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.
In the early days of September, that is to say, a year after his
injury, he had a vision. Above the church cross at Chantenay, where he
then was, he saw a rainbow-colored bird, passing slowly in the sky. He
lowered his eyes and the apparition followed and was projected on the
white walls around him. After some time it disappeared. The soldier
himself wondered whether his brain injury might not have something to
do with the vision, but none of his comrades wounded in the head had
had any such vision. So then he thought of tobacco, of which he was a
moderate user, and stopped smoking, but the vision returned in the same
intensity four months later. On examining the bird’s face carefully, he
found that it was the Holy Virgin’s. In dreams he also had analogous
visions and in the dreams the Holy Virgin spoke to him, but what she
said he did not remember. The bird’s head did not speak to him. The
soldier was now convinced that it really was the Holy Virgin who had
visited him in the form of a bird. He remembered that he had asked
Notre Dame de Lourdes to protect him on the day when he was injured.
He had, in fact, eaten a bit of cheese that day upon which he had
inscribed a prayer to the Holy Virgin.
Sometimes he saw a red globe shining like a church lamp; sometimes
white or black ladies descending from the sky; sometimes other visions.
Now the Holy Virgin was to direct all the soldier’s life, but why
should he be specially favored? Was he not to be called sooner or
later to hold a high rank? He confessed, in fact, that he was to be
the King of France, and, like Joan of Arc, was to save his country.
Now the soldier began to understand the hidden significance of his
surroundings. Everything around him was symbolic, thus, white, of
purity, order and royalty; red, of anarchy, disorder and atheism. Some
white ship which he saw outstripping some darker ship showed him how
the kingdom of France was arriving once more. In fact, there was a
symbolism in the whites and yolks of eggs, and the proportion of yolk
to white was as one to five. He made talismans to exorcise bad spirits.
Were there auditory hallucinations? If so, they were only episodic and
took no part in either the construction or the fixation of the man’s
delusional system. Thus, a voice once said to him, “All is not lost.
You will be ----.” May 25, 1917, he entered the neurological center at
Bourges.
As to the interpretation of this case, it seems that the patient’s
mother had crises of depression which at one time caused her to be
interned in the Charité. The contributors of this case do not believe
that there can be any causal link set up between the mystical delusions
and the brain injury.
As an auxiliary the soldier has a right to twenty per cent compensation
for his head wound with loss of substance without bulging of the
dura mater. Of course, as an insane person he must be retired. The
aggravating or accelerating part played by fatigue, emotion and cranial
trauma must, from the standpoint of compensation, be taken into
account.
Shell-shock dementia praecox.
=Case 160.= (WEYGANDT, 1915.)
A subaltern who had been in the service since 1909 was on patrol
under shell fire from the enemy, but shortly thereafter came with his
detachment into the zone of the German fire. Six men, two steps away
from him, were killed by a shell. The officer remained stationary with
the rest of his detachment until darkness set in, then returned, made
his report in due order, but thereafter tremors set in over his whole
body and he lost consciousness. He was carried to the hospital and on
the way met his best friend whom he did not recognize. Arrived at the
hospital he was unable to give answers to questions or obey requests
for two or three hours. He thought he was hearing calls, commands and
a dull _dröhnen_. If an automobile passed he was frightened and cried,
“Auto! Auto!” He remained subject to inhibition, anxiety and insomnia
for a long time; pulse accelerated; visual fields somewhat contracted
for red. Face asymmetrically innervated and dermatographia. Sent to the
reserve hospital, he was still apprehensive, especially at night, but
in the course of a few days became perfectly tranquil. Only if he took
part in the singing of war songs did he feel transient sensations in
his knees.
Here is a case of psychic shock with many traits, such as inhibition
and hallucinations, suggestive of dementia praecox. The Abderhalden
reactions (cortex, white matter, testes, not thyroid) all, according to
Weygandt, are suggestive also of dementia praecox.
Shell-shock dementia praecox.
=Case 161.= (DUPUOY, 1916.)
A machine gunner, 23, was the sole survivor, March 18, 1915, of the
explosion of a large calibre shell in a block house containing ten men.
He worked himself out of the débris and came to Dupuoy’s attention in
September, when an extension of leave was asked for him.
There were two groups of symptoms; persistent headache, painful
hyperacousia, vertigo, tremulous walk, cervical spinal column stiff and
painful both spontaneously and to pressure, muscular weakness, tremor
of hands, hypesthesia of extremities especially upper, exaggeration of
tendon and bone reflexes with tendency to ankle clonus and patellar
clonus, sterno sign lively, frequent nosebleeds (two to four times a
week), profound sweating, unequal pupils.
On the mental side it was clear that the man’s character had changed,
according to information supplied by the mother. Aprosexia, impairment
of memory, recollective and retentive, inability to give age, birth
date and similar data. Words came with difficulty. Some disorder of
comprehension; stereotyped replies; negativism; indifference; he would
sit hours in a chair or on a bed silent and inactive. Fixed attitudes;
dull glance; eyelids half closed. In short, it seemed as if this
patient was a case of catatonic dementia praecox.
_Re_ dementia praecox and shell-shock, Stansfield remarks upon the
similarity of certain symptoms found in Shell-shock to those of
dementia praecox; for example, apathy, retardation, amnesia and speech
defect. According to Stansfield, one often gets the impression in a
Shell-shock case as though the trench and shell fire stress had merely
brought out a latent dementia praecox.
_Re_ his new “sterno” sign (sternomastoid contraction on percussion
of neck at level of third dorsal vertebra), Dupouy claims it negative
in normal subjects, positive in concussion, meningitis, and general
paresis.
Shell-shock; fatigue; fugue; delusions. Recovery.
=Case 162.= (ROUGE, 1915.)
A sergeant, 40, had had nineteen years of service and had been married
five months when he was recalled to the colors when war broke out,
and sent to the front. March, 1915, he was exposed to bomb explosions
during a very intense bombardment. He then got into the way of saying
that he was akin to everybody. April 20, he was evacuated on the score
of general fatigue, rejoined the company May 17, left his comrades
at the end of June, and was taken up as a deserter by the police,
who, observing his state, brought him to a hospital. He there showed
“cerebral overexcitement” with “incoherence and nervousness.” In two or
three days he was much better. He was evacuated on the sixth day to the
hospital at Vichy.
There was amnesia for the fugue and he could remember no further back
than the extraction of a tooth at the Vichy hospital. In fact, he
attributed the fugue to this dental operation. His wife took him home,
but he soon threatened her with a revolver; got better in the night
and next day went about apparently normal, buying things, however,
extravagantly. His delusional state began once more, and two days later
he was brought to Limoux. It seems that, while in Mauretania, he had
formerly shown signs of mental disorder, having a mania for wireless
and airplane inventions and the like. A cousin-german had also been
in a hospital for the insane twice, recovering each time. There was a
lingual and manual tremor. The man had not been recently alcoholic. He
was a little irritable and showed a little megalomania, but worked hard
and made himself useful. He went out, recovered, November 12, 1915.
Analysis indicated that this sergeant received a moral shock as a
consequence of his fatigue and the shell fire, which emerged in a spell
of confusion. It may be that his predisposition had something to do
also with this spell and the fatigue. In any event, it seems as if the
latter phenomena were not all assignable to war stress.
