Chapter XI: Section D: Shell-Shock Treatment and Results (7)

A soldier, 32, was bowled over in a first-line trench by the bursting of a shell that he did not see coming, September 14, 1914. He regained consciousness only in the middle of the night, finding himself half covered with water. He was taken up by the stretcher-bearers at eleven in the morning. Paralysis in the legs was then absolute. There were pains in the legs and in the back, but there was no evident lesion. Knee-jerks, plantar reflexes, and abdominal reflexes absent; cremasteric reflex absent on the left, weak on the right. Tactile sensations, on the contrary, were almost intact except for a slight diminution over the feet and the external aspects of the lower legs. Sensitiveness to pin-prick, however, was abolished throughout both lower extremities, and diminished in the abdomen and back up to two or three centimeters above the level of the umbilicus; that is, including the territory of the first lumbar and the last three dorsal roots. Sensibility to heat was abolished in the feet, the external aspect of the lower legs, and the posterior aspect of the thighs, but was preserved in the second and third lumbar territory, in the anterior aspect of the thighs, as well as in the region below the umbilicus. Micturition was impossible. Constipation the first few days yielded spontaneously September 20. There were signs in the bases of both lungs, corresponding with a suffocating feeling. September 22, he was evacuated, almost well, without signs of pulmonary congestion, having regained the power of urination and some capacity to move the legs sidewise. February, 1915, after evacuation to a hospital at Vic, he showed sacral decubitus, soon reaching the size of a hand, as well as trochanteric decubitus; traces of albumin in the urine, sacral and sciatic pains (recalcitrant to morphine).

He began to improve December 25. Camphorated oil and the sitting posture relieved the pulmonary congestion; the temperature, which had oscillated round 38 degrees, fell; the decubitus scarred over; the knee-jerks reappeared to some extent, and movements began. February 5, the patient had become able to walk without crutches. There was still a two-franc sized area of decubitus over the sacrum, and still a little spinal pain in walking.

It is difficult to consider this case only functional in view of the decubitus, to say nothing of the radicular distribution of the sensory disorder. Heitz brings this and the previously given case (No. 1) into relation with Elliot’s case of transient paraplegia (see Case 210) and Ravaut (see Case 201).

Shell-shock (windage?); typhoid fever; “neuritis” actually hysterical.

=Case 135.= (ROUSSY, April, 1915.)

A Colonial soldier was sent back from the front, September 12, 1914, for nervous disorder due to the shock of the windage of a bullet. He had not lost consciousness. Under observation at his station, he got typhoid fever, and was cared for at Paris from the beginning of October. About October 15 he began to feel pains in his left shoulder, neck, and arm. The diagnosis, neuritis, was made and was strongly borne in upon the patient, so that upon the cure of his typhoid, he went out on two months’ leave with a complete impotence and much pain of the left arm. At the end of his relief, he was evacuated to Villejuif. January 24, it was found that he had no somatic phenomena whatever, despite the fact that the left arm and a part of the forearm was powerless, and so painful that the patient cried out when his arm was moved. There were a few cracklings in the scapulo-humeral joint.

Hot air and reëducation cured the man in less than two months (March 20), though the disorder had lasted for four months. The patient had been retired for hysteria before the war and had re-enlisted.

Bullet wound of pleura: Reflex hemiplegia and double ulnar syndrome.

=Case 136.= (PHOCAS AND GUTMANN, May, 1915.)

A soldier, 26, was wounded in the enfilading of an Argonne trench December 17, 1914. He felt the bullet like an electrical shock, and fell. He had been leaning forward at the time and suddenly felt the left half of his body go paralyzed and his mouth pulled to one side. He did not lose consciousness, and spat up a good deal of blood five minutes after falling. He lay in the trench all night, unable to move his left leg except by the aid of his right. He was evacuated next day. There was a five-franc piece wound at the upper border of the left scapula, four finger-breadths from the median line. There were a few lung signs which rapidly cleared up. December 28, the hemiplegia was better, although neurological examination showed weakness of left upper extremity, abolition of deep reflexes, and certain skin changes of the left hand with edema (_main succulent_), decreased resistance of muscles of lower extremity to passive motion, especially of adductors and flexors, exaggerated polykinetic left knee-jerk, ankle clonus, Babinski reflex, abdominal and cremasteric reflexes absent on left, platysma paralysis left, with complete paralysis in the inferior distribution of the facialis; whistling impossible. Also the left eye could not be closed singly. Synergic movements of the lower part of the paralyzed face when the right hand of the patient was grasped.

