Part 22

November 27, 1914, after a night in the trenches, when two shells burst near him, the adjutant turned up at the relief post with wild eyes and a complaint of fatigue, and of an old wound and headaches. The wound he had gotten in a fight which gained him his grade of adjutant. The physician prescribed rest. He sat down by the stove, silent and dejected, and at about four o’clock, in the presence of the medical assistant, made preparations to go, leaving sack and saber behind, but taking outer garments and revolver case. On the way from the farm, he met comrades and told them he had been evacuated to his dépôt on the colonel’s order, and walked with them, Indian file, in the midst of falling shells, the others talking but the adjutant himself silent. At nightfall, he said, “Good evening,” and parted from them. Of his further course to his home, all recollection was lost by the adjutant; in fact, he did not remember anything beyond the Palameix Farm, where he had seen a comrade wounded in the head. He got home November 29th, at eight in the morning. He had most of his money with him, having traveled by train some distance without a ticket; moreover, without asking for a ticket, and without having eaten. When the ticketman in his home town asked him whether he was back from the war, he looked at him vaguely and went out without replying; nor did he reply to a newspaper man on the road home. This was the more strange as he was ordinarily an affable person.

He had a convulsive crisis at home, after which he was exhausted and apparently unable to move or reply. A physician said that he had had a cerebral shock. When the police arrived, two hours later, he was apparently delirious, saying such things as, “_The Christians want to shoot me but I know the rules! Come, boys, stay in the trenches!_” “_There are two more dead ones!_” etc. During the day he recovered consciousness and was greatly disturbed at his military crime.

In point of fact, he had had, at the age of 17, analogous crises, as was certified by Régis, who had cared for him from 1907 to 1909 for hysteria with sudden somnambulistic attacks and amnesia.

While in prison after his arrest, he also had hysterical crises with agitation, flushed face, hard attempts to vomit, respiratory disorder due to interference in the throat (globus hystericus), and delirious phenomena (“Germans had followed him home”).

After his birth his mother had had two miscarriages and a stillborn child. The adjutant was declared irresponsible and acquitted. This is apparently an instance of hysteria without stigmata.

Hysterical Adventist.

=Case 172.= (DE LA MOTTE, August, 1915.)

An engineer, 31, in the Landwehr at the outset of the campaign, was first put on sentry service in Berlin on the ground that he was an Adventist. He was later put into the military service and had difficulty because he did not want to serve on Sunday. He was shoved from one company to another. He refused to be inoculated and was arrested therefor. In the prison, he began to hear God’s voice calling to him distinctly to tell his fellow-men that the end of this was going to be the end of all things. Back in the barracks, he again heard a voice--“_Come forth!_”--“_Go!_” He went! He had his revelations then published in the form of tracts, and held Bible readings day and night among his friends in Bremen--looking for the signs of the times in the Bible sayings. One of his fellow Adventists finally warned the police, and the military authorities put him under psychiatric observation. He proved to have numerous stigmata of hysteria. He talked freely about his visions, and was aware that he was punishable.

Here, then, was a case of hysterical psychosis, liberated by military service.

Fugue, psychoneurotic.

=Case 173.= (LOGRE.)

The question, Is this escape really a fugue? is brought up not only in epileptic, alcoholic, and melancholic cases, but also in cases suggestive of psychoneurosis. A son of an insane person was subject to what may be called a phobic or obsessive fugue. The case may be called one of morbid cowardice and was observed in a soldier in the trenches. In point of fact, the man had always been an anxious and fearsome person, given to phobias. He had night terrors and fear of diseases and death. He was agoraphobic in adolescence, and had to have a policeman or passerby go with him through a public place. He had had also suicidal and homicidal obsessions, and periods of psychoneurotic anxiety.

