A. PSYCHOSES INCIDENTAL IN THE WAR (continued 5)

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.