IX. CYCLOTHYMOSES
(THE MANIC-DEPRESSIVE GROUP)
A maniacal volunteer.
=Case 163.= (BOUCHEROT, 1915-6.)
An Alsatian became the object of much attention when he enlisted at
the outbreak of the war in the infantry at the age of 59. He was
interviewed and soon became more than naturally exuberant. The peculiar
things he did soon brought him to Fleury in a gay and expansive mood,
singing and talking as hail fellow with everyone he met.
The next day he grew more excited, disrobed and threw his things out
of the window, filled his bed with excrement and wanted to smear the
orderly therewith. He took other attendants for old friends and wanted
to kiss them. His language and ideas were incoherent. He broke glass.
This situation of alternate joy and anger lasted one month, leaving
him in an excitable, unruly state. He wrote many prolix letters to
the prefects and the ministers, insisting on the discharge of certain
patients and offering plans for the defense of France. He got better
and finally, in October, 1914, was invalided home still slightly
exalted.
_Re_ the cyclothymias, Montembault remarks that manias have been less
numerous than melancholias in the present war, whereas in 1870, manias
were more common than melancholias. Morselli likewise remarks upon the
rarity of manias amongst the Italian soldiers. Butenko reports upon the
maniacal cases amongst the Russians and how the men wish to enter the
ranks, the women the nurse corps. E. Meyer, for Germany, found 4 per
cent manic-depressives. Birnbaum quotes from Bonhoeffer (3 per cent)
and Hahn (2 per cent) for war times as against Stier’s 9.5 per cent of
cyclothymic cases in the antebellum period, 1905-1906.
Fugue: melancholia.
=Case 164.= (LOGRE, 1916.)
Logre classifies as a melancholic fugue the adventures of a man who had
been depressed for some days, had stopped talking and eating, and ran
away suddenly in the middle of an attack of anxious agitation. He was
very anxious over the health of his daughter, whom he thought to be
severely ill. It was, in fact, to go to Paimpol that he deserted, but
he deserted with his arms and without any money. He went off on foot
“in the Brittany direction.” He had gone 50 kilometers, the next day,
and was picked up near Chateau-Thierry by two gendarmes, who fell upon
him, seeing his regalia, and cried, “Give yourself up!” He replied in
a firm voice, “No, I shall not give myself up!” and seizing his gun he
made at one of the gendarmes. There was a fight. The gendarme declared
in his report that he judged it opportune to retreat behind a tree. The
soldier, knowing his trench lore very well, barricaded himself behind
a pile of beets. There he would have held the gendarmes in check for
some time if another had not succeeded by a détour through some woods,
in catching him. He gave himself up after firing several ineffective
shots, but not without getting a bullet in his left thigh himself.
With the charge of desertion and attempt to murder, he was handed
over for mental examination. He was, in fact, a melancholic patient,
subject to attacks of anxiety, and requiring long observation at a
neuropsychiatric center for diagnosis.
Chavigny observed numerous victims of melancholia characterized by
war terror. He remarks a somewhat curious fact that, whereas the
melancholics were numerous and their mental states related to the
war, on the other hand, the paretics were rather apt to be maniacal
than melancholic. Soukhanoff, however, remarks on the occurrence of
depression in a great number of types of psychosis, as was found
in the Russo-Japanese war. Soukhanoff found frequent instances of
schizophrenia, wherein the melancholia tends to conceal the actual
dementia praecox. Soukhanoff predicted that depression will figure
largely in the war.
Apples in No-Man’s-Land.
=Case 165.= (WEYGANDT, 1915.)
A soldier in November, 1914, suddenly climbed out of the trench and
began to pick apples from an apple-tree between the firing lines. The
idea was to get a bag of apples for his comrades, but he began to pelt
the French trenches with apples. He was called back and on account of
his strange conduct sent to hospital. Here he was at times given to
pressure of speech and restlessness; he would climb the posts of the
sleeping room and then loudly declare he wanted to get back to the
trenches; he did not want to go back to Germany alive; did not want to
live over to-morrow; was guilty of a sin; had a spot of sin, _Schand_,
on his heart. Sometimes he refused food and said anything else tasted
better. It seemed he had formerly talked about the Iron Cross.
After being transported to Germany, he was at first a little
negativistic and apparently blocked. He talked about his experiences
and said he wanted to go to Russia. He explained the episode of the
apples on the basis that they were all really hungry and that he had
sought to encourage his comrades who were unused to war. He had noticed
the French all shot too high.
Physically there was a somewhat uneven innervation of the face,
unilateral epicanthus and an areflexia of pharynx. Now and then the man
was very irritable, but in general he was in an elevated frame of mind.
Weygandt interprets this case as one of hypomania, remarking that
war influences may serve to bring out preëxisting manic depressive
tendencies.
_Re_ differential development of mania and depression, see remarks
under Cases 163 (Boucherot) and 164 (Logre).
Four months in trenches: Depression; war hallucinations,
arteriosclerosis (aged 38).
=Case 166.= (GERVER, 1915.)
A Russian reservist, a private, 38, went into the trenches, March,
1915. Without taking part in any battles or sustaining any injury,
he four months later became depressed and had to be evacuated to a
hospital and thence to the interior, little changed for the better.
He was an ill-nourished man, of middle height, with pallid skin and
membranes; arteries sclerotic; face, eyelids, and tongue finely
tremulous; hands tremulous; slight dermatographia; exaggerated tendon
reflexes; pulse 100.
He seemed disoriented for time and place; looked weary; walked with
back bent over; spoke in whispers, and appeared somewhat unclear.
Thinking was slow and difficult.
He occasionally shuddered and looked to one side, said he was afraid,
and was constantly troubled by thoughts of fire. The Germans were
pursuing him; he could hear their voices and footsteps. He himself
was doomed, and his family also; he felt he was the cause of all the
domestic woe. His own heart was dying away; he had fits of anguish and
causeless fear, and was under the constant expectation of death.
One day, he escaped from the hospital and went to the chief physician’s
tent, where he lay on the ground. When he was found and asked why he
was there, he begged the physician to save him from the Germans. The
man was not alcoholic and had no previous history of mental disease.
_Re_ early arteriosclerosis, Maitland in the second interim report of
the British Association Committee on Fatigue in Warfare, speaks of the
many Serbians, who, after six years of nearly continuous Balkan war,
show a marked arteriosclerosis. Maitland remarks that the line officers
were already showing (1916) a growing delicacy of perception as to the
“breaking point.” Men that do not break may return from the lines,
pale, with low blood pressure, and a _faiblesse irritable_, shown by
restlessness of hands and feet.
War stress: Manic-depressive psychosis.
=Case 167.= (DUMESNIL, 1915-6.)
A naval officer, 22, transferred from sea service, went into Belgium,
November, 1914, in a Fusilleur brigade of marines and there greatly
distinguished himself, growing very weary and enervated, however,
about the middle of April, 1915. His attitude to the men altered:
he sometimes struck them; gently, though, according to his account.
