Part 40

A German soldier, 35, of a nervous make-up (his mother was nervous, and he had been nervous and tremulous and easily excitable, and alcoholic to the extent of at least 5 glasses of beer every night), was called to the colors in September, 1914. He got through his training well; in May, 1915, was on very strenuous duty in a very exposed position, had frequently to stand up under heavy shelling, had a number of frightful experiences, was surrounded by corpses and mutilated bodies, and frequently took part in storming attacks. His nervousness came to a head with some suddenness; just as he was about to “go over the top,” he had no strength for the effort and collapsed. Thereafter he could no longer stand shelling, could not speak, and was inattentive to surroundings. When he was examined by a physician he fell asleep in his presence, although sleep had latterly been almost impossible on account of the shelling. He was immediately put on the hospital train and taken to the reserve hospital in Nuremberg, where he presented an appearance of extreme exhaustion, wept, seemed much fatigued, and trembled all over whenever he started to do anything. He was very easily excited and especially sensitive to noise. There was a fine tremor of the whole body and especially of the head; the knee-jerks were increased; there was a moderate vasomotor reddening of the skin after stroking; his tongue was heavily coated; but there was no other evidence of internal disorder. His pulse was strong and not rapid.

The patient got well gradually, complained at first of bad dreams, and was given to weeping. The tremors slowly improved. The patient grew better in a hospital at home.

As to the diagnosis of this case, Jolly regards it as one of nervous exhaustion. The remarkable feature is the tardiness with which the symptoms developed under the stress of war. Such a patient would probably never develop a neurasthenia under normal peace conditions. After recovery these patients may be sent back for garrison duty or for other work not directly connected with the firing line. As for the tendency to desire a pension, this wish, according to Jolly, must be strenuously opposed, both in the interest of the state and that of the patient. If there is no will to get well, some of these patients are found vibrating from garrison service to furlough and to hospital.

The above case is one of the simplest observed; yet there is evidence both of hereditary taint and of alcoholism. According to Jolly, the majority of the severe exhaustion states of a neurasthenic nature have been, in his experience, distinctly nervous before the war, and frequently show hereditary taint as well.

_Re_ neurasthenia, see views of Babinski relative to differentiation from hysteria (under Case 340).

Series of battles: Sudden mania followed by confusion with fixation of mind upon war experiences, possibly hallucinatory; general analgesia.

=Case 350.= (GERVER, 1915.)

A Russian private, looking much older than his years (35), had been in a number of battles without mental disorder. Where he was posted, however, there was a heavy artillery fire in the last of the battles. Suddenly the man became excited and leaped upon his comrades’ shoulders crying, “The devil is here! This is hell and murder, and here are the devil’s imps!” The commanding officer accordingly ordered him to the rear. His regiment had suffered severe losses in a succession of attacks upon a certain strategic height.

Upon evacuation to the field hospital and thence to the interior, his excitement did not lessen. He went about with a lost look, trembling, talking a great deal and gesticulating. His talk was incoherent and pointless. After every few phrases, he would repeat, “Don’t ride there! That’s hell! Murder is being done. Devils and unholy powers are beating and killing people.” As he said this, he would tremble, and hands and feet would stiffen with a suggestion of catalepsy. There was general anesthesia to pain; no response was made to deep pin-pricks. The pupils were dilated and failed to react, either to light or to pain. The tendon reflexes were exaggerated. No contraction of visual fields. The man was disoriented for time and place and much confused. No paralysis. No wound or contusion.

_Re_ analgesia, we may only say that hysterical anesthesia appears in a variety of forms; sometimes (_a_) in the form of a classical stigma of hemi-anesthesia; (_b_) in a segmentary form; again (_c_) in isolated patches; (_d_) in a very rough way approximating the peripheral nerve distributions. Babinski gives an unpublished note by Lasègue, in which he states that hysterical patients not enlightened by the doctor’s investigations do not make mention of anesthesia. But in case 350 a psychotic factor may have entered.

