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Seizures in a feebleminded subject—psychogenic components.

Case 57. (Bonhoeffer, July, 1915.)

A 21-year old tailor, unused to marching, went into the field in August. A month later, after a period of long standing, he was nauseated and fell in a faint. Upon waking, his fingers were stiff and he had pains in his legs. He got better in the reserve hospital and was sent back to the line. On the way he had a similar seizure, with nausea and fainting. On the way back to Berlin, he had a seizure in the railway station, and was carried to the Charité Clinic. At the clinic he stated that he could feel an attack come on; that he first had Angst all over his body, and that it was hot inside of his head. Latterly he had been able to stop an attack by clenching his teeth, after which the attack would not proceed except that all became black before his eyes.

He was observed for four weeks but no seizure appeared. He was somatically negative; his Wassermann reaction was negative. There was nothing hysterical about his make-up; he was somewhat surly and of low mental grade. He was unwilling to walk alone for fear of attacks.

As to the heredity of this soldier nothing is known. He had been an illegitimate child; he was a sleep-walker in childhood; he had sometimes spoken out loudly in sleep as a boy. At school he had been somewhat backward, fought readily with his mates, and often complained of dizziness and headaches. He could not stand smoking or drinking well, getting drunk upon two glasses of beer. He had not held positions well. He became a pionier in 1914, working chiefly as a tailor.

Early in his time as a soldier he had obtained an ulcer of the glans, which had been excised and burned. There had been no secondary symptoms.

According to Bonhoeffer, this is an example of a not infrequent condition. Although the attack itself and the habitus of the patient did not look hysterical, the manner in which the attacks repeated themselves speaks for psychogenic components. Just as genuine hysterical attacks may be looked on as reactions to unpleasant situations, so may these attacks. In fact, we are probably dealing with an hysterical fixation of the symptoms of emotional fright like those in the true hysterias following shell explosion. A great many of the phenomena of Shell-shock, to use the English phrase, are not in and of themselves of a psychogenic nature, but they are, according to Bonhoeffer, psychogenically liberated under the influence of unpleasant ideas.

Re reactive epilepsies, Bonhoeffer considers that there is a group of reactive epilepsies in which the war process plays an important part. The prognosis of these cases ought to be relatively favorable. In point of fact, Case 57, although a feebleminded subject, seems to have had a relatively favorable prognosis: at all events, no new seizures appeared under prolonged medical observation. These reactive seizures may occur in cases with a labile vasomotor system. They are, according to Bonhoeffer, aligned rather more with hysteria than with genuine epilepsy. Genuine epilepsy has not been developed in the war cases observed by Bonhoeffer except where an endogenous factor was clearly in evidence; or else where there was the requisite antebellum soil for the development of an epilepsy. In short, genuine epilepsies developing in the war are all, according to Bonhoeffer, predispositional. The antebellum soil was clearly in evidence in Case 57. Even before the war, according to Bonhoeffer, many German soldiers during the period of military service gave evidence of their epileptic soil by sundry suspicious phenomena. Among these were fainting spells during hard drilling and other exercises, spells of enuresis, abnormally deep sleep, and even phenomena of somnambulism. One of the Bonhoeffer epileptics had been released during his reservist practice as unfit for military service, and had only been put into the line at his own urgent request at the outbreak of the war. Three volunteers concealed their epileptic history. One man, who had had merely petit mal attacks before the war, regarded them as of little consequence, entered the service, and developed epilepsy.