Hard patrol work: Delirium; head tremor augmented by excitement: Virtual recovery on bandaging neck, isolation, open air, to-and-fro transfers to mental and nervous wards.
Case 505. (Binswanger, July, 1915.)
A metal moulder in civil life, 29, in military service 1907 to 1909 (no hereditary taint, moderately good scholar), became unconscious for a half hour after taking a cold drink following a somewhat long practice march, at some time during his first year of military service.
He was in several skirmishes in Belgium and Northern France early in the war, being once surrounded in patrol work (November 11) by Turcoes and Zouaves. There was a lively exchange of shots, in the course of which five of the eight men on patrol fell. The three survivors hid themselves for three days in a quarry, and on the fourth were found by the advancing troops, and immediately went into battle.
But during a pause while on the point of taking coffee, the man suddenly fell sick, tried to carry on, but lost consciousness and apparently remained unconscious for about three-quarters of an hour. It seems that he raved and shouted and tried to bite his fingers, being held with great difficulty by several comrades. He was removed to a dressing-station three km. distant.
At the dressing-station, his head began to shake, although he was unaware of this until his attention was called to it by his comrades. He said that he felt restless and that his head ached almost continually. He was carried to the reserve hospital, and from thence, December 9, 1914, to the nerve hospital at Jena, where he was unaware of the shaking of his head (which had now lasted for three weeks), and said that he felt a thick fog in his head (to say nothing of headaches), and was only free and clear in his head while standing in the open air.
His sleep was restless and poor; there were war dreams almost every night. In the process of getting to sleep, his arms and legs frequently twitched. He would soon tire and feel weak. Also since his dangerous experience, he had noticed a change in his speech: always fluent before, it was now hard for him to speak because one had to exert one’s head so much in speaking.
This head tremor was in fact the most marked symptom of his illness. It would increase on every active motion of the head, but ceased almost entirely when attention was diverted. The head would then be held bent to the right.
During emotional excitement, the shaking spasm would spread over the entire upper part of the body, but would remain more severe upon the right than upon the left side. The forearms would fall into a lively shaking movement of pronation and supination. The hands and fingers would be attacked by a less marked tremor. After calm had set in, a fine tremor of the right hand would remain plainly noticeable. The musculature of facial expression would frequently fall into spasmodic movement, the left corner of the mouth twitching, the lips set for whistling, or the upper lip making movements as if snuffing spasmodically.
Physically the man was of medium height, strongly built, with adherent lobules, and a somewhat pointed skull. The teeth were defective and irregularly placed. Both deep and skin reflexes were increased. Marked dermatographia and mechanical excitability of the muscles: periosteal reflexes strongly developed; numerous pressure points in the head. The right temple and back of the head were painful on percussion. The patient showed no disturbance in touch and pain sensibility. Outstretched tongue showed marked fibrillary twitching; speech was difficult, being slow, awkward, stumbling, and sometimes hesitating (suggesting the speech of general paresis). At other times, the speech was of a peculiar sighing, tremulous nature, reminding one of the speech of children complaining or asking for pity. Rest was secured by injections of salt solution. A few days later, the treatment was continued by a bandage about the neck. After this the tremor grew slighter and would even remain absent for some hours. The patient was told to rest in bed and not to speak much; being “seriously ill,” he was kept alone. He was often irritated, querulous, and subject to outbursts of profanity. He took food well and slept well, receiving sodium bicarbonate.
The bandage was changed after five days. The tremor was very marked. The patient was furious because visitors were refused to him. He was especially angry with his nearest relatives and his betrothed, and wrote defiant letters to all of them. He became one of the most troublesome patients in the psychiatric division of the hospital. He complained sometimes of anxiety and feelings of unrest. He received treatment by pantopon. He continued to be a very disagreeable patient, feeling himself opposed and not properly considered. He thought himself seriously ill, behaved much like a spoiled child, and was of the opinion that he would not get well in the hospital because they were grieving him so. His appetite became bad; he complained of pains in the loins and of rheumatism in the legs. A cord was found hidden in the bed. The patient expressed suicidal thoughts at various times.
At the beginning of January there was marked improvement. The headshaking ceased almost entirely; the patient walked in the garden some hours daily. However, in the middle of January, on refusal of furlough, the head-shaking began again markedly. At his request a bandage was placed on the head again for a few days. He seemed emotionally very tender; his head would shake at the sight of a dead rabbit.
He was transferred to the nerve division of the psychiatric clinic at the end of January. He had recently begun to complain of flickering before the eyes. The ophthalmologists established an existence of a choroiditis disseminata. The eye examination had a markedly depressing effect upon the patient, and the shaking spasm of the head appeared again. Upon being told that he would have to be sent back to the psychiatric section of the clinic, the shaking immediately disappeared (24 hours after it had begun).
Thereafter slow improvement followed. He stayed in the open a great deal and walked. March 2, he showed a vehement outburst of anger, quarreling and using violence with a comrade. He was brought back to the psychiatric section, and in transit had a severe hysterical attack with unconsciousness, crying fits, and stepping movements of the extremities. He was promptly taken to a section for those seriously ill. The next day, upon his assurance that he could control himself, he was put in a more quiet division. He began to take part in gymnastic exercises, worked as a coachman, and then as an experiment was sent to a gentleman’s estate for recreation. At last accounts he was feeling well except that he occasionally had headaches during work. He could not work so hard as before on account of the rapid onset of fatigue, especially when working in the sun. The head-shaking recurred but seldom and lasted for a few hours only when the patient became angry or when there was much noise about.