Ten months of military service (several battles) without reaction; then, hot machine gun battle: Mania with disorientation and war hallucinations.

=Case 351.= (GERVER, 1915.)

A Russian private, 24, in a scout company, entered the war on mobilization and took part in several battles without reaction. May 11, 1915, he was sent with the scout party into a hot encounter, hand to hand with machine-guns. After the battle, the man began to yell incoherent phrases at the men around him, started to climb over the top, and shot off his gun without permission. He was accordingly sent to hospital, where he was under observation for a week, during which he had occasional flashes of excitement, jumping out of bed and making movements of cutting or shooting, and then in a few minutes subsiding into inactivity.

He was a short but well-built and well-nourished man; the pupils responded rather weakly in accommodation; there was a small fibrillar tremor of the face, eyes, and tongue. The skin reflexes were diminished and there was a general hypalgesia; considerable mechanical overexcitability of muscles; no other neurological disorders. The mental state was one of confusion. Although he was in one of the corps hospitals, he said he was in a dug-out; the doctors were lieutenants; the attendants were privates in his company. Answers to questions were irrelevant or incoherent; there were a number of delusional expressions. He was to be shot because he had not himself shot enough Germans. If he were not to be shot, anyhow the soldiers would poison him. Rather than this he should be allowed to go into an attack. He would take a German fort and the Czar would name him a colonel. His regimental commander was saying to him, “You will be a hero, you will soon get a company.” His hallucinations sometimes included the voices of Germans saying, in broken Russian, “We will hang you and cut your belly open!” There was considerable amnesia for dates and even his last battle.

Numerous attacks and counter attacks in one day: Sudden incoherence with disorientation and the rapid development of war hallucinations of a scenic type. Suggestion of catatonic phenomena.

=Case 352.= (GERVER, 1915.)

A Russian lieutenant, 28 (no mental disease, non-alcoholic), was in battle August 14, 1914, on which day his company attacked and was itself attacked several times. An officer who observed the lieutenant said that he came to him and informed him that the Germans must first be burned and then fought with. Thereafter the lieutenant began to speak loudly and incoherently, sometimes yelling incoherent orders. He was accordingly removed from the battle-field to the hospital back of the line. Upon examination, he was found to be of middle height, with dilated pupils, responding weakly to light and not at all to accommodation; twitchings of face, eyelids, and tongue, digital tremor, marked dermatographia, general analgesia, tendon reflexes somewhat exaggerated, cataleptic tendency in feet and hands.

Mentally, the patient was in a stupor, sitting or standing in one place, without initiative; uncomplaining but occasionally uttering deep sighs or occasional isolated phrases. He answered no questions or only after a long pause. He was disoriented for time and place, but gave evidence of delusions and hallucinations. He thought, for example, that he was the chief of staff and had brought with him a squad of captured Germans who were standing nearby. Some wanted to be fed and let go; others were yelling and saying they would burn down the house. Sometimes the patient would hear shots and shells bursting, at which he would shudder and turn away. Apparently he would see his comrades falling under the shrapnel hail. However, he stood his ground and commanded the rest of the soldiers to go forward to the attack. Now and then he was negativistic, flexing the hands upon request to extend them, refusing food and drink. He was still apathetic on evacuation to the interior.

Shell-shock after two days in trenches: Hysterical STUPOR seven days. Cure in three weeks, barring amnesia for stuporous period.

=Case 353.= (GAUPP, March, 1915.)

F. S., in civil life a wreath-binder in a flower shop, and from childhood very nervous and excited, subject to frequent nosebleeds and fainting spells (_e.g._, at sight of blood), enlisted at 22, November 3, 1914, as a reservist. January 18 he went into the field.

The wreath-binder was only two days in the trenches before going unconscious under the whistling and exploding shells. Physically uninjured, he was received in reserve hospital C in a deep stupor, January 22. He was unresponsive at first, once however saying, lost in a dream, “When will mother come?” His gait was unsteady and he had to be led and held. He slept a good deal in the daytime.