They must do in ten seconds what they really could not do under ten
minutes. The officer, in fact, had lost all notion of time. He went
about agitatedly, contradicted his superior officers and was troubled
because, as he said, they often were men of inexperience as compared to
himself. He grew irritated, too, because there were Free Masons in the
army and when he was sent to the asylum in July, 1915, said it was the
doing of the Free Masons. He did not seem to have any hallucinations.
His ideas and sentiments were very labile, and a bit confused, and not
all his interpretations dealt with Free Masons and occultism. August
5, however, the phase of calmness was again followed by agitation;
he broke things and laughed explosively. August 10, another attack
occurred, with destructiveness. During the next few days there were
alternate phases of depression and excitation. He was negativistic,
resistive and struck attendants.
_Re_ war stress and psychoses, Morselli finds the acute cases on
psychopathic soil. First in the list, he places the neurasthenias and
psychasthenias, and second, the hysterias, two groups which, more than
the remainder, may be said to constitute the so-called Shell-shock
group. Third, he found depressions ranging over into a delusional
state with suicidal ideas; fourth, a species of stupor, occasionally
catatonic, recalling dementia praecox; fifth, transient hallucinatory
states; sixth, confusions (Meynert’s amentia?); last, manias.
The above case of Dumesnil appears to be a pure case of
manic-depressive psychosis developing on the war basis, but perhaps
merely comes from a latent cyclothymia.
Predisposition; war stress: Melancholia.
=Case 168.= (DUMESNIL, 1915-6.)
A farmer, 30, was mobilized August 2, 1914, and was wounded in the
hand September 27. He went back to his dépôt in December and stayed
there until March, 1915, when he was sent to Dunkirk. Before leaving
the dépôt he said that he had heard soldiers declaring that he was not
doing his duty, that he was going to be court-martialed, that life was
at an end for him. At Dunkirk he said these same soldiers continued to
say the same things about him, forming a band about him, led off by a
subaltern officer who meant to frighten him and to make him talk. One
night sulphur was thrown at him for poisoning purposes; he complained
of this to a sergeant and declared he did not understand why he should
be thus pursued. After the bombardment of Dunkirk the hallucinations
grew more intense. He was sent to hospital and was so harried by the
voices that he wanted to throw himself down a staircase but was caught
in time. At the hospital for the insane he complained that his thoughts
were being heard and loudly repeated; he was made to make incoördinate
movements; was treated as a spy. He thought he must be a German or they
would not treat him so. He waited for death as he wanted to be executed
at once.
This man’s father was alcoholic. He himself at the age of fourteen had
had a period of neurasthenia with some sort of nervous seizure for a
period of five months. At 28 he had a rheumatic seizure which kept him
in bed fifty days. A daughter born to his wife had died a few days
after birth.
Dumesnil’s analysis is melancholia with delusions of persecution, due
to war stress in a predisposed person.
_Re_ melancholia and the war stress, see remarks under Case 167. _Re_
manic-depressive psychosis in the Russians, Khoroshko found 9.4 per
cent of manic-depressive cases, the same percentage of epilepsies, 10
per cent of paretics, and 20.4 per cent of schizophrenic cases amongst
a group of 318 neuro-psychiatric cases. Almost all his manic-depressive
cases had been patently so antebellum.
Depression; low blood pressure. Pituitrin.
=Case 169.= (GREEN, 1917.)
A private, 22, was sent back from Germany as insane. He had been in the
asylum at Giessen seven months, and a prisoner in all fifteen months.
August 16, 1916, he was admitted to Mott’s wards at Maudsley in a
markedly depressed and lethargic condition. He had improved somewhat
in October, but still had periods of depression. He was put on thyroid
extract (Green’s treatment was in doses measuring from gr. ¼ to gr.
1, t.d.s.; according to Green, the effect of thyroid extract is more
rapid when coupled with pituitrin). In December he was given pituitrin
extract gr. 2, t.d.s. In January, 1917, he was no longer depressed or
lethargic. He complained of pain in his back, found to be due to a
bullet. This was removed.
_Re_ prisoners, Imboden found amongst 20,000 French soldiers taken
prisoner at Verdun after the severest drum fire and strain, only
five neurotic cases (data of Mörchen), and Wilmanns found but five
neurotic cases amongst 80,000 prisoners. Lust reviewed 20,000 war
prisoners in Germany and found singularly few instances of neurosis.
Shunkoff notes, however, that there are a number of psychotic cases
amongst the prisoners because the _mentally_ diseased who do not
disturb the military routine are kept in the line. Bonhoeffer found
amongst Serbians taken prisoners by Germany, emaciation, atrophy,
heart disease, and frequently tuberculosis. (See Case 166.) Bonhoeffer
noted the absence of psychoses amongst these Serbians, drawing the
general conclusion that campaign stress was unable to bring out
psychoses. But, although the exhaustion psychoses are not found,
there are exhaustion neuroses or states of acute nervous exhaustion,
characterized by somnolence and depression, followed by a mild degree
of overemotionality. vum Busch states that interned German civilians
have gone into psychosis frequently. It is said that one in 10,000
war prisoners in Germany has committed suicide. Bishop Bury found at
Ruhleben 60 or 70 cases of psychosis.
X. PSYCHONEUROSES
Hallucination in the field (surprise by _BOCHES_); scalp wound: Three
psychopathic phases--(_a_) over-emotionality, (_b_) obsessions, (_c_)
loss of feeling of reality (victim a “constitutional _intimiste_”).
=Case 170.= (LAIGNEL-LAVASTINE and COURBON, July, 1917.)
A cashier, 31 (of rather weak constitution but without hereditary
or acquired mental taint--a religious man and for religious reasons
chaste, always given to metaphysical speculation and introspection, but
on the other hand, much interested in sports and very sympathetic with
English manners), was about to go to live in the country on the advice
of his physician when the war broke out. He was called to the colors
and shortly lost his tendency to bronchitis, put on flesh, and felt
delighted with his situation.
After almost two years of effective service, June 2, 1916, when his
troop was cautiously advancing into a trench at the end of which they
might be taken by surprise, suddenly the officer cried, “_Sauve qui
peut!_ _The Boches are on us!_” The patient remembered seeing Germans
emerge from every side, remembered his fear, how he had turned about
and crossed over a palisade, and then no more until he found a scalp
wound being staunched by his comrades in the trench. He put on his own
dressing and followed his comrades on foot.
He quickly got well of his scalp-wound but remained in hospital,
very weak, extremely impressionable, jumping at every noise. He got
somewhat better with the rest in bed, though even a month after his
hallucination, he had a spell of insomnia, thinking about his future
and the possibility of a relapse, and having war dreams from which he
would awake in a sweat. Once on awaking, he distinctly heard a voice
saying, “_Well, Charles?_” This hallucination occurred five times,
under exactly the same circumstances, except that once it was in the
daylight. Adrenalin was given, 1:1000, 10 drops the first day, 20 the
second, 30 the third, and a like amount on the following days. After
three days of such treatment, the patient said he felt much better.
Later he had a period in which he had lost self-control and could no
longer take any initiative. Thus, if he wanted to reply to his mother,
it seemed to him that some one not himself was ordering him to write.
He now asked himself if he were not really dreaming. He would not be
sure of his actual existence unless something happened to prove it,
such as the nurse’s bringing him a plate.
