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.