This man’s sojourn at the front put his morbid personality to a cruel test. He was soon known by all in the trenches as a _froussard_. He had a terrible fear of the guns, jumped, grew pale, trembled, complained of palpitations, lumps in the throat, etc. He was the laughing-stock of his comrades; but according to the patient himself, he was more afraid of his own emotion than of the shells, although his comrades couldn’t understand it. He was employed as a kitchenman, in a post not much exposed. A more resolute comrade helped him to escape, escaping also himself, thus bringing up the problem of _fugue á deux_. Limited responsibility was decided for the case, although the fugue had been aided by his morbid anxiety. Of course, his place was not in the trenches at all. He was condemned to two years in prison. After his sentence, he was given a chance to rehabilitate himself by sending him again to the trenches, but he had to be evacuated a few weeks later on account of his increasing emotionality.

Shell-shy; war bride pregnant: Fugue with amnesia and mutism.

=Case 174.= (MYERS, January, 1916.)

A rifleman, 30 years old, was brought to a casualty clearing station, looking like an imbecile, with a history of having wandered about aimlessly, not knowing where he was or what he was doing. On questioning, he remained absolutely speechless and terrified. Four days later, in conversation with Major Myers, he was got to speak in a faint voice about his wife, home, and occupation, saying that the month was October (when it was actually August) and that he had been in France two months, when it was actually twelve. He described emotionally certain trench scenes, and then thought of his wife sewing.

Hypnotized, he remembered going into a dug-out after running away from shells; he was made to talk in a loud voice. Next day, during hypnosis, proper orientation for time reappeared. He was got to write an ordinary soldier’s letter to his wife. The following day he was active, making beds, but was mute (there was a case of mutism in the same ward). Under hypnosis speech returned. He had gone to a horse show, and upon his return, something hit his back; shells had begun to fall. Found hiding in a shack, he was carried to a hospital in an ambulance. After this hypnotic treatment, the power of speech was maintained, although his voice became faint or failed whenever he was asked about the incidents described above. Next day he waked speaking normally, nudging his neighbor and asking, “Is it me that’s talking?” He had before appeared dull and depressed, but now appeared an intelligent, agreeable, and garrulous fellow. It appears that his wife was a war bride and he had heard some months since that she was pregnant. He had been troubled, thinking she was in money difficulties and kept thinking about a friend whose wife had lost her first baby. Recovery appears to be complete except for occasional headaches, and the patient is now serving in his reserve battalion.

A neurasthenic volunteer.

=Case 175.= (E. SMITH, June, 1916.)

A man who volunteered for service at the outbreak of the war (he had recently been an inmate of a sanatorium) was sent back to England as neurasthenic after three trying months at the front. The case sheet read that he was subject to dazed conditions. In hospital he suffered from insomnia, and before his slight periods of sleep he constantly had visions of two comrades who had been terribly lacerated at his side. These hallucinations in their reality aroused in him a fear that he was insane.

There were also terrifying dreams, beginning with episodes at the front and ending with sex experiences. These dreams were ended by seminal emissions. These formed a second cause for the patient’s belief that he was insane, as he said he remembered literature read as a boy concerning spermatorrhoea.

In the treatment of this case the writings of psychologists who had studied hypnagogic experiences were used and the absence of hallucinations during waking hours was stressed. The remembered literature regarding spermatorrhoea was discounted by the rational explanation of his state.

He seemed to be getting on well when a trivial accident caused a relapse. While he was saying goodby to his wife, who had visited him, she was taken ill, and he went home with her. He was punished for being late in returning to the hospital. Although no moral stigma attaches to confinements in barracks in most soldiers’ minds, in this man a depression was produced and suicidal talk followed. It seems that his father had been sent to jail when he was a child, and he felt he had been tainted by his father in such wise that his “criming” was due to heredity. With the removal of this misconception he became more rational and immensely improved.

Five months’ war experience: Neurasthenia in subject without heredity or soil.

=Case 176.= (JOLLY, January, 1916.)

