongst the Italian soldiers. Butenko reports upon the maniacal cases amongst the Russians and how the men wish to enter the ranks, the women the nurse corps. E. Meyer, for Germany, found 4 per cent manic-depressives. Birnbaum quotes from Bonhoeffer (3 per cent) and Hahn (2 per cent) for war times as against Stier’s 9.5 per cent of cyclothymic cases in the antebellum period, 1905-1906.

Fugue: melancholia.

=Case 164.= (LOGRE, 1916.)

Logre classifies as a melancholic fugue the adventures of a man who had been depressed for some days, had stopped talking and eating, and ran away suddenly in the middle of an attack of anxious agitation. He was very anxious over the health of his daughter, whom he thought to be severely ill. It was, in fact, to go to Paimpol that he deserted, but he deserted with his arms and without any money. He went off on foot “in the Brittany direction.” He had gone 50 kilometers, the next day, and was picked up near Chateau-Thierry by two gendarmes, who fell upon him, seeing his regalia, and cried, “Give yourself up!” He replied in a firm voice, “No, I shall not give myself up!” and seizing his gun he made at one of the gendarmes. There was a fight. The gendarme declared in his report that he judged it opportune to retreat behind a tree. The soldier, knowing his trench lore very well, barricaded himself behind a pile of beets. There he would have held the gendarmes in check for some time if another had not succeeded by a détour through some woods, in catching him. He gave himself up after firing several ineffective shots, but not without getting a bullet in his left thigh himself. With the charge of desertion and attempt to murder, he was handed over for mental examination. He was, in fact, a melancholic patient, subject to attacks of anxiety, and requiring long observation at a neuropsychiatric center for diagnosis.

Chavigny observed numerous victims of melancholia characterized by war terror. He remarks a somewhat curious fact that, whereas the melancholics were numerous and their mental states related to the war, on the other hand, the paretics were rather apt to be maniacal than melancholic. Soukhanoff, however, remarks on the occurrence of depression in a great number of types of psychosis, as was found in the Russo-Japanese war. Soukhanoff found frequent instances of schizophrenia, wherein the melancholia tends to conceal the actual dementia praecox. Soukhanoff predicted that depression will figure largely in the war.

Apples in No-Man’s-Land.

=Case 165.= (WEYGANDT, 1915.)

A soldier in November, 1914, suddenly climbed out of the trench and began to pick apples from an apple-tree between the firing lines. The idea was to get a bag of apples for his comrades, but he began to pelt the French trenches with apples. He was called back and on account of his strange conduct sent to hospital. Here he was at times given to pressure of speech and restlessness; he would climb the posts of the sleeping room and then loudly declare he wanted to get back to the trenches; he did not want to go back to Germany alive; did not want to live over to-morrow; was guilty of a sin; had a spot of sin, _Schand_, on his heart. Sometimes he refused food and said anything else tasted better. It seemed he had formerly talked about the Iron Cross.

After being transported to Germany, he was at first a little negativistic and apparently blocked. He talked about his experiences and said he wanted to go to Russia. He explained the episode of the apples on the basis that they were all really hungry and that he had sought to encourage his comrades who were unused to war. He had noticed the French all shot too high.

Physically there was a somewhat uneven innervation of the face, unilateral epicanthus and an areflexia of pharynx. Now and then the man was very irritable, but in general he was in an elevated frame of mind.

Weygandt interprets this case as one of hypomania, remarking that war influences may serve to bring out preëxisting manic depressive tendencies.

_Re_ differential development of mania and depression, see remarks under Cases 163 (Boucherot) and 164 (Logre).

Four months in trenches: Depression; war hallucinations, arteriosclerosis (aged 38).

=Case 166.= (GERVER, 1915.)

A Russian reservist, a private, 38, went into the trenches, March, 1915. Without taking part in any battles or sustaining any injury, he four months later became depressed and had to be evacuated to a hospital and thence to the interior, little changed for the better.