There were also sensorimotor disorders in the ulnar distribution on both sides, with complete anesthesia to pin prick. There was also an area of hyperesthesia of the anterior and postero-internal aspect of the right forearm from below the elbow to the wrist. The tendon reflexes were weak but distinct on the right side. The left arm had feelings of pain, with _élancements_ and formication from the shoulder to the fingers on the ulnar distribution. There was, of course, also, local hyperesthesia due to the wound of the thorax.

Lumbar puncture showed a fluid normal in all respects. We deal with a hemiplegia of organic nature, associated with the bilateral ulnar syndrome. The hemiplegia followed the trauma immediately. When the ulnar phenomena appeared is unknown.

The lung complications cleared. The pains disappeared; motion returned up to the level of the facialis. The patient got up and three months later went on convalescence, still presenting Babinski, exaggerated knee-jerk and weak arm reflexes on the left side. The bilateral ulnar syndrome had disappeared six weeks after the patient entered hospital. Phocas and Gutmann cite a considerable literature on nerve complications of pleural trauma, among them syncopes of grave prognosis; a relatively frequent pleural epilepsy (forty-five per cent fatal) or epileptic status (seventy per cent fatal); and the rare hemiplegia. Accidents and death have followed exploratory puncture of the pleura. Air embolism is probably not the cause. Phocas and Gutmann prefer the theory of a reflex disorder starting from the pleura.

Hysterical tachypnoea.

=Case 137.= (GAILLARD, December, 1915.)

A man, 23, came to the Lariboisière November 29, 1915, in a hurry to show evidence that he had been invalided for valvular lesion of the heart. In point of fact, the interne found a murmur at the base. Yet there were things in the military papers suggesting caution. The patient next morning showed no malaise, dyspnoea, or any evidence of serious disorder. The contractions of the thorax beat in time with contractions of the alae of the nose, about 112 per minute. Here, then, was a cardiopulmonary patient. The heart impulse was exaggerated; the patient could not or would not stop breathing to aid the auscultation, but almost absolutely normal sounds could be heard at the apex and the base. A valvular lesion could be excluded. The lungs were perfectly normal. The patient was requested to stop his gymnastics, which might have succeeded elsewhere but could not at the Lariboisière!

How could the man have established the synchronism of pulse and respiration and synchronous tachypnoea and tachycardia? Why should he persist in this form of sport, since he had already been invalided? The family history was not especially suggestive (father albuminuric, died at 59; mother well, probably tuberculous). Scarlet fever at eight; occupation, tourneur. After four months of service there was gastric disorder followed by typhoid fever (despite vaccination, according to the patient). Convalescent leave at Paris, during which leave he had swollen legs and albuminuria. May, 1915, gastric difficulty; valvular lesion determined; examination; invalided. At home, a variety of complaints, for which treatment was unsuccessful.

During further examination it was noted that in auscultation the head of the examiner was lifted, as if there were hypertrophy of the heart or an aortic aneurysm. The synchronism was less exact on December 2; 112 beats to 128 respiration. Was this man a simulator? Had he become the victim of his own enterprise? There was no evidence of simulation. It was a question of a monosymptomatic hysteria. Gaillard discontinued the _manière forte_ and undertook a softer treatment, but the _manière forte_ had caused the family to want to take him away. Perhaps they feared a too efficacious treatment. He then escaped observation. It is probable that the tachypnoea ceased during sleep. It was not so marked after the medical visit was over.

Soldier’s heart.

=Case 138.= (PARKINSON, July, 1916.)

A corporal, 21, who had been a miner and entirely well up to enlistment in August, 1914, went to France in 1915. In June, came shortness of breath and palpitation on exertion; later, precordial pain (fifth space, between nipple and median line) and giddiness on walking. Like all cases of true so-called “soldier’s heart,” this soldier had no physical signs indicative of heart disease, yet reported sick for cardiac symptoms on exertion. In this particular case, as in about half of forty cases reported by Parkinson, there had been no disability in civil life.

