The patient was physically healthy and stalwart, mentally not excitable, and tolerably tranquil in the midst of shell fire. He would never have been reported sick had it not been for his wound. Aside from the tachycardia, of which he himself complained little, nothing wrong was found in the hospital. There was, to be sure, a feeling of discomfort without any hysterical tinge, and sleep was restless. Aside from the peroneus palsy, the injury made a good recovery. The nocturnal attacks persisted; bromides and even luminal failed of effect. There was, however, no longer any somnolence by day. In fact, for the five weeks of observation, there was no change in his condition.
Friedmann states that mild emotional alterations are not infrequent in the trenches with minds disposed thereto, although emotional shock, especially in shell fire, is the most frequent cause. However, these particular seizures are quite unusual. The stresses of field service lead to a sometimes complete paralysis of mental power, interfering transiently with service. There is no evidence of sudden circulatory disturbances such as would bring about dizziness, pallor, nausea, or fainting spells. According to Friedmann, the regulative brain functions, especially those that maintain consciousness, become weak on account of a condition which he terms Gehirnmüdigkeit, or, as we should say in English, brain fag. The situation forbids due completion of sleep. Thus, the explanation of the daytime attacks follows rather obvious lines of brain fag. The accidental awakening it is, which at night produces the absences; the wakenings are due to the general restlessness of the patient. The general weakening of cerebral function produces the disorder at the moment of wakening, since the regulative factors of consciousness are already out of order. The condition in the absence rather closely resembles the state of consciousness just before going to sleep, and also perhaps the state of consciousness during the process of awakening. It is as if the process of waking were somehow delayed a few moments. Friedmann is interested to show the relation of such absences to the so-called gehäuften kleinen Anfälle, originally described by him in 1906 as occurring in children, and distinguished from epileptic attacks. These attacks, after lasting for years, finally disappeared completely. The same sort of thing in adults was symptomatic of some other disease, such as neurasthenia, and was not a true entity. In children these attacks failed to be attended with any mental injury, nor were there any pronounced epileptic phenomena. Bromides had no effect upon them, and they already showed a somewhat striking and peculiar appearance, involving interruptions ten seconds long of capacity to think, speak, or move, without disturbance of consciousness or automatic movements. Sometimes the attacks occurred from six to 100 times in the day, without in any respect interfering with the general condition of the child. The occurrence of such series of mild seizures is nothing but a syndrome. To be sure, some cases turn out to be cases of genuine epilepsy with an eventual degenerative process. Some forms belong in the spasmophilia group, and some among the hysterias. However, according to Friedmann, there is a narcoleptic petit mal that is an entity by itself, proceeding after a period of years to complete recovery without complications. It is this form which may be regarded as a peculiar kind of brain fag. The case of the soldier may be supposed to be one which will prove to have this benign outcome.
Sham fits.
Case 78. (Hurst, March, 1917.)
An unwilling conscript developed numerous fits on board ship coming from Jersey, three days after enlisting. Fifty more developed during two days in hospital. He was sent to Netley.
On the hypothesis of hysteria or malingering, he was hypnotized. A fit was suggested to him, but did not come off. The Sister was informed in the patient’s hearing that the man was clearly shamming, as in all genuine cases a fit would occur after this treatment. A fit with marked opisthotonos immediately occurred. This fit immediately stopped when he was ordered to stop it and to wake up.
The man after waking promised to have no more fits.
Epileptoid attacks, controllable by will.