A 38-year old soldier is Jolly’s example of a neurasthenia produced in a person without previous neurasthenic traits or hereditary factors. This soldier had been a moderately good student and never ill. He went into the battle line in December, 1914, and came out in May, 1915, on account of exhaustion. The case is not wholly convincing since the patient had a shrapnel injury of the skull, described as of so inconsiderable a degree that he was not put on the sick list on its account. The patient finally arrived at the Nuremberg Hospital, complaining of pressure in the head, as if there was a band around the head, and dizziness. He wept a good deal saying that the sight of the dead had frightened him. Sleep was restless and there were unpleasant dreams of the battle field. Intelligence was not in any degree disturbed. The supra-orbital points were sensitive to pressure. The tongue showed a marked tremor and was coated; the mechanical excitability of the muscles was increased; and there was reddening of the skin on stroking. There was a fine tremor of the extended fingers, less tremor of the head and of the body at large. Knee-jerks normal. Nutrition well preserved. Partial recovery in the hospital.

Importance of arterial hypotension in the diagnosis of psychasthenia.

=Case 177.= (CROUZON, March, 1915.)

A man of 32 (never well, with general weakness, ideas of consumption and vacuous thinking following a good recovery from bronchitis at 28, unsuccessful in business, subject to weaknesses) had had eighteen months antebellum of what might be called psychasthenia. There were spells of loss of consciousness without convulsions, and probably of hysterical nature. There had been for two years insomnia and a general hypobulic slowing down of work.

In military service the crises became more frequent, coming two or three times a week. Tuberculosis could not be shown, nor was there any organic lesion of the nervous system. The arterial tension (Potain sphygmomanometer) stood at 11.

According to Crouzon, arterial hypotension is an objective sign tending to assure the organic nature of a psychasthenia. Whereas simple neurasthenics are hypertensive, others have long been recognized as hypotensive; but heart experts have recognized this asthenic hypotension more than psychiatrists or neurologists. In differential diagnosis it is necessary to consider and exclude the early hypotensions of pulmonary tuberculosis and those of Addison’s disease. This hypotension is most frequently observed in constitutional neurasthenics and psychasthenics. Hypertensive drugs, adrenalin, tincture of colchicum, have produced a transitory improvement in a number of cases, but the amelioration has halted with the stoppage of the drugs.

_Re_ hypotensive and hypertensive cases, see remarks of Lépine under Case 176. See also Case 169, illustrating some contentions of Green, from Mott’s clinic.

Service in France and Salonica: Psychasthenia.

=Case 178.= (EDER, March, 1916.)

A man, 29, after some months’ service (three months in France and later in Salonica) was invalided for backache, insomnia, and enuresis. It seems that this married man had never done any work after leaving school at 18, having substantial private means. He had been married for 3½ years, had a son, and was, according to Eder, perhaps morbidly attached to his wife and child. He had been a sportsman and was selected for sniping work in France. The son of a shipbuilder, he had always planned all kinds of ships and engines, never to be used. After seeing the world, he was about to enter his father’s business when he had to take care of his father in a nervous breakdown. After a second attack, the man never entered business.

February 6, 1916, wide-spread patchy analgesia and lumbar hyperesthesia were found. He thought sluggishly, being restless and holding attention poorly. He began twenty letters, destroying each after finishing a few lines. He was shy and felt that everybody was looking at him. He became speechless if he had to address his commanding officer. He had an obsession to mark each flagstone and touch each post, and various counting and arranging obsessions.

The _Horme_ (Jung) was elusive. A dream: “I was in a cargo boat in the river; we were steering straight into ferry and harbor. The pilot rang down ‘Full speed to stern’; I pushed him out of the way, and rang down ‘Full speed ahead, two points to starboard.’ We went straight past ferry and harbor without accident.” Again, a few days later, “In a motor car, came to some rocks which sprang up in front of me. The machine broke down. I abandoned it and clambered over the rocks. It was tough work. My object was a ship. I got to the ship, took hold of the wrench, and signalled ‘Let go.’” Herein, according to Eder, are certain obvious symbolic conversions.