In short as the first phase of diffuse over-emotionality had been
succeeded by a second of obsessions, so the obsessive phase was
succeeded by a third phase of mild loss of the feeling of reality.
The first phase following the wound was one of disorder of attention,
of memory, and in fact of all the mental functions, associated with
tremors, tachycardia and dizziness. The second phase seemed, as it
were, to crystallize intellectually the anxious apprehensiveness of the
first phase. There were fears that the ceiling would fall; there were
scruples concerning the past; there were fearful premonitions for the
future (such as, that any bomb he might pick up would burst). According
to Laignel-Lavastine and Courbon, there may have been a predisposition
in the vegetative system of this subject, or even a basis in his
tuberculosis, of which, in fact, the X-ray showed still some slight
evidences. The obsessions appeared at night, at a time, namely, when
the vital rhythm is passing from a sympathotonic period over into a
vagotonic period, at a time when the organic sensations are apt to swim
to the fore. According to this analysis, these somatic sensations,
precisely those that the battlefield had also brought out, brought out
again the other emotions which he had felt on service. It was always
the emotions first developed in military service that were revived in
the disease. In the third phase, the physical condition of the patient
had grown much better _pari passu_ with disappearance of the obsessions
and the onset of the personality disorder. The adrenalin raised
arterial tension, and going down to the sympathetic caused the anxiety
and war emotions linked therewith to disappear; but the adrenalin
treatment, according to Laignel-Lavastine and Courbon, disturbed the
organic sensations so suddenly that there was a break between the new
conscious status and the old. In consequence, the patient felt that
these new sensations no longer really belonged to him but were of a
xenic character, imposed upon him from without in such wise that he
continually asked himself whether he was really dreaming or no. This
man was a constitutional _intimiste_; a psychasthenic _en herbe_.
_Re_ neurasthenia, Lépine notes that there are transient and relatively
permanent cases. The term is often used to cover graver disorders,
such as various melancholias and anxieties. As a rule, in France, the
neurasthenics are evacuated for fatigue. There have been a number of
cases in officers, who find themselves unable to make decisions on
the minute and to remember military facts, or perhaps are unable to
make any physical or intelligent effort whatever. A true neurasthenic,
however, ought not to be a confused person. He is a man with a rather
unusual clarity of view as to his situation; and his trouble appears
to him to be somatic rather than as of the nature of a depression. He
feels that, if he could only rest, he could be cured. Neurasthenia,
according to Lépine’s war experience, is practically always the
disease of a highly cultivated nervous system, and appears in men
who have undertaken responsibilities. There is a group of young men
who have never been physically strong, bowled over at last by some
small event, such as a diarrhoea, and unable to carry on. Such men,
perhaps, are likely to have some traces of an old tuberculosis, an
adrenal insufficiency, or insufficient hepatic function. Martinet has
found them hypotensive and rather poorly aerated. There is another
group of neurasthenics (Maurice of Fleury) that are old arthritics,
with increased tension. These cases are not found at the front because
conditions there rather tend to reduce the trouble; but they are
found doing office work in the interior. Besides these cases of the
“cultivated” group, Lépine also finds a number of neurasthenics amongst
the peasants, in whom anxious ideas may lead to hypochondria.
Fugue, hysterical.
=Case 171.= (MILIAN, May, 1915.)
The fugue of an adjutant who left his regimental relief post at
Palameix Farm and was found several days later with his family at
Castelsarrasin, was reconstructed from partial records as follows:
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.
September 11, 1916, he had been admitted to Number 3 General Hospital,
France, in a noisy, excited, insolent state: said he saw spirits of
the dead; heard his sister urging him to lead a better life. Admitted
to Netley early in October, 1916: now said he was a spiritualist, a
Frenchman, had a quarrel with parents and enlisted in British Army,
in army service; went to France August 12, 1914, was wounded at Loos,
September, 1915, returned to front in February, 1916, “shell-shocked”
June 1, 1916; lost consciousness after this--did not know where he was
until July 22, 1916, when he had been arrested as deserter.
Admitted to Lord Derby Hospital October 14, 1916,--quiet, orderly,
coöperative: desired to return to his regiment. He now gave a history:
Enlisted British Army 1908, went to France, August, 1914, wounded
February, 1915, at Neuve Chapelle; recovered; then attached to 45th
Durham Light Infantry; blown up July 22, 1916, came to August 5,
1916, in hospital in Boulogne; then back to his regiment--but month
later left without leave to pay off old score on a former comrade
who had insulted his sister--arrested later by military police; put
under observation in 65th Field Ambulance. No deterioration noted,
school knowledge fairly well retained; no hallucinations or delusions
(maintained he was a spiritualist, also that following shell-shock
had suffered from insomnia and seemed to hear sister’s voice).
Physically--small, well nourished, effeminate looking.
Oct. 23, 1916, he broke parole, but a month later returned to hospital
under arrest. The police reported he had been masquerading as wounded
French soldier attached to British army as interpreter; imposed on
people; had two leaden types in his possession: “Interpreter R. le
Auldere, attached to 1st Division.”
Story in hospital on return:--Born in France, did well in school,
entered military academy at Paris. Quarreled with father--ran away
to sea. Adopted by a French lady at Pembroke Dock. On account of
drunken habits, quarreled again; joined army at Bristol, 1908. Went
to France in August, 1914; January, 1915, invalided home because of
“trench feet”--discharged as unfit. Reënlisted June, 1915, in Durham
Light Infantry. January, 1916, again ordered to France. Blown up on
Somme, July, 1916, by shell--remembered nothing until brought to No. 3
General Hospital. He remembers being accused of desertion but sentence
was not passed, as he was held by the medical officer to have been
irresponsible (as a matter of fact he was, at that time, considered to
be a case of dementia praecox.)
Said that during twenty-five days, due to drunkenness, his friends had
taken him to Manchester with them; arrested by police as he attempted
to get back to hospital. He was now accused of wilfully lying and,
confronted with his police record, at first denied it, but later gave
following approximately true story:
Born, England, 1890; early life of a roving disposition, good at
school, liked books of adventure. Drank early. Ran away at sixteen; was
returned home. Ran away again--convicted of drunkenness. Three-year
sentence to reformatory in 1910 for stealing: escaped. Rearrested for
stealing in 1911: released in 1913, enlisted in army and deserted.
Arrested in January, 1914, for stealing; sentenced to three years:
released to rejoin army in June, 1915. Arrested as deserter: imprisoned
but released in January, 1916; left for France. August, 1916,
“shell-shocked,” sent to Field Ambulance No. 3, General Hospital,
Netley, and Lord Derby War Hospital. Court-martialed for desertion:
nothing came of it on account of medical evidence.
After breaking his hospital parole, he masqueraded in district as “R.
le Auldere,” “Le Marchal” and imposed on various persons.
Psychopath almost Bolshevik.
=Case 184.= (HOVEN, 1917.)
