Part 10

The man was tall, powerfully built, without visceral disease, speech defect, or other symptoms except that both pupils showed the typical Argyll-Robertson phenomenon. The deep reflexes of arms and lower legs were increased. The superficial reflexes were diminished, and the Wassermann reaction strongly positive. A seizure was observed by Hewat and the diagnosis of major epilepsy was revised. The diagnosis of cerebrospinal syphilis, non-paretic, was preferred to that of paresis on account of the absence of all the ordinary symptoms of paresis and of tremor. It might be asked whether these fits were chiefly alcoholic in origin. However, the patient had two or three fits while in hospital during a period of eight teetotal weeks. Hewat remarks that the case suggests that the serum of any patient developing epileptiform seizures for the first time say between 35 and 50 years of age, should be given the Wassermann test.

Syphilis may bring out epilepsy in a subject having taint.

=Case 54.= (BONHOEFFER, July, 1915.)

A man of 35 in the _Landwehr_ acquired syphilis some time in the summer of 1914. He was a good soldier, passed through several clashes, and was promoted to _Unteroffizier_.

To understand what followed it must be stated that he had been a bed-wetter to 11, had been practically a teetotaler (Bonhoeffer’s point is perhaps that otherwise epilepsy might have developed sooner?), and, when he did drink, vomited almost at once, and had amnesia for the period of drunkenness. His father drank. His sister had fits as a child.

February, 1915, the _Unteroffizier_ lost appetite, got headaches, and went to hospital for a time. Upon getting better, he was sent on service to Berlin. In a Berlin hotel he had his first convulsions and unconsciousness, biting his tongue. He was confused for several days, and, when he had become clear, had a pronounced retrograde amnesia together with a tendency to fabricate a filling of events for the lost period.

This retrograde amnesia is uncommon in epilepsy and suggests organic disease. No sign of such was found, or signs of the epileptic make-up. The serum W. R. was negative. On the whole, Bonhoeffer regards the epilepsy as “reactive” to the syphilis, as a syphilogenic epilepsy.

Alcoholism caused amnesia in this man in the same way as the syphilitic epilepsy now did.

_Re_ epilepsy and syphilis, Bonhoeffer states that he has repeatedly seen syphilis giving no other symptoms than epilepsy develop in the campaign. At the same time, Bonhoeffer does not find that the incubation period in paresis can be shortened by war factors; at all events, by the exhaustion factor in war (see Case 25). It might be questioned whether the above case (54) was not psychogenic; that is, whether the syphilis did not act in combination with being sent to Berlin on service as a psychic factor. However, this epilepsy on the whole seemed not psychogenic.

Syphilis in a psychopathic subject. Convulsions 5 days after Dixmude.

=Case 55.= (BONHOEFFER, July, 1915.)

A soldier in the reserves, 23, was, subsequently to his being brought to hospital, described by his wife as a rather over-sensitive fellow, who could hardly look at blood and was meticulous about the household. He had always been subject to headaches, especially after hard work. However, he had passed through his military training well in 1910, not even having been _bestraft_.

He began service in October and fought at Dixmude on the 19th. On the 24th in the trench and while being carried back, he had several spells of pallor, falling stiff, and then having convulsions. Brought finally to the Charité in Berlin, he had more spells of sudden pallor, collapse with brief convulsions, tossings in bed, as well as absences, post-convulsive headaches, and mild bad humor.

There were numerous attacks several days apart in the first seven weeks. The patient was not of an “epileptic” disposition, though readily dissatisfied and headachey.

The serum W. R. was positive. Treatment by mercurial inunctions. No further convulsions. Prognosis doubtful.

_Re_ epilepsy and the war, during the first six months Bonhoeffer observed 33 cases in the Charité Clinic in Berlin. Twenty of these 33 cases, unlike Case 55, had attacks before the war, although ten of these had become epileptic rather late, namely, after the period of active military service, at ages from 22 to 27. The development of epilepsy like Case 55’s is not without frequent precedent.

Bonhoeffer states that aside from epilepsy directly due to brain injury by shells, there has been no certain case in which we have the right to regard the war itself as the total cause of the epilepsy. Some, like Case 55, are of syphilitic origin. No subject with a severe long-standing epilepsy has been able to get into the field, according to Bonhoeffer; when they do, they prove constitutional subjects.

