Case 494. (Binswanger, October, 1917.)
A soldier (brother choreic, sister infantile palsy) had had measles at 13 and in his fever climbed out of bed upon a couch, fell from the couch and was found by his mother lying on the floor. He was of moderate intellectual grade, of an emotional, passionate Saxon nature and had now and then been intoxicated.
In September, 1914, he was wounded over the right eye. He did not lose consciousness but concluded that he could not get back to his own lines on account of the enemy fire. Using a knapsack to cover his head, he lay down for twenty-four hours, until rescued by a passing body of the sanitary corps who were about to leave him for dead when he called loudly to them.
He was very weak in hospital and, towards the evening of the day after receiving his injury, he must have fallen into some sort of psychotic state lasting ten days. For this he remained quite amnestic, although he was told by comrades that he had hallucinations and had scolded and yelled, hearing voices. Apparently there were situation-deliria—the call to go over the top. Temperature, which had run to 38.8, after ten days sank to normal, and consciousness cleared up.
Was this a case of protracted febrile delirium? Or of psychosis due to commotio cerebri, that is, an effect of heightened intracranial pressure? Or was it exhaustion-delirium following loss of blood, sleep and food?
But this was not the end. The wound suppurated, and in May, 1915, eight months after the injury, operation was performed to relieve this abscess. Temperature immediately rose to from 38.4 to 38.6, the fever lasting three days, and a second psychotic phase with complete amnesia entered. He went into this phase immediately after recovering from the operative narcosis, looking wildly about and cursing the sister. The patient was violently excited and was put in a straight jacket on the second day. This phase may be regarded as one of epileptiform excitement with delirium. The operation may have played a part in the psychosis.
There were no further psychotic phenomena which could be attributed in any way to commotio. There were, however, attacks of cortical origin and emotional seizures. The patient became emotionally excitable and lost all inhibitions against expression of emotion, such as crying. Once he actually tried to suppress his emotion with a noose about his throat. He became seclusive and withdrew within himself—a victim of Kaplan’s explosive diathesis, or of Bonhoeffer’s emotional hyperesthetic defect condition.
A second operation was performed in September, 1916, to loosen the brain scar, and a large splinter of bone was removed. During the operation, under local anesthesia, there was a severe cortical seizure with complete disappearance of the reflexes. Ether was then administered. Later, in the same day, there were several minor cortical attacks.
After this operation the man’s emotional status changed; he was no longer irritable or exclusive, but became slightly euphoric and contented. He received during the next two weeks four tablets of Sedobrol and for a long time thereafter two tablets daily. There were never any phenomena of bromidism or any suggestive effects of the bromides.
The first attack after the second operation came in November, 1916, and was followed by slight dysarthria. Repeated attacks followed which were attributed to contractions in the scar. Accordingly, a third operation was performed and an attempt was made to bridge over a defect in the right frontal bone. The man’s emotional status remained good after the operation, but further attacks appeared six weeks later and there were spells of dizziness. Occasionally, in process of thinking, he said something stuck in between his thoughts. Sometimes thinking broke off sharply as if he had cut through a wire with an electrical current in it. There was a slight reduction in attention and a slightly increased fatiguability.