Antebellum attacks, with dizziness: Fainting on horseback. Neurasthenia.

=Case 179.= (BINSWANGER, July, 1915.)

A harness-maker, 37, a corporal, was called to the colors on the second day of mobilization. He was attacked by a slight dizziness in the evening (see previous history below). He went into the field on August 7 and had repeated attacks of dizziness, despite which he took part in several skirmishes. He could not ride on horseback, since dizziness, ringing in the ears, headaches, and trembling of the whole body would develop. October 27 a severe fainting attack came while he was sitting on a horse. He woke ten hours later, vomited several times and felt dazed. Two weeks later hearing in the right ear began to be impaired. During several transfers from hospital to hospital near the East front, there were two more severe attacks of dizziness and vomiting. Brought back to Germany, the patient finally came to the Jena Hospital, May 20.

The estimate of this case depends somewhat on the previous history. He appears to have come from a healthy family, was married, and had two healthy children. His bodily and mental development had been normal; he had been an unusually good scholar, but he stammered from his tenth year without apparent reason. He had had treatment in an institution for stammerers at 17, achieving a complete cure in six weeks. His military service was as a cavalryman, 1897-1900, after which he had married. There was no excess in alcohol; he was not a smoker. From his own account, he had always been somewhat nervous, had trembled easily, and had fallen to stammering when excited. In 1913 there had occurred, after physical exertion, three violent attacks of fainting, with dizziness, vomiting, and excessive perspiration, each attack lasting from two to three hours. However, from that time to just before the war, he had been free from attacks.

On examination at the Jena Hospital, the patient complained of general weariness, a feeling of pressure in the back of his head, a hammering all over the head, ringing in the right ear, impairment of hearing in this ear, a feeling of dizziness on raising the head, palpitation of heart, especially at night, occasional trembling of the whole body, and absolute inability to walk.

The man was slenderly built, of medium height, in moderate nutrition; pale of face and mucosae; pulse small, regular, and 114. Neurologically, the deep reflexes were generally increased, and the skin reflexes decreased. Percussion on the back of the head elicited marked pain. There were no pressure points. The movements of the arms were free; there was a marked tremor of both hands, more marked on the right. The left grasp was 45, the right, 20, by the dynamometer.

When lying upon his back, the patient could move his legs, but he moved them only slowly and with tremor. The heel-to-knee test was successfully executed despite the tremor; nor could it be demonstrated that there was a genuine ataxia. Placed upon his feet, he would collapse, nor could he be made to walk at all. With trunk supported, he was able to make only a few unsuccessful attempts to drag the feet forward.

Associated with this apparent paralysis, the sensitiveness to touch had entirely ceased in the legs, as well as sensitiveness to pain. The zone of analgesia, however, was more extensive than the anesthesia, spreading upwards three or four cm. farther in front. Ticking of the watch could not be heard even at the meatus of the right ear, although hearing of the left ear was entirely normal; bone transmission on the left side. Whispers could be heard close to the meatus. On speaking, the patient stammered in starting sentences.

He looked extremely anxious during the first few days in the Jena wards, claiming that he could not raise himself. When his trunk was raised, he would let himself sink feebly back into dorsal decubitus. However, when believing himself unobserved, he was found to be able to move himself in bed somewhat quickly. He was able to get a box from beneath the bed, to open the drawer of the night-stand, and to take remarkable care of his moustachios. He complained more and more of headache, though his appetite and sleep were good. He was often irritable.

Treatment at first consisted of cold packs of the legs twice a day, salt-water baths, active and passive exercises of the legs in the position of dorsal decubitus. The patient declaimed against this treatment. There was slight improvement after a week of treatment. He was then able to raise himself in bed, seat himself on the edge of the bed, and stand without support, all the time, however, groaning and moaning. After a few moments, he would fall back on the bed, complaining of violent headache and dizziness. While standing, both legs trembled.