An epileptic imbecile, court-martialed.

=Case 56.= (LAUTIER, 1916.)

A Belgian soldier was condemned by court-martial February 27, 1915, to five years imprisonment for leaving his post in the presence of the enemy. It seems that he was mounting guard with two of his comrades and all three left to eat as no food had been brought to them.

A physician examined the Belgian soldier and declared him responsible, although a little sick. All three were condemned to imprisonment. The Belgian attracted attention in prison through crises of anxiety and agitation; he had terrible nightmares, seeing Germans in his cell and hearing gunshots. He was accordingly sent to a special infirmary of the dépôt, whence July 24 to Sainte-Anne, July 26 to Villejuif. He talked Flemish, hardly understanding French, and spoke slowly and with difficulty. He hardly knew how to read or write. He had been a truckman.

At 18, this soldier, according to his own account, began to have nervous crises in which he fell, lost consciousness, bit his tongue, foamed at the mouth and urinated involuntarily. The attacks were somewhat rare. His father sent him in 1910 to Gheel where he stayed two years. Returning home he helped his father in the trucking work.

When the Germans came the family fled to France and, about the end of 1914, he was put into the military service and sent to the front after a very short period of instruction.

The man had followed the example of his two comrades without taking the slightest thought. He did not understand the gravity of his act. He was not remorseful, regretful or angry against his judges. He was well oriented but quite indifferent. He was a tall, intelligent looking man with adherent lobules, slight facial asymmetry and evidence of tongue biting. He wrote like a child and read slowly, spelling out the complicated words. He was employed at various manual tasks during his sojourn at the asylum and had no epileptic attack. He was given over to the Belgian military authorities October 5, 1915.

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.

Responsibility of a drunken epileptic.

=Case 58.= (JUQUELIER, March, 1917.)

The question of responsibility arose in the case of a soldier who left his camp the morning of October 23, 1916, and went to a neighboring place, where he drank, with four others, two quarts of wine. At about three o’clock in the afternoon, his captain met him on the street, lost, and looking drunk. He told him that he would send him to the trenches in the evening. The man lay down and went to sleep. At about six o’clock, it was found that he could not put on his equipment alone, and in fact threatened the other men with his bayonet, and then went to sleep. He woke up and explained that he had had one of his nervous crises. He remembered the matter of the bayonet but had forgotten everything else about the struggle.

This soldier was 29 years old, the son of an alcoholic, and the ninth child of a mother who died shortly after her tenth pregnancy. He had had measles and bronchitis as a child, and in childhood had had bad dreams; at the age of ten he had swooning spells. He became a quarryman and a habitual drinker, subject to dyspepsia, nightmares, and nocturnal cramps. There had never been any crises, however, up to wartime.

January, 1916, when a shell burst near him, the first sharply-defined epileptoid crisis came, and was followed by a number of others, either on leave or on service, March 8, June 2, and July 13. These attacks showed a sudden fall without warning, loss of consciousness, convulsions, tongue biting, incontinence of urine, a period of more or less coördinate agitation at the time consciousness was reappearing, sometimes a fugue, and often amnesia for the whole. He had a scar on the left border of the tongue.

Should this epilepsy be regarded as entailing irresponsibility? He left camp before the crisis, accordingly in a period when he was in full possession of consciousness and will, and he had gotten into an irregular situation by drunkenness before his epileptic crisis started in. His struggle with his comrades, however, appears to be a portion of a post-critical dazed state. The medicolegal decision, therefore, was that he was guilty of leaving his command but not of the other misdemeanor. Considering the general nature of epilepsy, the responsibility of this man for the whole adventure is rather slight. The Council, however, condemned the man to five years of labor, without admitting that the crisis following so soon the actual misdemeanor should argue a diminution of responsibility.