A sergeant, accountant in civil life (father insane, mother pulmonary,
grandfather alcoholic, cousin insane; patient himself anemic as a
boy, victim of chronic gastritis and gonorrhea), was evacuated from
the front to Chateaugiron in March, 1916. It appeared that instead
of watching over his men as a sergeant should, he gave utterance to
baroque theories of the divine right, the influence of the grace of
God on man, and the end of the war. He went so far as to ask leave to
transmit to the Inventions Bureau of the War Ministry an invention
with respect to the problem of locomotion, and he sent to the King of
Belgium a manuscript to the effect that he had received from heaven
a mission to reëstablish the world’s balance. He was, in fact, the
victim of delusions of a mystical nature with visual hallucinations. To
explain his mission, he wrote, “It was my duty to take supreme command
of war operations.… I have the power, the right and the duty to give
the following order … general armistice … peace will be symbolized
by the house undivided and will be constituted by general Christian
religious unity … as a consequence of what we shall say they will give
up our territory to us of their own accord.”
This case of paranoia apparently took its coloring in part from the war
situation itself.
Hysterical mutism: Persistent delusional psychosis.
=Case 185.= (DUMESNIL, 1915.)
A sergeant, aged 23, evacuated from the front to a hospital for the
insane, had been mute, though not deaf, since February 28, 1915. If
asked to cry out he grew black in the face and could utter only a
raucous scream which made everyone jump. He wrote very frequently,
stating in February that as he was still a sergeant and had no hope
of advancement, he cared nothing more for life. “The idea of death
got anchored in my head.” In this state of mind, on the afternoon of
the 27th two bombs came. “I saw the first one coming and cried out
a warning. Coming back I saw the second one. The bombs were coming
rather softly. From this moment on and up to the time when they burst,
I thought I had gone, that I had been carried off and crushed. I was
quite astounded at finding myself covered with earth and stones … but
I could not talk any more, I could just say in a low voice ‘Papa,’ and
the next day in an ambulance I could not talk at all.”
There was complete pharyngeal anesthesia. The man had been a foundling
and was clearly a degenerate. He had always been of a depressed
disposition and given to thoughts about his misfortunes. Over and
above the mutism gradually ideas of persecution and revindication
developed (such as that he merited adjutant’s rank and was being mocked
and treated as a simulator). He drew up a long letter to the War
Ministry in which he stated his desire to be sent back to the front.
He complained to the police about a hospital sergeant and offered a
duel in an elaborate and inflammatory style, “with whatever weapons
shall please you, either sabre of 1845, revolver of 1902 or bayonet of
1886 or the _chassepot_. One of us two must disappear.” He had become
dangerous enough to be interned and in hospital remained mute with the
same ideas of persecution and revindication, the same alternate phases
of calmness and excitation. According to Dumesnil: hysterical mutism
with persecutory delusional psychosis.
A peasant’s psychopathic inferiority brought out by the war.
=Case 186.= (BENNATI, October, 1916.)
An Italian peasant began to feel sick on being called to arms.
Antebellum he had been an even-tempered, good-natured man, according
to his own story, satisfied even with stale food, and always enjoying
his sleep. He had been in the war about a month, doing construction
work, sentry duty, and chores. Though he lived in the trenches under
damp conditions, there had really not been much excessive war strain.
He shortly developed migraine and war-weariness, as well as middle-ear
disease.
A number of times he heard shooting nearby, and was subject in his
sentry duty to a good deal of anxiety and painful associations. On
sentry duty he had digestive disorder, vomited, and became intolerably
weary; in point of fact, a fever, regarded as malarial, then developed,
together with diarrhea.
Upon hospital observation, he was found fatigued, given to terrible
dreams, tremulous in the fingers, with skin reflexes a little
excessive, and the Moebius phenomenon. The thyroid was somewhat
swollen. The pulse stood at 80. The Mannkopf sign was well marked, as
well as that of Thomayer (80-120), and Erben (120-87). The oculocardiac
reflex was prominent.
Psychopathic episodes.
=Case 187.= (PELLACANI, April, 1917.)
A Neapolitan, 26 (neuropathic stock: mother epileptic, brother
psychopathic; patient had previous criminal record; married and then
appeared to behave himself for several years; had always been excitable
and of violent temper), after but one severe day in the trenches, woke
and found his night clothes soaked in urine. Another time, his comrade
had awakened him because he was gnashing his teeth in his sleep. Again,
his grief became very violent at learning of his wife’s infidelity, and
during the night he bit his finger. He thereafter suffered from severe
headaches, dizziness and vertigo though without falling. He was granted
a furlough, but the condition was aggravated on account of his wife’s
abandonment of him, and one day, finding her with her lover, he threw
himself at them, wounding her severely in the face: he did not remember
this impulse later. Many hours later, on awakening in prison with his
wounded hand, he recalled the entire episode. He showed a confused and
excited condition, which, however, quickly diminished. He became lucid
and tranquil, though easily aroused. He cried at the thought of his
daughter, whom he wanted to save. Insomnia, instability of reaction,
habitual migraine, and dizziness. Tremors of the fingers and of the
eyelids. Exaggerated reflexes. Very striking cutaneous analgesia.
Maniacal and hysterical delinquent.
=Case 188.= (BUSCAINO AND COPPOLA, January, 1916.)
An Italian soldier, 25, a foundling, was always off and on in a
military prison. At a tavern one night the man unsheathed his sword and
threw three bottles at the host. Bystanders overpowered him and carried
him to the local police station. Handcuffs were put on to stop the
mania. His pupils were dilated and he was sweating profusely. Alcohol
could absolutely be excluded from the history of this incident.
Observed in clinic, the patient was rather silent, but on the whole
normal and without delusions or hallucinations. It seems that he had
committed a number of crimes in the army that were always excused on
account of his mental state. He had been strongly alcoholic, although
not at the time of the incident mentioned. He was covered with
tattooings of an obscene and violent nature.
He showed pharyngeal and conjunctival anesthesia and concentric
limitation of the visual fields of unusual degree, and a remarkable
hypalgesia. The knee-jerks were lively. The man was, in point of fact,
sent back to military service, with, however, the suggestion of reform
school.
Psychopathic delinquent.
=Case 189.= (BUSCAINO AND COPPOLA, January, 1916.)
An Italian, 20 (family history negative), was described by officers as
of an odd disposition, at times thoughtful and again chattering and
presumptuous, and often very vulgar in talk and manner. He had tried
several trades, with little success.
While in the army he discharged his gun three times, claiming to
have heard noises in a nearby field. On account of the inopportune
repeated discharges, he was condemned to the barracks for ten days. The
following day, instead of returning to the barracks, he abandoned his
musket, cartridge box and uniform, and, returning to town, left for
Leghorn. Being sent to prison, he began to scream that he was thirsty.
He tore his jacket into strips with his teeth, and making a noose of
it, attempted to hang himself.
On being transferred to the military hospital, he was often very
restless, screaming and making a great uproar. On being questioned,
he answered indifferently and had a vacant stare. During his stay at
the clinic, patient was always quiet. Once, however, he had a spell of
intense psycho-motor agitation, brought on without any known cause and
followed by a short period of bewilderment, lasting altogether half an
hour.
Patient had insomnia and his visual fields showed concentric
contraction for white. He was sent to a military convalescent hospital.
Psychopathic excitement.
=Case 190.= (BUSCAINO AND COPPOLA, January, 1916.)