He was an ill-nourished man, of middle height, with pallid skin and membranes; arteries sclerotic; face, eyelids, and tongue finely tremulous; hands tremulous; slight dermatographia; exaggerated tendon reflexes; pulse 100.

He seemed disoriented for time and place; looked weary; walked with back bent over; spoke in whispers, and appeared somewhat unclear. Thinking was slow and difficult.

He occasionally shuddered and looked to one side, said he was afraid, and was constantly troubled by thoughts of fire. The Germans were pursuing him; he could hear their voices and footsteps. He himself was doomed, and his family also; he felt he was the cause of all the domestic woe. His own heart was dying away; he had fits of anguish and causeless fear, and was under the constant expectation of death.

One day, he escaped from the hospital and went to the chief physician’s tent, where he lay on the ground. When he was found and asked why he was there, he begged the physician to save him from the Germans. The man was not alcoholic and had no previous history of mental disease.

_Re_ early arteriosclerosis, Maitland in the second interim report of the British Association Committee on Fatigue in Warfare, speaks of the many Serbians, who, after six years of nearly continuous Balkan war, show a marked arteriosclerosis. Maitland remarks that the line officers were already showing (1916) a growing delicacy of perception as to the “breaking point.” Men that do not break may return from the lines, pale, with low blood pressure, and a _faiblesse irritable_, shown by restlessness of hands and feet.

War stress: Manic-depressive psychosis.

=Case 167.= (DUMESNIL, 1915-6.)

A naval officer, 22, transferred from sea service, went into Belgium, November, 1914, in a Fusilleur brigade of marines and there greatly distinguished himself, growing very weary and enervated, however, about the middle of April, 1915. His attitude to the men altered: he sometimes struck them; gently, though, according to his account. They must do in ten seconds what they really could not do under ten minutes. The officer, in fact, had lost all notion of time. He went about agitatedly, contradicted his superior officers and was troubled because, as he said, they often were men of inexperience as compared to himself. He grew irritated, too, because there were Free Masons in the army and when he was sent to the asylum in July, 1915, said it was the doing of the Free Masons. He did not seem to have any hallucinations. His ideas and sentiments were very labile, and a bit confused, and not all his interpretations dealt with Free Masons and occultism. August 5, however, the phase of calmness was again followed by agitation; he broke things and laughed explosively. August 10, another attack occurred, with destructiveness. During the next few days there were alternate phases of depression and excitation. He was negativistic, resistive and struck attendants.

_Re_ war stress and psychoses, Morselli finds the acute cases on psychopathic soil. First in the list, he places the neurasthenias and psychasthenias, and second, the hysterias, two groups which, more than the remainder, may be said to constitute the so-called Shell-shock group. Third, he found depressions ranging over into a delusional state with suicidal ideas; fourth, a species of stupor, occasionally catatonic, recalling dementia praecox; fifth, transient hallucinatory states; sixth, confusions (Meynert’s amentia?); last, manias.

The above case of Dumesnil appears to be a pure case of manic-depressive psychosis developing on the war basis, but perhaps merely comes from a latent cyclothymia.

Predisposition; war stress: Melancholia.

=Case 168.= (DUMESNIL, 1915-6.)

A farmer, 30, was mobilized August 2, 1914, and was wounded in the hand September 27. He went back to his dépôt in December and stayed there until March, 1915, when he was sent to Dunkirk. Before leaving the dépôt he said that he had heard soldiers declaring that he was not doing his duty, that he was going to be court-martialed, that life was at an end for him. At Dunkirk he said these same soldiers continued to say the same things about him, forming a band about him, led off by a subaltern officer who meant to frighten him and to make him talk. One night sulphur was thrown at him for poisoning purposes; he complained of this to a sergeant and declared he did not understand why he should be thus pursued. After the bombardment of Dunkirk the hallucinations grew more intense. He was sent to hospital and was so harried by the voices that he wanted to throw himself down a staircase but was caught in time. At the hospital for the insane he complained that his thoughts were being heard and loudly repeated; he was made to make incoördinate movements; was treated as a spy. He thought he must be a German or they would not treat him so. He waited for death as he wanted to be executed at once.