August, 1915, the soldier was admitted to the casualty clearing station, where the apex beat was found in fifth intercostal space internal to the left nipple line. The first sound was duplicated in all areas. The second sound was duplicated, though not loudly, at the base. After nine months’ treatment, this man went back to light duty with slight symptoms.

According to Parkinson, the absence of abnormal physical signs in the heart of a soldier should not prevent his discharge from the army if under training or on active service he shows breathlessness and precordial pain whenever he undergoes exertion well borne by his fellows. A simple exertion test, such as climbing 25 to 50 steps, reproduces the symptoms in such a patient. The rate of the heart at rest is a little higher than that of normal men, though the increase on exertion is greater. Nevertheless, it has been proved that the increase of rate on exertion bears no relation to the symptoms elicited and is therefore without value in judging the functional efficiency of the heart.

Soldier’s heart?

=Case 139.= (PARKINSON, July, 1916.)

A sergeant, 36, had been in the army from 17 to 29, but in 1908 he had acute rheumatism and was discharged from the army. He then became a furnace man and had shortness of breath and palpitation on severe exertion with syncope three times.

He re-enlisted in August, 1914, and had an attack of orthopnea and edema after exposure at a review. However, he improved and went to France in May, 1915, where he again had symptoms; namely, precordial pain and breathlessness on severe exertion. One day while carrying telephone wire under fire, the sergeant felt a sudden pain in the region of the apex beat, shooting down the right arm. “I thought I was shot.” He fell down, very short of breath. His left arm remained sore and weak. Two days later came a similar attack, this time with unconsciousness, and the left arm was now useless. Two days later he was admitted to hospital, where slight breathlessness but no pain and no enlargement of cardiac dulness could be found. No further details are available but it seems clear that this man is unfit for duty. According to Parkinson, it is probable that the infection indicates the presence of some degree of myocardial disease.

Strain and shell-shock: Acceleration of diabetes mellitus.

=Case 140.= (KARPLUS, February, 1915.)

An infantryman, aged 22, previously healthy and from a healthy family, was struck by a shell fragment in the forehead and lay for several hours unconscious. He did not vomit. He had a number of furuncles on his body and his urine, upon examination, showed a severe diabetes mellitus which increased despite treatment. Upon an attempt to withdraw carbohydrate, the sugar suddenly sank from six to four per cent. Acetone at the same time increased. An abrasion had been noticed by the patient a few days before the shell explosion on the spot rubbed by the _tornister_. The patient said that since his accident he had had to urinate every night several times and was often very thirsty, neither of which tendencies had he had before. A month before he became _merod_ he had had an injury of the hand produced by a shell fragment. He had undergone tremendous strain.

The chances are that the excitement and the strain had more to do with the diabetes mellitus than the shell explosion.

Dercum’s disease.

=Case 141.= (HOLLANDE and MARCHAND, March, 1917.)

An adjutant in a chasseur battalion was buried by a shell explosion, which killed his lieutenant beside him, January 5, 1915, at Hartmannsweilerkopf. Hematuria followed; ten days later, fever with anorexia, and the appearance of two or three lipomata on the anterior surface of the thighs. Remaining at his post, the adjutant took part in an attack, March 5; was evacuated on the 8th; “lipomatosis with febrile reactions.” He spent eight days at Bussang, and thence went to the hospital at Pont-de-Claix. Here marked albuminuria was noted; the lipomata increased in volume; others appeared in the arms. The patient was transferred to the Des-Genettes, where the diagnosis nephritis was added to the previous diagnosis, and a milk diet was prescribed. Convalescence of five months was proposed. The lipomata increased in volume and in number. The patient was then hospitalized at Avenue Berthelot, placed in the auxiliaries, and stationed eight months at his dépôt.