An Italian soldier, 22 (father and brother both committed to insane
asylums), since his enlistment had been conducting himself strangely,
being impulsive, undisciplined and unbalanced. He had been in Libia
from January to August, 1913, and was returned to Italy on account
of persistent severe headaches. A month later he was returned to a
regiment in camp.
September 23, 1914, the patient, who had been reproved by a superior
officer to whom he had given a disrespectful answer, began to be
excitable. He was calm during the day, but acted in a sullen and gloomy
way and kept entirely to himself, avoiding even his most intimate
friends. When, however, he suddenly recalled his punishment of the
morning, he began to race around the yard and finally threw himself
upon the ground, remaining there in a cowering and squatting position.
At the beginning of the attack he was possessed of a paroxysm of fury,
which made a great impression upon those present: eyes agape, face
swollen and distorted. He resisted being transferred to the hospital
and a furious struggle followed. He tried to bite and scratch everyone.
It required ten persons to carry him by his hands and feet safely to
the hospital, where he arrived in a state of great excitement and rage.
At the clinic, during the period of observation, he was always
tranquil, rather silent, gloomy, somewhat hostile; said he did not
remember why he was brought there. Often he was not able to sleep,
especially during the first few days of his stay. Has had painful
headaches and feeling of dizziness. Several times he showed a
tendency to be untruthful. Bodily examination revealed the absence of
conjunctival and pharyngeal reflexes. W. R. of serum was negative.
Patient was sent to an interior hospital for convalescence.
Desertion: Dromomania.
=Case 191.= (CONSIGLIO, 1917.)
An Italian private, 19, came up for desertion in the face of the enemy.
He had had a good record during a year of military service and his army
conduct in the war was regarded as very good.
He felt sad and preoccupied for a number of days, but all of a sudden
“some indomitable force” thrust the idea into him to go out into the
country a distance of some 20 kilometers from the front, with the
definite object of praying in a certain church. It seems that this same
impulse had occurred to him several times before but not so forcibly.
These prayers were to be said in memory of some sad events in his life.
Upon examination he was found in a sad and self-accusatory state, much
discouraged with ideas of his guilt, unworthiness, and ruin. He had a
variety of gloomy fears and obsessions, all of which contributed to the
dromomania that culminated in desertion.
As to his previous history, he had had a depressive psychosis two years
before, but the delusions at that time were of persecution. He had also
suffered from typhoid fever a few weeks thereafter.
Suppressed homosexuality.
=Case 192.= (R. P. SMITH, October, 1916.)
A man, 32 years, of high intellectual attainments and unblemished moral
character--a teacher--enlisted as a private. He apparently found his
associates in camp very uncongenial and undesirable. He grew physically
tired, then mentally tired and unable to concentrate attention. He
began to neglect his uniform, could not keep his equipment in order,
became introspective and depressed. The drums he heard seemed to point
to his funeral. There was but one thing to do in his opinion: that was
to humiliate himself by committing sodomy. He thought of committing
suicide.
Upon discharge from military duty, he began to show improvement. Smith
regards this case as one of suppressed homosexuality.
Of the cases in which change or excessive work is the precipitating
cause, four out of six of Smith’s cases were men.
_Re_ homosexuality in the Italian army, Lattes has made a special
study. The effeminate homosexual is decidedly unfit for the army, being
unable to stand the war stress. Homosexuals diminish army morale.
The cases of functional effeminacy with normal physique are likewise
unfortunate for the morale of active units, though they may be employed
in garrison duty and office work. The medical decision in these cases
may prove difficult unless a broad interpretation of the concept
“psychopathic” is allowed to prevail.
Psychopathic: suicidal, then self-mutilative.
=Case 193.= (MACCURDY, July, 1917.)
An English soldier as a child had night terrors and fear of the dark;
as a youth wanted to throw himself down from heights; took delight
in seeing animals killed; was shy with both sexes; was never able to
run great distances; was taken from school at the age of fifteen for
weakness, and had always been subject to headaches, somewhat improved
by lenses.
During training sharp pains appeared in the left groin that grew
better when the man lay down. These pains were regarded as hysterical.
Thereafter began shortness of breath, pain above the heart, with
palpitations and occasional attacks of dizziness. After a short sick
leave he insisted upon going to the front, though his superior officer
thought it unwise, and, after a period of seventeen months training,
was finally sent to France in September, 1916.
He was at first somewhat afraid of shells and, though he soon got
used to the shells, the horror of the war grew on him, with pity for
the Germans as much as for the British. He became depressed over his
weakness and when his commanding officer committed suicide got obsessed
with the idea of committing suicide himself. He went so far as to drive
a knife into his upper lip and to smash a looking-glass to avoid seeing
himself. After a long spell of trench duty he had to be sent home
incapacitated.
In hospital in England he was depressed and suicidal. He began to want
to mutilate himself, yet found that a slight pain and the drawing of
blood was all that he really craved. Of course, he had been a failure,
but now he rationalized the failure by a comfortable conviction that
he should never have been sent to the front. He complained of memory
and attention disorder, insisted that he was physically incapable of
outdoor exercise, complained of headache if he stayed indoors. He said
he wanted to go back to the front; knew, however, that he could not,
and even refused to consider the possibility of getting well to work
at home. At the time of report he argued there was nothing left but
suicide.
Bombardment: Psychasthenia?
=Case 194.= (LAIGNEL-LAVASTINE AND COURBON, July, 1917.)
A twenty-year old engineering student of high grade and without
hereditary taint, a scientific and non-introspective man of a brilliant
and gay disposition, not very religious, without special sexual
abnormality, was mobilized in class 1914, was put into the artillery,
and was soon appointed _maréchal des logis_. He left for the front
April, 1915, yet had to be evacuated in November. One afternoon, at the
end of a bombardment, he rose from a recumbent attitude and immediately
felt a dreamy, bizarre feeling, as if a fog lay between him and his
surroundings. Next day, after a good night, he woke in the same state.
Everything was bizarre and novel despite the fact that he recognized
men and things. A physician ordered rest and after a few days evacuated
him.
He was cared for in various hospitals, but the psychasthenia increased.
He felt a terrible and causeless anguish, with precordial constriction.
He felt as if he were about to be executed. His fears appeared after
seeing some turning object, such as a wheel or a cane twirling.
Gradually this fear was transformed into a genital excitation, though
lascivious pictures did not excite him. Seeing anything turning gave
him a voluptuous feeling in proportion to the speed of the rotation.
It seems that all sexual interest had been at a standstill for several
months in the early part of his disease, when suddenly this new
aberration appeared. It seems that a portion of the man’s work in the
artillery caused him to use screws and cogwheels every day. Attacks
of vertigo occurred, with the appearance of an infinity of small,
colorless spheres turning over one another, the whole forming a sort
of animated system of rotation. In the night this system was luminous
and somewhat like what one feels on compressing the globes of the eye.
There was a retraction of the visual field. The man would be found
in the dream state, especially after waking in the morning or when
some novel kind of act was being performed. He got somewhat better
and did not wish to go on leave, because he feared the recurrence of
these psychasthenic paroxysms. However, he took a leave July 14th.
In the first part of his journey he had some vertigo and some of the
voluptuous sensations, but in the next two days he was much better. He
returned to hospital without trouble.