_Re_ epilepsy in the army, Lépine notes the serious theoretical and practical problems to which it gives rise. In the first place, epilepsy occurs in the army more frequently than in the same number of men in civilian life. Consequently, the diagnosis as to the really epileptic nature of the attacks observed is not too easy. Again, the situation affords much opportunity for simulation (see, for example, the case of sham fits (Case 78, Hurst), and the case of epileptoid attacks controllable by the will (Case 79 of Russell)). Wounds may produce it, and even wounds which do not affect the brain; besides which, a variety of war conditions, short of trauma, may produce it. When the ordinary impulsiveness of the epileptic turns into automatism and to epileptic equivalents (_états seconds_), much of medicolegal interest may happen. Case 58 was just short of a murderer. Cases of actual murder in epileptic equivalents have been known under military conditions. Fugues with amnesia for the phenomena (which look to the military man like intentional desertions) form another group of epileptic events; but aside from the manias and the fugues, there are still more dubious epileptoid phenomena of a delusional and confusional nature, such that the proof of epilepsy comes only afterward, when frank convulsions supervene. _Re_ fugues and desertion (the most frequent of military delinquencies according to Régis), we may think of the fugue reaction, according to Lépine, as a natural reaction on the part of both the true delinquent and the mentally sick subject. The loss of liberty, alcohol, fatigue, minor phenomena of _commotio cerebri_, may lead to states of mental depression that favor the fugue. It is an affair of the greatest delicacy for the expert to build up again the exact plight of the soldier at the time of his desertion. Special inquiry must be made of the man’s mates. Only in this way can the wheat be separated from the chaff and punishment allotted to those only who deserve it.

According to Lépine, there are fewer guilty fugitives than there are innocent ones, or at least partially innocent ones. In the decision, one takes account of the duration, the course, and the peculiarities in the termination of the suspicious flight. According to the military code, there are cases like Case 58 in which the fugue itself was carried out in an unconscious state, and yet in which the martial responsibility of the man was absolute. Drunkenness is no excuse for the fugue, even if the latter is automatically carried out. Of course, the paretic is not responsible for his fugue any more than the organic dement, the delirious uremic, or the chronic alcoholic, who is already severely demented. For a case of this sort, see Case 1 (Briand).

In the differential diagnosis, we must also consider that fugues may be carried out in confused states as well as at times in various paranoid states, and even in melancholia.

A disciplinary case: Epilepsy.

=Case 59.= (PELLACANI, March, 1917.)

A Milanese workman, 28, was exposed to the sun on sentry-go and had an attack of convulsions, on awaking from which he found himself in hospital. He always had attacks in reaction to emotion. One day, in a quarrel provoked by jealousy concerning a prostitute, he apparently lost his mind, whipped out a hunting-knife, and wounded a comrade. Thereafter he lay unconscious until the next day. The court-martial decided that he was not fully responsible.

Eventually, he was sent from the front for having insulted and struck a superior officer. The report read also that he was a prey to delirium and had frothed at the mouth. In the interior he had convulsive attacks, with falling and loss of consciousness. He told of arguing with a sergeant about a bicycle, of seeing darkness before his eyes like a veil, and of subsequent amnesia. In hospital he had intense headaches at times, with spells of sullenness, hostility, and complaints concerning nurses and attendants and other patients. At other times, he was quiet and comfortable. One day he went into an excitement and wept, asking to be sent back to the army, striking the table with his fist and head. He then screamed, flew into a passion, and fell to the ground in semi-stupor, shaking his body and trying to kick and knock away those who intervened. He was placed in bed but remained agitated and unconscious, with anesthesia and frothing at the mouth. The abdominal and cremaster reflexes were absent in this attack, and the pupils were rigid and myotic. The pulse was rapid and the blood pressure high. Afterwards he was sleepy, stupid and weary, and showed fine rapid tremors of hands, tongue, and eyelids. The abdominal reflexes now returned in excess, and a marked dermatographia developed.

