Post-traumatic (ANTEBELLUM) seizures with unconsciousness: Further seizures, astasia-abasia, anesthesias, following no special period of stress in field service. Recovery by reëducation.
O. F., 26, healthy, of a healthy family, in military service, 1908-1910, a miner in October, 1912, had fallen into a shaft from a considerable height, and is said to have been unconscious for three days and two nights and to have had some sort of attack a short time after waking. Later he had another attack, beginning with violent headaches, running from the back to the fore part of the head, then dizziness, then a fall with unconsciousness. The whole attack lasted about four minutes and was followed by feelings of extreme fatigue.
It seems that in the spring of 1913 these attacks had begun to repeat themselves two or three times a week. In the spring of 1914 there had again been two attacks at an interval of two weeks. They had occurred on the way to work and had been introduced by the same symptoms as before. They lasted about half an hour.
He was in the war in France from August 6, 1914. While he was cooking, one day, in the middle of September, he had an attack and this without special occasion. The next attack occurred a little while afterwards, at the time of an assault. He said that he fell down and lost his senses. When he came to his senses again, he found he could not move his legs.
He was taken to a reserve hospital in Germany, and while there had several attacks with unconsciousness and spasmodic convulsions—the last on December 7, 1914. He was transferred to the Jena Hospital on the 11th.
The Jena examination had the benefit of an inquiry concerning the case. It seems that he had left the field hospital in the enemy’s country, in a half-conscious condition, and rode away therefrom aimlessly. It was only in Germany that he, on his own story, found his bearings again. However, upon admission the disturbance in walking was very noticeable, since the patient came hobbling through the garden of the clinic with the upper part of his body bent forward, and with the support of two canes. The legs were moved with difficulty; he seemed to take short, tripping steps, with the toes dragging on the ground. His inability to walk he explained through the violent pains which he would feel in the joints of the legs and an extraordinary weakness in his legs.
Physically, the man was a tall, strongly built and well-nourished subject. Neurologically, the knee-jerks were somewhat decreased and weaker on the right side than on the left; the Achilles reflexes were lively. The plantar reflex was not obtainable on the left side; decreased on the right. The abdominal reflexes were absent on both sides.
Most remarkable was the general diminution in sensitiveness of the skin to touch and pain, involving the whole body, up to the neck, where the sensory impairment abruptly ceased in a sharp line. The anesthesia was not everywhere complete. In a few places pencil strokes were successfully localized and recognized. Deep pin-pricks were everywhere recognized as itching. When the trunk was everywhere examined on both sides symmetrically, a strong pressure with a pin-head was felt as a strong pressure on the right side, but was felt not at all on the left side. Anesthesia and analgesia were total in the legs. Deep folds of skin could be punctured by needles without reaction.
The legs could be moved freely upon urgent request with the patient in dorsal decubitus. Still these movements were slow and difficult, as explained by the patient, on account of violent pains in the joints. If put on his feet, he would begin to sway greatly and permit himself to slide down to the ground, stating that he was quite incapable of standing or walking without aid. With two canes, however, he could move freely about in the ward and in the garden, and even with considerable speed, in a peculiar, dragging, shuffling way; in the execution he gave no sign of pain, contentedly smoking a cigar or a pipe.
While his status was being taken on admission, he became suddenly dull and irresponsive, with a staring look. He could not state his age or his birthplace. However, he became clear shortly, upon urging, and explained the spell by saying that the blood had risen to his head. A few days later, he was transferred to the psychiatric division. He was given strict rest in bed, smoking was forbidden, prolonged baths were used, and the legs were massaged. He felt very comfortable in the prolonged baths and could then move his legs without pain.
A few days later he was taken out of bed several times a day, the canes being removed immediately, and he was led about the day-room with the light support of two nurses. Being promised a cigar as a reward, he proved able to walk through the day-room supported by but one nurse. A week later the pains in walking exercises had disappeared. He had become able to walk alone, supporting himself lightly along the wall with one hand. Walking was still uncertain and slow.
December 20, the patient could stand free without support, swaying slightly; improvement became rapid. He could shortly stand and walk without support though his walk was still awkward and on a wide base with knees pressed in and body bent forward, soles were kept applied to the ground. December 22, the patient could walk in the garden without aid.
December 23, there was a spell of great weariness and complaint of being sick. The patient lay down on the bed, cried aloud, and had rhythmic twitchings and sudden movements with arms and legs. He scratched the right half of his face with his right hand. This spell lasted about a minute. It was repeated in the same way twice within the half hour.
He had complete amnesia for these attacks. The pupillary reactions were entirely normal in the attacks. He had been in bad spirits that day because a Christmas furlough had been refused. The attacks provoked no bad consequences and his gait improved. He was on furlough from the 30th to January 3; on the 4th he was transferred to the nerve department, but on the 12th of January he was reprimanded for a breach of discipline, whereupon at 9:15 he had an hysterical attack with the same coördinate rhythmic motions as before. This attack lasted about 20 minutes. Two hours before the attack he had complained of weariness and a boiling-hot feeling in the body. Long walks were taken. On February 15 he began to feel very happy. He was informed that the charge against him for leaving his troop had been dropped. He complained of sudden weariness and headache and was markedly depressed, but he had no hysterical attack.
After February 23 he took part regularly in gymnastics, executing the movements with joy and without special weariness. He wanted to be discharged. He was discharged as fit for garrison duty and he has since gone back to field service.
Re gymnastics, Binswanger holds that they have a special value in overcoming inner psychic resistances and weak-willed persons. The Realsuggestionen (see under preceding case, 575), such as hydrotherapy and electrotherapy, serve to concentrate the person’s attention on certain regions. These regional suggestions then smooth the way for the curative suggestion, namely, the constant and monotonously repeated assurance that recovery is advancing. At the next stage, according to Binswanger, gymnastic exercises may be brought in to overcome hopelessness, indifference, or exaggeration of morbid feelings. Binswanger sets methodical tasks for the attention and the will (a so-called Uebungstherapie). If these gymnastics lead to manifest improvement, then a proper educational therapy is prescribed, which is no longer a merely exercise therapy, but consists of actions of actual value in hospital routine. The convalescents are gradually led to carry on housework, food service, gardening (the latter under supervision). Hospital clerical work is a suitable occupation. Re supervision over gardening, mentioned by Binswanger, Canadian experience indicates that the idea of supervision may be greatly extended. Particularly is this true in vocational reëducation. Kidner describes the functions of a vocational counsellor, who has to have an expert knowledge of industry and methods of industrial training, as well as an acquaintance with the varying demands for workers, a knowledge of the seasonal variations in employment, and a knowledge of occupational diseases. Re occupational therapy, Todd estimates that from 0.5 to 1 per cent of wounded men in France will require vocational reëducation. Occupational therapy is the proper vestibule to vocational training. He lists the following forms of treatment used in institutions for vocational reëducation:
Central specialized institutions such as those developed in France are necessary, and such centres should be large rather than small, according to Todd, and should contain not less than 200 beds. Todd insists that work is, after all, the most important measure of reëducation; and Turner, speaking of the home for neurasthenics at Golders Green, says that during a period of three months (the number of the patients is limited to 100, and three months is the limit of stay), the vast majority, even of the most obstinate cases, get well through the effects of sympathy and insistance upon work. Near Golders Green is the Maida Vale Hospital for nervous cases, so that in case of need the physicians there may treat the patients. Salmon gives a list of the occupations which are suitable for these cases.