When he was observed by Hollande and Marchand, four nut-sized tumors were found on the anterior surface of the left thigh; two smaller tumors: one of them painful to pressure, lay on the inner aspect, another the size of a small egg lay in the right thigh, and there were two others on the internal aspect and two on the external aspect of the thigh. A nut-sized tumor was found on the inner border of the right forearm, and below it another lenticular tumor. A nut-sized tumor was found on the left forearm below the elbow on the internal border. Small tumors were found on the buttocks. There were no tumors below the knees, in the upper arms, or on the thorax. There were 14 tumors in all. The smaller the tumor the more sensitive, and there was more pain when the tumor had just appeared and during the first days of its growth. There was no spontaneous pain; pain only upon a blow or pressure. Diminished knee-jerks, especially the right; no other neurological disorder, although the patient complained of often having something before his eyes. There was a marked diminution in the memory. Heart was in the 5th space on the nipple line, pulse 110; Wassermann reaction negative; red blood cells, 3,520,000, white cells, 6500; albuminuria, hematuria, leucocytes, and urethral cells in the urine. The temperature had now become normal. The lateral lobes of the thyroid were slightly larger than normal, but not painful. Sella turcica was unchanged upon X-ray. Exploratory puncture of a tumor showed much free fat, without fatty acid crystals and with some fat cells. The cells could not be cultivated in test tube. The authors believe it doubtful whether this instance of Dercum’s disease is related with the shell explosion.

Hyperthyroidism.

=Case 142.= (TOMBLESON, September, 1917.)

A private, 22, was selected by Col. Garrod for hypnotic treatment by Tombleson from among the hyperthyroid cases. He was admitted April 3, 1916, with a typical hyperthyroidism, with manual tremor, enlarged thyroid, pulse 120, blood pressure 136-40, and hemic murmur. Tombleson induced deep somnambulism at the first hypnotic sitting and suggested an increase of nerve strength and steadiness. The suggestions under somnambulism were repeated for ten days. An occasional added suggestion was given as to lessening of the thyroid. At the end of the ten days the patient declared himself quite well.

Eight of twenty consecutive functional cases treated by hypnotism by Tombleson were cases of hyperthyroidism and in virtually all of these an effect like the above was registered.

Shell-shock; thrown against wall, stunned, emotional: Paroxysmal heart crises six days later, observed for two months. Neurasthenia? Mild Graves’ disease?

=Case 143.= (DEJERINE AND GASCUEL, December, 1914.)

An infantryman, 29, was sent to auxiliary hospital No. 274, for heart trouble, a little thin but looking vigorous enough (typhoid fever at 13 and some diseases of unknown nature and of brief duration while in military service).

September 24, a large calibre German shell burst and threw him against a wall, producing no wound or contusion. He was momentarily stunned, emotionally much affected, and noted at the time extreme palpitation. He was evacuated to Paris September 30, six days after the shock. His pulse was 130-134, regular, and the heart seemed not to be anomalous in any respect.

But there were paroxysmal crises in which the pulse rose to 180 and in which the patient fell into a state of great anxiety. The mouth temperature in the midst of such crises would always rise to 38°, and this temperature would outlast the rest of the seizure. The man was mentally depressed and apparently indifferent, preoccupied with his heart and his insomnia, but at the same time emotionally easily affected. In short, he was a neurasthenic. There was no change in mental state, tachycardia, or paroxysmal seizures in two months, except that he gained weight. Walking and climbing stairs produced dyspnoea. Urine was negative. According to Dejerine, such a case should be treated by psychotherapy.

Alquier, in discussion, called attention to the slight but distinct tremor in this case, dermographia, and spells of perspiration. He suggested that the case might be one of mild Graves’ disease.

Hyperthyroidism three months, following ten months’ service, at times under protracted shell fire.

=Case 144.= (ROTHACKER, January, 1916.)

A man in service ten months, under strong excitement and at times under protracted shell fire, complained of palpitation, insomnia, dizziness, and dyspnoea. Hospital notes showed that the left lobe of the thyroid was somewhat enlarged. Before the war his neck could not have been very thick; he had served his year out without difficulty. His mother is said to have suffered at one time from thick neck. According to the patient, he had never suffered with heart trouble. Heart not enlarged; blowing first sound over the apex. Graefe, Stellwag and Möbius signs negative. Heart rapid, not irregular; pulse strong. There was fine tremor of the hands, as well as a tremor of the tongue. Knee-jerks increased.