Antityphoid inoculation: Neurasthenia.

=Case 180.= (CONSIGLIO, 1917.)

A corporal, 39, began to be sleepless and weary, with headache, pains in the back, and dizziness. He was homesick. Upon hospital examination he was very variable in mood, rather hostile in attitude, and at the same time suggestible. He was so confident of being sent home that he anticipated the diagnosis by sending his belongings back to Sicily at the time he was transferred to hospital from his regiment.

After a month’s rest and psychotherapy, the man’s general condition was greatly improved; he was no longer sleepless and had no longer any sign of neurotic disorder. He still maintained that his memory was weak, although in point of fact his memory was very good and quick. He could narrate all the facts about his neurasthenic state. The man’s complaints were out of all proportion to any demonstrable somatic disorder. He was discharged, cured, to be put to work at shoemaking, with the diagnosis, neurasthenia. This neurasthenic state developed after antityphoid injection.

_Re_ the occasional curious effects of antityphoid injection, see Case 65.

Neurasthenia (monosymptomatic: Sympathy with the enemy).

=Case 181.= (STEINER, October, 1915.)

A non-commissioned reserve officer, 26, in civil life a merchant, had a strong hereditary taint, having been also in peace times very nervous and on that account obliged to give up his studies. At the age of 14, he had seen a man fall down from a roof and was much excited about it.

At the beginning of mobilization he suffered a functional aphonia for a few days. He could not let his men shoot at the enemy because of an idea that occurred forcibly to him: that the enemy’s soldiers had wives and children! He felt badly on this account. Later he had a constant taste of blood in his mouth and a smell of corpses in his nose. Toward nightfall all these symptoms would change for the worse, and the symptoms would become especially bad whenever he had anything to do with the wounded. He tended to weep much and was easily frightened and had also various physical symptoms of neurasthenia.

_Re_ the amazing sympathy with the enemy, see Case 229 (Binswanger) and Case 554 (Arinstein), in which chloroform lifted from a German and a Russian consciousness respectively opposite emotional tendencies.

Shell-shock CLAUSTROPHOBIA: Preferred shell exposure to shell-proof tunnel.

=Case 182.= (STEINER, October, 1915.)

A colleague of Steiner, an army physician, 35 years of age, with strong hereditary taint, having two sick sisters (one dementia praecox), had been incapacitated for work through a neurasthenia a few months before mobilization. However, at first he felt very well, marching through Belgium and into Northern France.

On the night of the 17th of October, 1914, a shell struck the house next where he was and startled him up out of sleep. After that, especially at nightfall, upon entering a cellar he would have the feeling of the ceiling falling down, and he would go restlessly from one space to another. Afterwards, any closed room, however secure or distant from the front and free from shells, would give him the feeling of the ceiling about to fall down. He could no longer sit quietly anywhere, but walked about and avoided the company of others.

A characteristic observation is the following as described by the physician himself: There was an absolutely shell-proof tunnel running to the position at the front where he was on duty. It took about 25 minutes to go through the tunnel, but on account of his feelings he could not bring himself to use this tunnel but walked over the exposed hill which was frequently shelled. Curiously enough, after the appearance of the first symptoms, a shell exploded nearby without any marked psychical effect. This happened about noon. The obsessions were stronger in the evening. Objectively, there were neurasthenic symptoms of a bodily nature; there was vasomotor excitability. He was depressed, wept easily, and showed lack of decision; he had tormenting thoughts that he had not fulfilled his duty.

XI. PSYCHOPATHOSES

(GROUP OF VARIOUS PSYCHOPATHIAS)

A case of Pathological Lying occurring in a soldier.

=Case 183.= (HENDERSON, July, 1917.)

No. 27369, a private, attached to the 15th Battalion Durham Light Infantry, was admitted Oct. 14, 1916, to Lord Derby War Hospital from Netley.