He became somewhat more active mentally, January 24 (remarking that he had slept well), and made his toilet, but he did not yet have bearings and wanted to go to his place of business. The next day his condition was similar. Asked what troop he was with, he said, “In the flower business.” January 26 he was much better, telling of the army training and a little about the war, and wrote a postcard to his parents. The stupor disappeared after January 27 and the patient became mentally normal. Amnesia persisted for the time, January 20 to 26. Headaches. February 9 he was well, except for the limited amnesia still persisting. He was eventually sent back to garrison duty, cured.

_Re_ stupor, Grandclaude remarks that stupor is probably the most frequent of the mental symptoms of Shell-shock, and that it may last from a few moments to a week. During the stupor the patient is asthenic, stertorous, and staring. Upon recovery from the stupor, a condition of dulness with amnesia and disorientation ensues. There may be a third phase of a more hyperkinetic character, with hallucinations and delusions concerning the war. These stuporous cases are among the most serious of the conditions found, as some of the victims may even suggest dementia praecox from the persistence of childishness and silliness. As in Gaupp’s case, Grandclaude finds that headaches and amnesia persist. Relapses are frequent on the basis of a kind of sensitization.

_Re_ amnesia and Shell-shock, Roussy and Lhermitte speak of amnesia as ordinarily a phenomenon of confusion. Amongst the mental disorders of the Shell-shock psychoses, these authors describe a group due to inhibition or diminution of mental activity, including the rare narcolepsy, or pathological sleep, and the confusional states proper. Simple confusion involves slowness in thinking, and amnesia often anterograde from the moment of the shock. Simple confusion ought to be distinguished from so-called “obtusion” or torpor, in which there is a disorientation for time and space, such as was shown in Mallet’s case. Chavigny has described an aprosexic form (with “birdlike” movements). More common is the amnestic form of torpor. The amnesia may not merely be anterograde from the moment of shock, but may extend to a prolonged period prior to the accident. Sometimes the amnesias are selective, producing phenomena of pseudo aphasia.

Amnesia, monosymptomatic. Progressive recovery.

=Case 354.= (MALLET, January, 1917.)

An infantryman, 36, arrived without information at a psychiatric center, March 15, 1916, looking confused and knowing little more than his name, believing himself in a distant town. The disorientation lasted to March 21, on which day the man recognized the doctor as such, knew that he was at a hospital, but felt that he had just left home and wife. From this time on, he began to pick up his surroundings, evidently not knowing that there was a war or that he was a soldier. He did not recognize one of his own company. It was not until March 31 that the first memory of the war reappeared, namely, a memory of the call to the colors, drums, bells, and crowds. April 11 he recollected that he was a soldier and that his wife was in the country, where he had left her on the eleventh day of the mobilization. In the next few days, memories came back bit by bit. He had been at first a little thin and showed a slight fever, oliguria, and poor digestion. All these symptoms now lapsed, and the man became apparently perfectly well.

Such states, according to Mallet, are relatively frequent in soldiers, both in epilepsy, and in infectious deliria,--more than in the deliria of exhaustion.

Aviator shot down: Organic mental symptoms.

=Case 355.= (MACCURDY, July, 1917.)

A Canadian, 20, of normal makeup, in 1915 lost part of his left foot in a railway accident, but, notwithstanding, was finally commissioned in the Royal Flying Corps. He enjoyed the nine months of English training greatly. In France he made several successful flights over the lines, but was shot down and crashed to the ground within the British lines after two weeks of service. He got black eyes and bruises and lost consciousness for about four days, though a week later he was still hazy about recent events and was not quite sure in what hospital he lay. After another week he arrived in a London hospital.