The patient was at first sleepless and excited, but after three weeks in bed the heart murmur had disappeared. After three months, he was ordered to _Ersatz_ with the left side of the neck measuring 20 as against 18 cm. on the right. There was a soft pulsating swelling of the thyroid. First sound over apex still impure; heart action now regular; pulse 64; blood pressure 120 Riva-Rocci; after test exercises, slight dyspnoea. No cyanosis. The outstretched hands were no longer very tremulous. The knee-jerks were still increased. The man had begun to sleep well. His neck was apparently much diminished in girth.

Here then was a case of Graves’ disease of acute development, brought out by nervous stress and excitement as well as by 10 months of war work and exposure to shell fire,--with approximate recovery after three months of rest.

Graves’ disease, forme fruste.

=Case 145.= (BABONNEIX AND CÉLOS, June, 1917.)

A farmer, 31, entered the Rosendael Hospital, Jan. 25, 1917. He had been two years in active service. The family history was negative except that one of his sisters had had dyspepsia. The patient denied venereal disease and alcoholism and had always been well. At the Battle of the Marne he was slightly wounded in the left knee. January, 1915, he was exposed to gas bombs and explosive shells. He was several days in the hospital spitting, or perhaps vomiting blood and was sent on a long convalescence. On returning to the front, he had to be sent back to hospital with a note, “not fit for service, nervous troubles and paroxysmal tachycardia.” In point of view he now showed a number of symptoms suggestive of Graves’ disease, such as a definite exophthalmia which, according to the patient, started up a short time after the shock and a tachycardia (110-120) with circulatory excitement, a tumultuous heart, neck arteries contracting, almost dancing in their contractions, together with a systolic murmur maximal in the pulmonary area, not retaining, variable,--in short, suggestive of an inorganic murmur. There was also a generalized rapid tremor and a variety of vasomotor disorders, such as blushing and paling, perspiration, exaggerated reflexes, emotionality, logorrhea, jactitation. There were also digestive troubles, regurgitation after meals and the patient had become thin and weak.

There was, however, no swelling of the thyroid gland nor any eye signs other than the exophthalmia. In short this case is doubtless one of the _forme fruste_ of Graves’ disease. It seems to show that Graves’ disease may have a traumatic origin.

Somatic complication in a shell-shock hysteria (Trauma).

=Case 146.= (OPPENHEIM, February, 1915.)

Musketeer. No faulty heredity, but was always somewhat nervous. On October 26, a shell burst one meter in front of him, burying him under the anterior wall of the trench. He was dug out and taken to the field hospital, where he remained unconscious until the next morning. On October 29, he was taken to the reserve hospital. Severe pain in the head, entire scalp tender on pressure, especially in the left frontal region, left side upper lip swollen, bluish and discolored. Left tenth and sixth ribs broken. Fracture of skull(?). November 10, at eight o’clock at night, sudden attack of vomiting, and the patient was found in a faint in the water closet. Almost complete paralysis of speech and all of the four extremities. Consciousness obscured; no sensory disturbances. November 11, severe headache and vertigo. Speech somewhat more intelligible. Pulse, 60 to 68. “Evidently secondary hemorrhage in the brain.” November 12, to Augusta Hospital. November 20, admission to nerve hospital. Typical aphonia. Limitation of motion in all four extremities, but no paralysis--anergy. Reflexes normal. Unable to stand and walk. Sensibility preserved. Under suggestive treatment, curative gymnastics, as well as electrotherapeutics, the aphonia and abasia disappeared in a few days, but the patient continued to complain of headache and insomnia. December 16, an attack of nausea, headache, vomiting, loss of consciousness, followed by epistaxis, marked tachycardia. January 4, in his sleep he felt a prick in his left upper arm, as if he had pushed a sewing needle into the arm. X-ray examination showed a needle in the arm. This was extracted under local anesthesia.

VIII.[5] SCHIZOPHRENOSES

(DEMENTIA PRAECOX GROUP)

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

The Sister’s ear boxed for blow to a German soldier’s pride: Diagnosis PSYCHOPATHIC CONSTITUTION! A true psychosis develops: hate of Prussia and the Junkertum: Diagnosis, DEMENTIA PRAECOX!!

=Case 147.= (BONHOEFFER.)

A sick soldier in a military hospital kept complaining of being waked up too early, and of poor food. His reactions looked like the irritable weakness of a psychopath. One day he went into a room where a woman was being examined, without knocking. When ordered out, he boxed the Sister’s ear.

He said himself, on transfer to the psychiatric clinic, that he had always been quarrelsome as a child with his brothers and sisters, subject to fainting spells, and poor and stubborn in military service,--all of which seemed to clinch the diagnosis of psychopathic constitution.

But he seemed to show a decided lack of autocritique. About boxing the Sister’s ear on her saying “Please go out,”--his idea was that he could not let a thing like that happen to him,--a German soldier and a patient! Moreover, “It should not be thought that perhaps I had a love affair with her! There was a cynicism about her.” The Sister had a strong sex impulse, he could see that by her nose: she was, so to speak, “hypochondriacal.” Both in speech and writing he used stilted phrases. The ego at last swelled to the point of his saying that he was an inhabitant of the World and hated Prussia and Prussian _Junkertum_.

Then came unmotivated states of excitement, with pressure of speech and motion, and eventually negativism. Accordingly, the diagnosis hebephrenia finally replaced that of psychopathic constitution.

Dementia praecox, arrested as spy.

=Case 148.= (KASTAN, January, 1916.)

A German private, called to the colors, was supposed to take his civilian clothes to the post office along with his comrades on March 21, 1915. He did not get his package ready in time and was ordered to go with another troop. At an opportune moment, he left the barracks with the package of clothing. When later arrested, he said that he had gone by railroad to Dirschau; then he had visited Berlin. After this, he had walked to Bromberg, Schneidemühl, and Landsberg.

At last he had ridden back to Küstrin. At Küstrin some children told a railway official that the man was making drawings. There was a petroleum tank near by. Accordingly, he was arrested as a possible spy. He claimed that he was not a soldier.

In the clinic, he looked dull and smiled a good deal. It seems that, before being called to the colors, he had been very angry with his wife and had even threatened her. He now explained this anger as his wife’s fault. She had attacked him, he said. He said that he sometimes had attacks of weakness, which used to last two days at a time, but they had recently lasted for a shorter time. He said that his thoughts always wanted to be somewhere else. In fact, he had not performed military duty. His uniform had been gotten for him, but he had had no further orders. Sometimes in a fever or dream his head seemed to be as big as a room, as if there were no space for it. There was an itching in his legs, he said, which often fell asleep so he could not stand on them. He had had syphilis seven years before, after which he had been hoarse, forgetful, and anxious.

Examination showed perceptive power and knowledge to be good. He played the violin, but always the same tunes. He said that he had not worked in Berlin during the winter of 1914. He spoke as if he had been in another sanitarium, where he did nothing but dream by himself, taking no interest in things, and lying indifferently, with a blanket over him.

He said that when he received the uniform he had a longing for clean underclothes. Requested to explain the meaning of the uniform, he remarked: “Why, many have these things on.”

_Re_ dementia praecox, Lépine states that in the French army instances of dementia praecox have been numerous in the interior, both at the time of mobilization and at the time of calling out sundry new classes. He notes that the courtmartial and invaliding experts have neither the leisure nor the experience necessary to keep these men from going into the army. The somewhat frequent remissions in dementia praecox make the task all the more difficult. To be sure, the stuporous and catatonic cases are not very much in evidence in the army; when such cases do occur, it is easy enough to evacuate the patients to a hospital for observation. Far more troublesome are cases of a less advanced or milder nature. Here are cases in which judgment is deficient, and in which quite unsystematic, incoherent, and transient delusional ideas occur. The patient looks quite normal to the non-psychiatric expert. Something odd happens which quite suddenly reveals the delusional ideas. For example, there is a fugue, or else the soldier goes to his superior and aggressively chides him for having troubled him the night before. These particular psychopaths are among the most dangerous to be found in the army.

Fugue, catatonic.

=Case 149.= (BOUCHEROT, 1915-6.)

A gunner, aged 23, enlisted on the expiration of his regular period of service and was a good soldier, in excellent health, up to June, 1915. He then began to have a few vague ideas of persecution. In a short time these became more definite and he caused talk by requesting to go into another corps because his comrades did not like him. He told his brigadier that the soldiers were frightening him by magnetism. He had hallucinations of hearing people say, “He will get it.” He kept by himself, would not eat and stood motionless for long periods of time before his mess-tin. He was often found in a dreamy state of apathy. One day he left the cantonment without leave, wandered through fields, had coffee in a village and then started off in no special direction. The police took him without resistance the next day. He said, “My comrades are in politics; they are going to cheat me.” He was brought to Fismes and the ambulance surgeon said that he found he did not know what he was about. He was amnestic for the fugue, explaining that he went because he was frightened. It was hard to get him to eat.