Upon investigation, it was found that the patient’s father was also an epileptic and was alcoholic; that one paternal uncle had died in an asylum; another of apoplexy; that two maternal uncles were chronic alcoholics (one in an institution); that an alcoholic brother had been six times convicted of assault and battery; that a sister had howling, crying, and hair-pulling spells, throwing herself to the ground. The patient himself had had an early Bright’s disease and had always been an undisciplined, excitable, and impulsive boy, sometimes kept out of school. His first conviction was at 18, for assaulting a policeman, and he had been arrested four further times for assault and battery. He stated that his convulsive attacks with the veil before the eyes came on when he was irritated or had taken cold, or had drunk to excess, or had over-exerted himself. He said he suffered from intense headache, weariness, and sleepiness after an attack. He always bit his tongue at the same period. Irritation and exertion sometimes caused attacks of dizziness and vertigo without unconsciousness. Alcoholism; ulcer in an inguinal gland. He had been confined in an asylum 40 days for epilepsy, attacks of which had become more frequent after he had heard of his father’s death.

_Re_ violence and epilepsy, Lépine remarks that a pure epilepsy unclouded by alcoholism may occasionally give rise to acts of extreme violence, but these pure epileptic violences are infinitely rarer than the alcoholic ones. The Milanese was in point of fact alcoholic, and in his ancestry were a number of alcoholics as well as epileptics. According to Lépine, when subjects are “out for blood,” they are almost always either, like this Milanese, hereditary alcoholics, or else strongly predisposed subjects, or even the offspring of the insane.

A disciplinary case: Epileptic attacks with amnesia.

=Case 60.= (PELLACANI, March, 1917.)

A Veronese, 23, quarrelled with his comrades, and one day wounded one. Another time, when reproved by a superior, he struck him with a shoe; and at still another time, hurled himself upon his superior officer and bore him to the ground. Yet he seemed to have a perfect amnesia for all these violent acts. At other times, he had convulsive attacks with a mental state which seemed to combine anger and depression, after which he would fall to the ground, lose consciousness, go into clonic spasms, spit bloody saliva, and cause wounds and abrasions upon his body. Once, after such an attack, he passed into a brief excited spell. Finally he was so insubordinate and violent to superior officers, that he was brought under hospital observation, having been excited and confused for a day.

Next day he was lucid, oriented, and tranquil; entirely amnestic for what happened the day before, though his acts were sufficiently unusual. He had threatened his superior officer and been reproved and sent to prison to think it over. In prison he had suddenly thrown himself against another innocent person and clutched him tightly about the neck. He threw another violently to the ground and then ran to help the previous victim! Bound fast, he had succeeded in freeing himself and thrown himself furiously against the prison door, whereupon he had fallen to the ground in an epileptic fit. He had tachycardia (120) and a generalized hypalgesia. The vasomotor reactions were excessive.

Upon investigation it proved that his mother had been subnormal and that the patient had been constitutionally excitable and unstable, given to attacks of anger and impulsiveness from youth up. In fact, he had been in prison several times for violence. He described himself in his restless spells as feeling a trembling all over his body as if his blood were boiling in his heart and his head, whereupon he would lose knowledge of what he was doing. He had been a quarrelsome boy, pursuing his mates with knives and stones. Once, after arguing with a car conductor, he had broken the car windows, turned everything upside-down, and thrown the conductor into the street.

Case 60 is clearly in the same group as Case 59. The Veronese falls into the same frame with the Milanese except that he appears not to have been alcoholic. The insubordinations of the Veronese were apparently carried out in a state of unconsciousness. The majority of insubordinates appear not to be epileptics. Some authors have called attention to pathological politeness as an occasional symptom in epilepsy. Perhaps the majority of insubordinate cases are feebleminded or schizophrenic.

Desertion in epileptic fugue.

=Case 61.= (VERGER, February, 1916.)

A blacksmith from the Rochefort Arsenal, 27 (nothing known as to grandparents; father, now in the fifties, for 30 years in an asylum with frequent attacks of furor; mother, 45, well and apparently well-balanced; brother with the colors, wounded and decorated with the military medal; a cousin-german, who has had a typical epilepsy--in the patient himself enuresis up to 13 or 14, later, less frequently; apparently no tongue-biting; no information as to infectious diseases; graduate from primary school, apprenticed to a blacksmith; an unskilful worker; never able to rise to the level of a _frappeur_), in 1909 had passed the board of review and been put in the sixth division of the line. Antebellum there was a history that one night at supper, he had slipped away from quarters and gone 30 kilometres, home. His astonished mother sent him back to the military post by railway.