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.