This man’s father was alcoholic. He himself at the age of fourteen had had a period of neurasthenia with some sort of nervous seizure for a period of five months. At 28 he had a rheumatic seizure which kept him in bed fifty days. A daughter born to his wife had died a few days after birth.

Dumesnil’s analysis is melancholia with delusions of persecution, due to war stress in a predisposed person.

_Re_ melancholia and the war stress, see remarks under Case 167. _Re_ manic-depressive psychosis in the Russians, Khoroshko found 9.4 per cent of manic-depressive cases, the same percentage of epilepsies, 10 per cent of paretics, and 20.4 per cent of schizophrenic cases amongst a group of 318 neuro-psychiatric cases. Almost all his manic-depressive cases had been patently so antebellum.

Depression; low blood pressure. Pituitrin.

=Case 169.= (GREEN, 1917.)

A private, 22, was sent back from Germany as insane. He had been in the asylum at Giessen seven months, and a prisoner in all fifteen months.

August 16, 1916, he was admitted to Mott’s wards at Maudsley in a markedly depressed and lethargic condition. He had improved somewhat in October, but still had periods of depression. He was put on thyroid extract (Green’s treatment was in doses measuring from gr. ¼ to gr. 1, t.d.s.; according to Green, the effect of thyroid extract is more rapid when coupled with pituitrin). In December he was given pituitrin extract gr. 2, t.d.s. In January, 1917, he was no longer depressed or lethargic. He complained of pain in his back, found to be due to a bullet. This was removed.

_Re_ prisoners, Imboden found amongst 20,000 French soldiers taken prisoner at Verdun after the severest drum fire and strain, only five neurotic cases (data of Mörchen), and Wilmanns found but five neurotic cases amongst 80,000 prisoners. Lust reviewed 20,000 war prisoners in Germany and found singularly few instances of neurosis. Shunkoff notes, however, that there are a number of psychotic cases amongst the prisoners because the _mentally_ diseased who do not disturb the military routine are kept in the line. Bonhoeffer found amongst Serbians taken prisoners by Germany, emaciation, atrophy, heart disease, and frequently tuberculosis. (See Case 166.) Bonhoeffer noted the absence of psychoses amongst these Serbians, drawing the general conclusion that campaign stress was unable to bring out psychoses. But, although the exhaustion psychoses are not found, there are exhaustion neuroses or states of acute nervous exhaustion, characterized by somnolence and depression, followed by a mild degree of overemotionality. vum Busch states that interned German civilians have gone into psychosis frequently. It is said that one in 10,000 war prisoners in Germany has committed suicide. Bishop Bury found at Ruhleben 60 or 70 cases of psychosis.

X. PSYCHONEUROSES

Hallucination in the field (surprise by _BOCHES_); scalp wound: Three psychopathic phases--(_a_) over-emotionality, (_b_) obsessions, (_c_) loss of feeling of reality (victim a “constitutional _intimiste_”).

=Case 170.= (LAIGNEL-LAVASTINE and COURBON, July, 1917.)

A cashier, 31 (of rather weak constitution but without hereditary or acquired mental taint--a religious man and for religious reasons chaste, always given to metaphysical speculation and introspection, but on the other hand, much interested in sports and very sympathetic with English manners), was about to go to live in the country on the advice of his physician when the war broke out. He was called to the colors and shortly lost his tendency to bronchitis, put on flesh, and felt delighted with his situation.

After almost two years of effective service, June 2, 1916, when his troop was cautiously advancing into a trench at the end of which they might be taken by surprise, suddenly the officer cried, “_Sauve qui peut!_ _The Boches are on us!_” The patient remembered seeing Germans emerge from every side, remembered his fear, how he had turned about and crossed over a palisade, and then no more until he found a scalp wound being staunched by his comrades in the trench. He put on his own dressing and followed his comrades on foot.

