66. Psychopathic bravery is not shown in the feeble-minded only: [Case 158] is that of an Iron Cross winner who, after an hysterical-looking attack with hallucinatory reminiscences of a Gurkha whom he had bayoneted, turned out to be hebephrenic. [Case 159] might at first sight have been placed among the encephalopsychoses on account of the trauma to the occiput, and in fact the mystical hallucinations shown were of a visual nature (a rainbow-colored bird with the face of the Holy Virgin). In point of fact, there was probably no causal relation between the mystical delusions and the brain injury.
67. [Case 156], above mentioned, might perhaps be interpreted as one of Shell-shock dementia praecox, but the interval of nine months, though filled with hysterical symptoms, is decidedly long in which to suppose that shell-shock factors could be in process of causing dementia praecox. Cases [160] and [161] are more suspicious. Six German soldiers were killed by a German shell within the zone of German fire, two steps away from the subaltern officer ([Case 160]), who carried on for some hours, made his report duly, but thereafter developed tremors and lost consciousness. According to Weygandt, the case is one suggestive of dementia praecox, but very possibly should be regarded as one of psychoneurosis. At all events, it would be dangerous to found a doctrine to the effect that dementia praecox can be initiated by shell-shock upon such a case as [160]. [Case 161] is similarly doubtful. There are a number of symptoms in this man (the sole survivor of an explosion in a blockhouse) consistent with the diagnosis Shell-shock, and a number of others which hardly can be given any other interpretation than that of catatonic dementia praecox. But the available medical data do not begin until five months after the shell explosion. We must conclude here also that no definite evidence exists that dementia praecox can be initiated by the physical factor shell-shock. [Case 162] is one in which there are shell-shock factors and fatigue factors in a man who had once ante-bellum shown signs of mental disorder, and who developed delusions subsequent to a fugue following shell-shock. The most one could make of this case would be to say that a latent schizophrenia had been liberated by shell-shock.
68. To sum up concerning the schizophrenias (dementia praecox group), there are cases of great disciplinary interest in which alleged espionage and desertion turn out actually to be schizophrenic phenomena. Again, there are interesting diagnostic problems in the differential diagnosis of hysteria and catatonia. There is evidence that experience in the war may be woven into the hallucinatory and delusional contents of cases of pre-existent psychosis.
69. As to the important question whether shell-shock can initiate dementia praecox, the evidence from these reported cases is against the hypothesis; but if the query be, whether Shell-shock might not aggravate dementia praecox, it may be stated that a military board has decided that dementia praecox may be aggravated by some forms of military service. There is no reason to suppose that shell-shock factors might not operate in this way. Cases [152] and [162] will be of service in the proof of this contention; and [Case 162] seems to be definitely one in which a latent schizophrenia, showing itself in one ante-bellum attack, was liberated once more after shell-shock. Of course, the plan of this book and the method of choice of its cases precludes any statistical conclusions of great weight from the relative number of cases found in the different groups; and it might well happen that psychiatrists would not report cases of an everyday and commonplace nature which might yet be very frequent. On the whole, however, it would not appear that dementia praecox is at all a frequent phenomenon in the war.
70. Nor can the cyclothymias (manic-depressive psychoses) be charged up to war factors to any important extent.
On account of the somewhat close resemblance between the phenomenon of manic-depressive psychosis and what we ordinarily feel ourselves—a logical situation reflecting merely the fact that the phenomena of over-activity (mania) and of under-activity (depression) are merely quantitative variations from the normal—it might be supposed that the war life and its shock and strain would start up the cyclothymias in some numbers. Why should not a shell explosion start up a mania or throw a man into a depression? In point of fact the literature somehow does not agree with this presupposition.
Some years ago in Massachusetts a brief investigation was made of the assigned causes of the successive attacks in a great number of cyclothymic (manic-depressive) cases, and it was found that each successive attack progressively had less of the physical in the previous history. Something like 45% of all the first attacks had a pretty obvious cause in the soma, such as a kidney disease, a heart disease, a puerperal condition and the like, but the second attacks failed to show even 20% of such obvious somatic causes, and the third attacks even less than 10%, and so on.
Now war conditions and even the shell explosions themselves have apparently not set up any such conditions as those of mania or of depression. Most of the instances of cyclothymia are instances of men who are cyclothymic before they enter the army. These experiences, when after the war we can sift them all out, may allow us to form better ideas as to the etiology of many of the psychoses, and the great war may thus prove a gigantic experimental reagent which will aid in solving some of the major problems of mental hygiene.
71. The cyclothymic or manic-depressive group is represented in strikingly few cases, seven in number ([Cases 163-169]). One of the ideas in the literature concerning the manic-depressive group has been that it is very possibly remotely allied to Graves’ disease, a hypothesis upheld by Stransky in Aschaffenburg’s Handbook. Hyperthyroidism itself has been, of course, a rather striking feature in the foreground or background of many sick patients in the war. However, war factors have proved able to bring out very few instances of cyclothymic (manic-depressive) disease. Amongst our seven cases, the first ([Case 163]) was that of a maniacal Alsatian of 59 years, who volunteered because of his hypomania. [Case 165], the case of a German who pelted French trenches with apples from an appletree in No Man’s Land, was another case in which the war had little or nothing to do with the development of the mania. One of fugue ([Case 164]) was a case of melancholia and anxiety not closely related with war experience. In three further cases trench life and war stress may be thought to have liberated the cyclothymic phenomena. [Case 166] was that of a man of 38, previously referred to, who developed arteriosclerosis and whose depression and hallucinations had followed four months of trench life devoid of battles or injury. It is possible that this case should be regarded rather as syphilitic or of some unknown organic origin. At all events, it is not clear that it could be made to bear a heavy weight of hypothesis concerning the genesis of cyclothymic psychoses. [Case 167], a naval officer who distinguished himself greatly by work on land in Belgium, was regarded by its reporter as one of manic-depressive psychosis with the fatigue of war as its base. It might be queried whether the man’s distinguished work was not due to an early phase of hypomania, after which the cyclothymic effects began. In [Case 168] there was some evidence of the effect of war stress, as certain hallucinations grew more intense after the bombardment of Dunkirk; but in point of fact, this man had shown a predisposition and indeed a period of so-called neurasthenia ante-bellum. It is doubtful, therefore, whether there is any case here abstracted which can be used to support the hypothesis that the manic-depressive (cyclothymic) group of mental diseases has had or is likely to have its genesis in war stress. The remaining case ([Case 169]) is one illustrating a method of treating low blood pressure in depression.
To sum up concerning the cyclothymias: War stress seems to have had singularly little effect in the production of fresh attacks, and so far as we are aware, no effect in starting up a manic-depressive diathesis, unless [Case 167],—that of the naval officer who distinguished himself in land battles,—looks in that direction. It is, of course, to be conceded that hypomania might readily be overlooked under war conditions, and that suicidal melancholias, belonging in this group, might be interpreted as natural war-made depressions. Very possibly, therefore, this result (running to the effect that the cyclothymic forms of mental disease are rare in military life) may need revision.