The authors somewhat doubtfully term this case one of a quiet
psychasthenia, but in discussion still further talk arose as to the
diagnosis.
_Re_ psychasthenics, Lépine notes that the lack of any out-standing
symptoms in many psychasthenics allows them to stay in the army longer
than would epileptics or hysterics of the same degree of disease. The
line officers tend to consider them exaggerators or simulators. The
fact that they besiege the line officers and the physicians with their
troubles may add to the impression of falsification. The basis of the
psychasthenia is often also, genuinely enough, a fear. Lépine divides
the military cases into anxiety neuroses and hypochondrias. The anxiety
cases are hypotensive and given to tachycardia. They have very labile
vasomotors. When it comes to the necessary exclusion of malingering, it
is the history, with its hereditary and collateral taint, that tells
the tale. A history in the patient himself of alcoholism, typhoid
fever, syphilis, or especially cranial trauma may play a part. An
agoraphobic may actually be in general a courageous man except for his
crises of anxiety about open spaces.
As to the hypochondriacs, fear of syphilis must be noted. Akin to the
syphilophobics are a group of pseudo genitourinary cases that fear
effects of an old gonorrhoea. See Case 195 (Colin and Lautier) below.
Gonorrhoea: NOSOPHOBIA, depression, suicidal attempt. Recovery,
thirteen months.
=Case 195.= (COLIN and LAUTIER, July, 1917.)
A munition worker came to Villejuif, December 6, 1915, with cord marks
on his neck and conjunctival ecchymoses. He had tried to hang himself.
Non-alcoholic, he had, however, long since shown signs of imbalance;
his father had died insane, in an institution. When the man came in,
he wept and groaned and made vague complaints of having contracted a
venereal disease, insisting that his genital organs were purple.
After a few days, he grew less anxious and told how he was married and
how his wife had made life a hell for him, giving herself up to drink
and becoming a sloven; how several months since he had contracted
gonorrhoea; how though told that the condition was cured, he had found
filaments in the urine and had tried a variety of drugs, spending most
of his money; how he found more and more filaments, thought himself
incurable and unable to live with his wife; how at last, desperate, he
had tried to hang himself.
He got well quickly, though his convalescence was interrupted by
several periods of depression a few days in duration, with anxiety and
tears. February, 1916, he was discharged well.
He returned four months later; he was still occupied with his disease,
still going to physicians and buying drugs. It took six months more
before the man could be discharged from the service, at the end of 1916.
This man appears to be a hereditarily predisposed subject, who simply
affixed his delusional ideas to a disease which had begun some time
before the mental trouble itself. The family plight is important and
practically constant in this group of cases. The fear lest the disease
shall be revealed by the physician to the family is deep-grounded and
impossible to overcome by mere statements concerning professional
secrecy. The impulse to suicide is extraordinarily keen.
A soldier (neuropathic taint) after hardships for two days stumbles
over a corpse; unconsciousness: Stupor; episodes of fright with war
hallucinations; look of premature old age; paresis; anesthesia.
=Case 196.= (LATTES and GORIA, 1917.)
An Italian soldier (a shoemaker with an epileptic mother and two
nervous brothers; himself always irritable and for long periods
melancholic; at 15 condemned to nine years in prison for homicide in
a quarrel) took part in a number of attacks at the beginning of the
war. His company was heavily engaged in October, 1915, and there was no
sleep two nights, and only a bit of cold food. He was dazed.
October 24, the company had to advance at night in the rain and under a
heavy rifle fire. The shoemaker stumbled over a corpse, fell, and lost
consciousness for a time that he thought was very long. He woke up in a
camp hospital, remembering all the experiences he had undergone up to
the time of losing consciousness. He now fell into a state of torpor,
occasionally jumping out of bed and shouting with fear, hurling himself
at non-existent persons, assuming a position of defence, and suddenly
awaking in anxiety.
October 29, he was transferred to a second hospital, and October 30,
in a third hospital, was examined and found well and strongly built,
but looking prematurely old. He was inactive, depressed, and stuporous
looking. He fell to weeping often and rarely gave any answer to
questions. Sometimes he refused food. There was a slight paresis of the
left arm, and the left pupil was smaller than the right; both pupils
reacted poorly to light. The larynx and cornea did not respond to
stimulation. Skin reflexes were poor, and the plantar reflex lacking.
The left side about the shoulder and hip showed large patches of
anesthesia to touch, pain and heat; but deep sensibility was present in
these areas. He slept well at night. Status unchanged for two weeks.
He was experimentally sent to the guardhouse, but was soon back in
hospital with the same symptoms as ever.
B. SHELL-SHOCK: NATURE AND CAUSES.
--la buia campagna
tremò sì forte, che dello spavento
la mente di sudore ancor mi bagna
La terra lagrimosa diede vento,
che balenò una luce vermiglia,
la qual mi vinse ciascun sentimento;
E caddi, come l’uom, cui sonno piglia.
--the dusky plain
trembled so violently, that the remembrance
of my terror bathes me still with sweat.
The tearful ground gave out wind
which flashed forth a crimson light
that conquered all my senses;
And I fell, like one who is seized with sleep.
Inferno, Canto III, 130-136.
Bombardment; shell explosion nearby: Mania; death in 24 hours. The
AUTOPSY showed superficial punctate hemorrhages of brain and congestion
of pia mater. CAUSE OF DEATH--small bulbar hemorrhage, congestion
of veins, and nerve-cell changes of a local and differential nature
(chromatolysis of vago-accessorius nucleus). SHELL-SHOCK SYMPTOMS due
to capillary anemia and chromatolysis of various regions.
=Case 197.= (MOTT, November, 1917.)
A soldier became rather nervous at the Somme, and later underwent
intense bombardment for some four hours, February 22, 4 to 8 P.M.
Although he said he “could not stand it much longer” he carried on
for twelve hours more when perhaps six shells went over, February 23.
One of the shells burst about ten feet away, just behind the dugout.
The first day of the bombardment he was tremulous and depressed;
later coarsely tremulous in the limbs. February 23 there was crying
and inability to walk or do any sort of work. Questions were not
answered. The pupils were dilated. The evening of February 23 the man
was admitted to the field ambulance in acute mania, shouting: “Keep
them back! Keep them back!” He was quieted with morphine and chloroform
and slept well during the night. There were at least two hypodermic
injections of morphine in the ambulance. He woke up the morning of
February 24 apparently well, but suddenly died.
The autopsy showed small scratches on the anterior chest wall, but
otherwise no sign of external violence. Both lungs were edematous;
the left lower lobe showed a considerable hemorrhage. The heart was
enlarged and the right side dilated. The liver was somewhat congested.
The kidneys were small, but otherwise showed no gross change (urine
without sugar or albumin).
CHART 7
EFFECTS OF HIGH EXPLOSIVE SHELLS
EMOTIONAL
COMMOTIONAL
LESIONAL
After Vincent and others
CHART 8
SHELL-SHOCK
^
|
+----+-----------------------------+
| |
| |
| SUGGESTION | ESSENTIAL!
| (AUTO-, HETERO-, MEDICAL) | (Babinski)
| |
| | SOMETIMES SOLE
| | FACTOR?