He quickly got well of his scalp-wound but remained in hospital, very weak, extremely impressionable, jumping at every noise. He got somewhat better with the rest in bed, though even a month after his hallucination, he had a spell of insomnia, thinking about his future and the possibility of a relapse, and having war dreams from which he would awake in a sweat. Once on awaking, he distinctly heard a voice saying, “_Well, Charles?_” This hallucination occurred five times, under exactly the same circumstances, except that once it was in the daylight. Adrenalin was given, 1:1000, 10 drops the first day, 20 the second, 30 the third, and a like amount on the following days. After three days of such treatment, the patient said he felt much better. Later he had a period in which he had lost self-control and could no longer take any initiative. Thus, if he wanted to reply to his mother, it seemed to him that some one not himself was ordering him to write. He now asked himself if he were not really dreaming. He would not be sure of his actual existence unless something happened to prove it, such as the nurse’s bringing him a plate.

In short as the first phase of diffuse over-emotionality had been succeeded by a second of obsessions, so the obsessive phase was succeeded by a third phase of mild loss of the feeling of reality. The first phase following the wound was one of disorder of attention, of memory, and in fact of all the mental functions, associated with tremors, tachycardia and dizziness. The second phase seemed, as it were, to crystallize intellectually the anxious apprehensiveness of the first phase. There were fears that the ceiling would fall; there were scruples concerning the past; there were fearful premonitions for the future (such as, that any bomb he might pick up would burst). According to Laignel-Lavastine and Courbon, there may have been a predisposition in the vegetative system of this subject, or even a basis in his tuberculosis, of which, in fact, the X-ray showed still some slight evidences. The obsessions appeared at night, at a time, namely, when the vital rhythm is passing from a sympathotonic period over into a vagotonic period, at a time when the organic sensations are apt to swim to the fore. According to this analysis, these somatic sensations, precisely those that the battlefield had also brought out, brought out again the other emotions which he had felt on service. It was always the emotions first developed in military service that were revived in the disease. In the third phase, the physical condition of the patient had grown much better _pari passu_ with disappearance of the obsessions and the onset of the personality disorder. The adrenalin raised arterial tension, and going down to the sympathetic caused the anxiety and war emotions linked therewith to disappear; but the adrenalin treatment, according to Laignel-Lavastine and Courbon, disturbed the organic sensations so suddenly that there was a break between the new conscious status and the old. In consequence, the patient felt that these new sensations no longer really belonged to him but were of a xenic character, imposed upon him from without in such wise that he continually asked himself whether he was really dreaming or no. This man was a constitutional _intimiste_; a psychasthenic _en herbe_.

_Re_ neurasthenia, Lépine notes that there are transient and relatively permanent cases. The term is often used to cover graver disorders, such as various melancholias and anxieties. As a rule, in France, the neurasthenics are evacuated for fatigue. There have been a number of cases in officers, who find themselves unable to make decisions on the minute and to remember military facts, or perhaps are unable to make any physical or intelligent effort whatever. A true neurasthenic, however, ought not to be a confused person. He is a man with a rather unusual clarity of view as to his situation; and his trouble appears to him to be somatic rather than as of the nature of a depression. He feels that, if he could only rest, he could be cured. Neurasthenia, according to Lépine’s war experience, is practically always the disease of a highly cultivated nervous system, and appears in men who have undertaken responsibilities. There is a group of young men who have never been physically strong, bowled over at last by some small event, such as a diarrhoea, and unable to carry on. Such men, perhaps, are likely to have some traces of an old tuberculosis, an adrenal insufficiency, or insufficient hepatic function. Martinet has found them hypotensive and rather poorly aerated. There is another group of neurasthenics (Maurice of Fleury) that are old arthritics, with increased tension. These cases are not found at the front because conditions there rather tend to reduce the trouble; but they are found doing office work in the interior. Besides these cases of the “cultivated” group, Lépine also finds a number of neurasthenics amongst the peasants, in whom anxious ideas may lead to hypochondria.

Fugue, hysterical.

=Case 171.= (MILIAN, May, 1915.)

The fugue of an adjutant who left his regimental relief post at Palameix Farm and was found several days later with his family at Castelsarrasin, was reconstructed from partial records as follows: