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.