+----------------------------------+
^ | ^
| | |
| | |
+------------+ | +------------+
| | | | | INTRABELLUM
| | | | | FACTORS
| | | | | USUALLY
| EMOTION | | | SHOCK | ONE OR
| | | | | BOTH
| | | | |
| | | | |
+------------+ | +------------+
^ | ^
-------|--------------------|----------------------------
| |
+------------------------------------+
| |
| SOIL | FREQUENT BUT
| (ACQUIRED, ANTEBELLUM) | NON-ESSENTIAL
| |
+------------------------------------+
^
|
------------------|--------------------------------------
|
+-------------------------------------+
| |
| TAINT | FREQUENT BUT
| (HEREDITARY) | NON-ESSENTIAL
| |
+-------------------------------------+
The scalp showed a slight frontal bruise. The brain was extremely
congested. On each side of every superficial vessel there was an
ecchymosis. A number of minute punctate hemorrhages was found on the
surface of the brain in connection with very small vessels. The brain
substance was soft, but not markedly edematous. The cerebrospinal fluid
was tinged with blood. On each side of the great sinuses of the skull
there was considerable ecchymosis. This examination was made by Capt.
A. Stokes, R.A.M.C., in the mobile laboratory. There were no areas
of large hemorrhage anywhere in the brain substance and no smaller
petechiae, except the superficial ones above noted.
Microscopically Mott confirmed the pial congestion and macroscopic
subpial hemorrhages described in the gross. He found besides congestion
also actual hemorrhage in the vascular sheaths of the corpus callosum,
internal capsule, pons and bulb. Now and then blood corpuscles were
found extravasated into the nervous tissue.
The microscopic examination showed a generalized early chromatolysis
in the nerve cells of varying intensity, especially affecting the
small cells. The Nissl granules of the larger cells were also somewhat
abnormal, being smaller and packed rather loosely together.
The small cells of the bulb and pons were slightly swollen and their
nuclei large and clear. As to the larger cells of the bulb and pons,
there was less evidence of this swelling and nuclear change.
According to Mott, this chromatolysis may perhaps be regarded as a sign
of loss of biochemical neuropotential. The chromatolysis indicates a
relative degree of exhaustion of the kinetoplasm. Mott assumes that
the cells of this victim of shell-shock are in a state of beginning
nervous exhaustion. He remarks that the cells of the vago-accessorius
nucleus show more signs of this nervous exhaustion than others. With
respect to cerebellar findings Mott remarks that the changes found are
very similar to those described by Crile in the case of an exhausted
and wounded soldier. Mott correlates the mania shown on the evening of
February 23 with the venous congestion of the cortex, the small subpial
hemorrhages and evidence of scattered arterio-capillary collapse.
HISTOPATHOLOGY OF CASE OF SHELL-SHOCK,
BURIAL, GAS POISONING?
(F. W. MOTT)
[Illustration: Punctate hæmorrhages in corpus callosum from a
case of shell-shock and burial; very probably accompanied by
gas poisoning while lying unconscious and buried. Observe the
small white area in the centre of the hæmorrhage, in the middle
of which is a small vessel which, under a higher magnification,
will be seen to contain a hyaline thrombus. (× 20.)]
[Illustration: Hyaline thrombus of vessel in centre of a
punctate hæmorrhage. The thrombus was stained brown by
dissolved pigment. Around the blocked vessel is a white area of
brown substance containing numbers of leucocytes; outside this
is the hæmorrhage, not very distinctly seen. The specimen was
prepared from the subcortical white matter of the frontal lobe.
(× 345.)]
[Illustration: Leash of small perforating optostriate arteries
filled with pigment granules. Two of the arterioles show
miliary aneurisms. (× 350.)]
[Illustration: Three punctate hæmorrhages showing optostriate
arterioles filled with pigment granules. (× 30.)]
HISTOPATHOLOGY OF SHELL-SHOCK
(F. W. MOTT)
NOTE THAT THE CHANGES IN CELLS OF FIG. 3 ARE DIFFERENTIAL FOR
NUCLEUS AMBIGUUS: CELLS NEARBY PROVED NORMAL
[Illustration: FIG. 1.--Photomicrograph of section of corpus
callosum from case of shell-shock showing the capillary
punctate hæmorrhages. In several a small white area is seen of
brain tissue in the centre of which is a small artery or vein.
(Magnification 20 diameters.)]
[Illustration: FIG. 2.--Section of medulla oblongata from case
of gas poisoning, stained by Nissl method, showing the swollen
cells of the nucleus ambiguus. Observe the enlarged, clear,
eccentric nucleus; the surrounding cytoplasm shows an absence
of Nissl granules. In not a single cell is the nucleus seen in
the centre as it should be. (Magnification 450.)]
[Illustration: FIG. 3.--Section of medulla oblongata from
case of shell-shock with burial, stained by Nissl method,
showing the swollen cells of the nucleus ambiguus. Observe the
enlarged, clear, eccentric nucleus; the surrounding cytoplasm
shows an absence of Nissl granules. In not a single cell is
the nucleus seen in the centre as it should be. (Magnification
450.)]
[Illustration: FIG. 4.--Section of third cervical segment of
spinal cord from case of concussion, stained by Nissl method,
showing the medium group of anterior horn cells corresponding
to the nucleus diaphragmaticus. They show certain amount of
perinuclear chromatolysis. But all the cells exhibit the Nissl
granules. Even at the seat of concussion, the fourth segment,
an external group of cells remains showing Nissl granules.
Concussion therefore does not destroy the Nissl granules.
Probably the cells of the nucleus diaphragmaticus show a
certain amount of chromatolysis because they were continually
discharging impulses along the phrenic nerves, and the few
cells that were left of the nucleus had therefore much more
work to do. (Magnification 300.)]
Mott suggests that the sudden death of the case may be due to a
hemorrhage into a sheath of a fair-sized vessel in the median raphe
of the bulb; the general venous congestion; and the almost complete
chromatolysis of the vago-accessorius nucleus (adjacent hypoglossal
nucleus normal).
According to Mott, also, many Shell-shock symptoms, _e.g._, headache,
giddiness, amnesia (anterograde and retrograde), dizzy feelings, lack
of power of attention, and fatigue, stupor, inertia, mental confusion,
terrifying dreams, are to be explained on the basis of capillary anemia
and chromatolytic changes.
Mine explosion. Ecchymoses; no bone or visceral consequences seen at
AUTOPSY (third day after explosion) except SUBDURAL HEMORRHAGE and
PUNCTATE HEMORRHAGES OF BRAIN.
=Case 198.= (CHAVIGNY, January, 1916.)
A sergeant in a Chasseur Battalion was in a mine explosion and
entered hospital June 19, 1915, so agitated that he had to be tied to
the stretcher during transfer from the railway. There were remains
of epistaxis and blood in the right ear, not proved to be due to
otorrhagia; blue-black ecchymoses of both eyelids; and small ecchymoses
of the bulbar conjunctiva of the right eye. No other sign of trauma
or fracture. The explosion had probably taken place on June 17 or
18. Patient was but semiconscious and irresponsive; rolled upon the
mattress, beating the air with arms and legs, assuming fighting
postures and uttering cries. Urinary incontinence. No fever.