Here he would not answer questions, but stared at the examiner, finally shouting: “I want to get up.” He said he was in a certain suburb of Toronto, which, however, he insisted was a part of London not far away. He wanted a taxicab to go thither. He pondered, but seemed content when told that Rosedale was across the ocean. A superficial machine gun wound of the hip the patient said must be the mark of a hospital in France; it was a secret mark, meaning that he could return to the line and fight whenever he wanted to and that he could use the lavatory whenever he wanted to. He sometimes uttered brief phrases after questioning. Asked if he dreamed, he looked up cunningly and said, _e.g._, “I down the Boche. I am a live wire.”

Next day it was clear that he had gained a good deal of information from the nurses, and the day after he had become oriented for time and able to recognize the physician, though still confused about hospital names and his recent movements. The 7 from 100 test he did slowly and made several bad unrecognized mistakes. He was over-fatigueable, complained of foggy eyesight, showed haziness and redness and obscure margins in the optic discs, with the remains of one hemorrhage, and presented nystagmus on looking to the extreme left. Two weeks later he complained less of his memory and said that he was beginning to remember what had happened during the last day of his fighting; the chase by the German airplane and the maneuvers. He worried about being sent back to France by a medical board, which would not realize that he was incompetent to fly again. The left pupil was slightly larger than the right.

In this case there were no neurotic symptoms and according to MacCurdy the difficulties here are strictly those of organic type.

_Re_ organic cases of traumatic psychosis, Lépine sums up the subjective phenomena as follows: There is (_a_) a cephalea, often a feeling of weight, varying at different times of the day; often frontal; often subject to marked alteration on movement. There may be (_b_) a number of visual phenomena like those mentioned under Case 355, part and parcel of a sort of absence, suggesting an epileptoid effect. Sometimes (_c_) there is vertigo, but this is rare. There are also congestive attacks. The patients are unable to work, and have strange head sensations when they attempt to work. The memory disorder is not as a rule markedly accentuated. This amnesia is usually a disordered fixation of current events, but there is also a retrograde amnesia. Insomnia and impulsiveness are also found, and more rarely is a depressed and melancholy state suggesting that which Case 355 exhibited. Lépine has tried to define the traumatic psychoses (not _neuroses_) on the basis of phenomena found in trephined cases. He remarks upon the extreme analogy, not to say identity, between the late sequelae of trephining and the syndrome of _commotio cerebri_.

Daze with relapses; mutism--following shell fire and corpse work.

=Case 356.= (MANN, June, 1915.)

A soldier lost his voice apparently from two factors: shell fire and the emotional shock of helping to fill the big common graves. The man could never tell for certain (retrograde amnesia) whether he went from corpses to shell fire or from shell fire to corpses.

Several weeks of daze followed in which he hardly reacted to outward stimuli, but occasionally said “It smells!” “Leave me still!”

He recovered gradually from the daze. But merely hinting at his experiences, especially the smells, sufficed to throw him into another daze.

The loss of voice lasted for some time after he had wholly stopped lapsing into the dazed states.

There was some alcohol in the previous history of this case, which is the only case among twenty-three Shell-shock cases reported by Mann which had a psychiatric disorder of any lasting nature due to shell fire.

_Re_ mutism and the two factors of shell fire and emotion spoken of by Mann, compare the views of Babinski to the effect that emotion alone is unable to cause such a hysterical manifestation as mutism.

_Re_ the corpse work, see remarks under Case 342.

Mine explosion: Mental confusion. Amnesia effected through Y. M. C. A.

=Case 357.= (WILTSHIRE, June, 1916.)

A sapper, 21, was admitted to a base hospital semi-stuporous, unable to answer questions and mistaking the identity of persons about him. At first he slept, but next day found he was in hospital. His mind was “all of a blur.” He did not remember coming to France; “It all seems a mist.” He felt he was ill and was afraid of becoming insane. There was no physical sign of disease except coarse tremor of hands.

