A man (not previously nervous, no faulty heredity, heatstroke August 21) suddenly fell down in a great heat, after a fatiguing march, and remained unconscious for several hours, waking with vertigo, headache, paralysis of left side, vomiting, and twitching of the face. On September 23, admitted to reserve hospital. Knee phenomenon increased. Urinary retention; catheter used. Speech disturbance, facial twitching. Vomiting had stopped September 10. Catheterization could be avoided through warm sitz-baths. October 30, on sitting up, occipital pain and vertigo. November 15, urinary symptoms improved. Also improvement otherwise. December 1, gait vacillating and uncertain. Headache. Admission to nerve hospital, December 3. Here complained of twitchings in the frontals and corrugators. Wide palpebral gaps. Rare, or absent, movements of lids. The extended hands showed active, rapid tremor. Tendon phenomena increased in the arms and especially in the legs. Abdominal reflexes increased. Active tremor in the legs. Gluteal tremor. Very pronounced Graves’ symptoms. Syndactylism very pronounced in the feet, between second and third toes. Later on, improvement under half-baths, etc. Worse after ten days’ leave of absence, especially marked increase of tremor (rest tremor), augmented on movement.
Re heat stroke, Wollenberg has called attention to the effect of the heat of the summer months upon German soldiers. Cases of heat stroke have not been rare in the German army. About half the cases have convulsions or epileptoid seizures, as well as tremors and nystagmus. About a quarter of the cases have shown confusion and delusions, with anxiety and mania. A degree of mental impairment has followed a number of these heat strokes, together with sundry signs of organic disorder, such as reflex changes, pupillary changes, and difficulty in speech.
Forced marches; skirmishes; rheumatism: Generalized TREMORS. On the road to recovery in six months.
Case 327. (Binswanger, July, 1915.)
A German letter carrier, 27, entered the war at the outset, made forced marches in great heat, was in a number of skirmishes and in the capture of Namur, and fell ill early in September, with swollen and painful right foot and rheumatic pains in knees and shoulders. He was put on garrison duty; but the rheumatic pains in the joints increased toward the end of September, and he was treated in hospital for rheumatism.
He became able to walk only in the second half of December, marked tremors affecting the whole body. His bodily condition had been good. He slept well, and while at rest in bed he felt entirely well; but upon every attempt to get up and put his feet down, these violent trembling motions would always reappear. Treatment by hydro- and electrotherapy remained entirely unsuccessful. February 8 he was transferred to a nerve hospital.
He had been in the postal service from 1903. He was of normal bodily and mental development and had had no previous illnesses. His military service had been executed from 1909 to 1911. He had always been a passionate smoker but had not abused alcohol. His mother is said to have been for some time paralyzed, following a fright.
Physically, the patient was a slender but strongly-built and fairly well-nourished soldier. The first sound at the apex of the heart was rough and impure, and the heart was somewhat enlarged to the left. The pulse was irregular, 106. The arteries were somewhat stiff. Neurologically, there was a marked dermatographia of comparatively long duration. The periosteal reflexes were increased; the deep reflexes could not be properly examined. The whole leg trembled and heaved unsuccessfully on attempts to raise it voluntarily. After even a slight stroke on the patellar tendon, the trembling became excessive and irregular, and the leg passed into a heaving spasm which would outlast the percussion for some time. The patellar clonus could be obtained with the knee extended. The shaking movements were somewhat more marked on the right than on the left side. Similar phenomena occurred when the Achilles reflexes were being examined. The triceps reflexes on both sides were increased but there was no tremor or spasm of the arms. The plantar reflexes were very lively, and following these reflexes appeared tremors of the legs. When the spinous processes of the vertebral column were percussed, a general shaking spasm appeared. Tactile sense was everywhere normal, but the pain sense was increased. Upon slight pin-pricks in the skin of the legs, there would occur a marked shaking spasm of the leg, passing directly to the other leg. These phenomena were more marked on the right side than on the left. When sitting upon a chair with back supported, a slight tremor would appear when the hands were raised and stretched out, more markedly on the right side than on the left. Movements of the arms were normal. However, the hand-grasps were: right, 105; left, 80. In dorsal decubitus the movements of the leg were performed comparatively well at first, but after a few repetitions, the shaking spasm would occur on both sides, and the movements would become very awkward. The heel-to-knee test would then fail. If the patient were put on his feet, he would immediately fall into spasms, first in the right leg, then in the left. The trunk would now be involved, and soon the arms, whereupon the whole body, with the exception of the head, would be seen trembling and shaking, and the patient would fall forward, trying to get support by leaning against a wall, seizing a chair, or sinking down slowly. The spasms disappeared at once in dorsal decubitus and in sitting with supported back. Outward irritation by the acoustic, optic or tactile avenues would bring out spasms in the legs, always more markedly on the right side than on the left. Psychic irritations would cause spasms. The muscles of the limbs were held in great tension, the flexors and extensors being alternately affected. When the patient was moving along a wall with a difficult, swaying gait, his efforts reminded the examiner of the attempts of a heavily intoxicated man to walk. Upon attempts to create passive movements of the lower limbs, severe shaking and trembling movements set in, followed by a general spastic tension of the leg musculature such that it could not be further flexed or extended.
The patient was put in the psychiatric section, as too seriously ill for the nerve hospital. He improved after a few days, being then able to walk without much support although still with some shaking and tremor. If his attention was diverted, passive movement of the leg could be carried out without developing spasm. He was treated in a room by himself with removal of all outward irritation. His legs were treated for an hour, three times daily, by means of moist packs. On account of complaints of insomnia he was given small doses of hypnotics.