July 14, he was evacuated to Fleury protesting arrogantly, but this phase of excitement passed and he became absolutely indifferent and disoriented. He became untidy in his person and in no way could his attention be attracted whether by mentioning his family or the war. He sometimes made ape-like grimaces and sometimes laughed causelessly. He was occasionally negativistic, but in general was perfectly compliant with the requirements of the hospital. Now and then he started off impulsively to escape but was brought back quite indifferent. Now and then he went into bizarre contortions on a medical visit or aped gestures of bystanders. He began then to go into stereotypical attitudes. This case is the only catatonic one found by Boucherot in his war group.

Desertion: Schizophrenic-looking behavior. Adjudged responsible.

=Case 150.= (CONSIGLIO, 1915.)

An Italian private in the artillery, a telephone operator at the front, came up for desertion in the face of the enemy. It seems that he had often left his post, going off for a number of hours and drinking. At last he lost his position in the battery, went off and got drunk again, and was removed to a hospital and held as a neurasthenic and psychopathic patient. At the territorial hospital he was regarded as a melancholic. He still showed signs of alcoholism, was hallucinated, did a number of peculiar things, was impatient of medical examination, and was given a furlough of two months for convalescence. He apparently grew somewhat better in his father’s home, but went to a physician there and presented his certificate as a mental case. His behavior was so peculiar on subsequent arrest that he was sent for observation to Consiglio.

It appeared that he had been in military service from August, 1912, and had been imprisoned for a space of eight weeks for disobedience when he had been in military service for six months. He had been punished in the army nine times, once being given 70 days for lying. He was regarded as an undisciplined soldier but not as a nervous or mental case.

At hospital he was in a semi-stupor, claimed that he was forgetful, was apathetic concerning home and relatives, complained of pain in the head, and altogether preserved a strange and stolid attitude with occasional gestures, mimicry, and stereotyped reactions. As he had come to be operated upon, he looked about for the cannon that was to be used in the operation. Accordingly the question of dementia praecox might well be raised.

His indifference turned out actually to be assumed and pretentious. He preserved throughout an arrogant tone, and there were features in his voice that strongly suggested simulation.

According to Consiglio, we are dealing with an epileptic degenerate, addicted to alcohol, lying, and immorality. The question concerning responsibility was settled in the affirmative. Of course, it might be thought that the case was one of pathological intoxication, in which case, the man might be regarded as only semi-responsible. However, the phenomena of simulation, not merely in the observation hospital but also in the period of apparent depression and strange conduct immediately following his arrest for desertion, led to the decision that the man, despite his nervous abnormality, was responsible for his act. He was condemned to 20 years in prison.

_Re_ dementia praecox, Buscaino and Coppola found a number of cases of dementia praecox amongst soldiers admitted to hospital during the period of mobilization; cases amongst men who had not yet been at the front. These mobilization cases, in fact, were as a rule either cases of dementia praecox, cases of a psychopathic constitution, or cases of alcoholism.

A disciplinary case: Schizophrenia, alcoholism.

=Case 151.= (KASTAN, January, 1916.)

In October, 1914, a German soldier returned to his barracks late from a drinking bout. He insolently called for order, brandishing his arms, and when the captain rebuked him, he kept a cigar in his mouth. Examined in hospital (Allenberg), he was very reticent at first but wrote his name up over the bed with the additional word “_Dead_.” He answered, “I don’t know” to most questions. Although it was December, he said the season was summer. He was to be shot for disrespect, he said, but showed more disrespect at every remonstrance. “What is your regiment?” “I am no soldier at all, you know. I have already been discharged as unfit for service.” “Have you been in prison?” “I don’t know. My father often thrashed me.” Then suddenly, after a moment, “I was in prison five, seven, and two years, and my father was in prison four, six, and three years.” He said that he had drunk ether and urged the physician to try it, as one saw all sorts of beautiful pictures and figures and heard music.

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.