At intervals over a period of about half an hour, helped by questions, he was able to get out the following with much emotion:

“Joe, don’t go--Give me my rifle, Joe--Ten killed. Poor old Taffy--Dreamed last night--Saw Harry Edmands with all his ribs broken--when we had the explosion--5000 bombs or two and a half tons of explosives blew up.--Joe--Clay said he would never live three weeks,--Glasses blown in.--Taffy killed by shell in stomach--S-- L-- All privates blown off him--Just after leaving workshop.”

Between the above statements, the patient might go off into short trance states, staring and pointing out of the tent.

Next day he was found in a condition of cheerful emotion, saying that he was ever so much better; an orderly had “saved him!” This orderly had taken him to the Y. M. C. A. recreation tent, played the piano to him, and made him play himself. His whole emotional state suddenly changed over. He now had a good memory for everything previous to his reaching France, and remembered simply that there had been an explosion. He remembered two names that he had mentioned, but he could remember nothing about their fate in France. He did not know where they were but he was not anxious about them.

Shell-shock: Hallucinations; alternations of personality.

=Case 358.= (GAUPP, March, 1915.)

A soldier, 29, a helper in a wholesale house, came to a hospital by hospital train, uninjured, directly from the field, having become completely deranged under shell fire. He arrived at the clinic January 11, 1915, in deep emotion, anxiously excited, and looking tensely and suspiciously at the bystanders. He seemed to hear very badly and shouted his statements like a deaf person. Led to the sick section, he shouted out of the window, “Frenchmen!”; then he went willingly to the bath and was put to bed, unresisting. He lay in bed on his elbow, listening in the direction of the window or the wall, answering loud questions with a quick, yelling voice after a pause. He gave his name correctly. He seemed to think he was in the trenches and to see hallucinatory pictures of battle.

In the examining room he immediately sat down, back to the wall, taking the chair at the desk and leaning it against the wall. Asked why he did so, he said with a horrified expression, “The shells, they are coming over! Whew! they are shooting all the time.” He ducked, imitating the hissing and whistling of the shells. Asked if he had been struck, he said, “There are two dead and one’s head is off.” He declined to be told where he was, and when he was told that he was no longer in the enemy’s country, but in Württemberg, he said, “No, no; they don’t come so far. No, the Frenchmen don’t come so far.” He was very easily frightened and started at every touch as if wakened from a dream. Sometimes his whole body would tremble with anxiety. He would not allow his pulse to be taken, at first. He would suddenly shout, “That’s the Krupp now flying by. Now it has struck.” He cast his eyes along the ceiling as if to follow the course of the shell. Asked what he was doing, he said he was in the trench on the mountain.

He was able to tell about his family, his marriage in Berlin, and his child, and he could tell time by the clock. Then he would suddenly shout: “The shells, they are shooting everything; they are shooting like another earthquake.” Gaupp stepped up to him, in uniform, and asked if the patient knew him. He examined Gaupp suspiciously from top to toe, looked at the shoulder-straps, and then quickly cried loudly, “Physician.”

At another time he described the shell havoc with evidence of extreme anxiety. He would take food only when one broke off a piece and ate of it before him. He would not drink out of ordinary drinking-glasses but only out of his field cup, examining it carefully. He denied he was on patrol duty at Soupis. His comrade was merely asleep just now. A civilian physician in his long coat was termed by the patient “a baker” after careful examination. There seemed to be no pause in the man’s behavior, which looked absolutely genuine and dominated by strong emotion. He had the look of a man in immediate danger of death, exerting himself to escape shell fire.

This dream-like disorder of consciousness with war delirium persisted for a number of days. There was no marked motor excitement. He would remain for the most part quietly in bed, absorbed in his thoughts, watching and listening, sometimes looking about in astonishment but not getting his bearings. Gradually his emotions declined and he developed a certain confidence in the nurse. She was able to convince him that he might be in a hospital, although he objected that there were no wounded there. (He was in a mental section where there were no bandaged men.) All the while he was very hard of hearing and shouted loudly in speech. For twelve days he could not be convinced that he was in Germany. The fact that the Sister was speaking German was met promptly by the fact that in France the physicians and Sisters spoke German too.