Part 30

In differential diagnosis, one has to consider, according to Roussy and Lhermitte, Pott’s disease, traumatic spondylitis, as well as Bechterew’s vertebral ankylosis, Pierre Marie’s rhizomelic spondylosis, Kocher’s intervertebral disc contusions, and Schuster’s myogenic ankylosis of the vertebral column; but in Pott’s disease, the fixed pain points, rigidity of column, fluid examination, and signs of myelitis, should suffice for the differential diagnosis. Traumatic spondylitis follows the contusion after months and after a phase of neuralgia. Ankyloses do not so much concern the trunk as the vertebral column itself; disc contusion produces disorders in standing and gait as well as pains and edema. Schuster’s disease shows paresis, hyper reflexia, and amyotrophy not shown in camptocormia.

Shell explosion; partial burial; forcible flexion of spine. Paraplegia, cured by suggestion. Then camptocormia, also cured.

=Case 245.= (JOLTRAIN, March, 1917.)

An infantryman in the Côte du Poivre was sitting on the ground in the opening of a dugout eating soup, when a shell burst and the roof of the sap fell in on him. The planks and the stonework fell heavily on the dorsolumbar region. The patient was almost bent in two, head to knees, legs buried, hardly able to breathe. He did not lose consciousness and cried out, feeling for a moment very anxious and fearful that his comrades had left. Only two hours later was it possible to dig him out. He said he had been absolutely unable to make any movement, had kept his body bent, and felt violent pains in the back. He was carried back twelve hours later and reached the dressing station in eight more hours, eventually reaching the neurological service two days and a half after the accident. On entrance he was prostrated, complained of lumbar pains and of inability to move, and was able to make only a few contractions on the left side when asked to try. The right leg was flaccid. The left knee-jerk was stronger than the right. Other reflexes normal. Hyperesthesia to pin prick on the right side. Slight saddle hypesthesia, reaching to the iliac crests above and perineum below with preservation of touch sensation. Slight forward posture of vertebral column. The patient complained of pain on pressure of the spinal processes and the lumbar spine. There was slight ecchymosis about the left iliac crest.

Lumbar puncture showed clear fluid without hypertension, in which were a few lymphocytes. There was a large amount of albumin. The blood pressure was normal. There had been a slight diarrhea following the accident which disappeared on entrance to the hospital. The question was raised whether the case was one of slight hematomyelia or was pithiatic.

Suggestive therapy was tried, and liquid was injected into the muscles of the lumbar region and the posterior surfaces of the thighs. In a quarter of an hour the patient found himself able to raise the foot above the bed. There remained an extensor paralysis of the right leg. When the patient was made to raise the foot he began to show the phenomenon of Souques, called camptocormia. He could walk, nevertheless, and took a few steps sustaining the weight of his body by placing his arms on his thighs. Though he complained of lumbar pain, it was finally possible for him to pick up an object from the ground and lean sidewise. He could not, however, stand up. Yet when the patient was made to lie down, his back was spontaneously straightened. Treatment of the camptocormia was also successful.

Astasia-abasia: Two cases from (a) thigh wound, and (b) shell-shock and wound of thorax. Cures by faradism.

=Case 246.= (ROUSSY and LHERMITTE, 1917.)

An infantryman was wounded September 23, 1914, by a bullet in the anterior and middle part of the left thigh. From the moment of the trauma, he had not been able to walk, but gradually regained his ability to stand, and then to walk. He was returned to the front (January, 1915).

Slightly wounded again in the neck, January 6, 1915, he was evacuated and operated on. After the operation he could neither walk nor stand. His reflexes were normal; he could perform all movements when lying down, although the movements were executed very slowly. As soon as he could sit upright, he was taken with tremors and could not hold himself in a vertical standing position, nor take a single step. If he was given crutches, he dragged the two legs.

Under the influence of electric treatment--a mild faradic current--he was cured at a sitting so that he could both stand and walk (March, 1916).

=Case 247.= (ROUSSY and LHERMITTE, 1917.)

Astasia-abasia after shell explosion occurred in an infantryman observed by Roussy and Lhermitte at Villejuif, July 8, 1915.

The patient had been wounded September, 1914. The wound was a superficial one in the thoracic wall, under the right nipple. He had been cast into a very deep shell hole, but had been able to get back to the aid station alone, taking very short steps only.

As soon as he reached the station, his gait became spastic, trembling and hesitant. Given two canes, he could walk painfully, trembling. At each step, he would balance his body back and forth. He gave the impression of a man drawing some sort of vehicle, who had to make a considerable effort at each step.

The faradic treatment cured this patient at one sitting.

War strain; fall into water-filled trench: Dysbasia, tremors, vasomotor disorders. Cure by hypnosis. Case to demonstrate “traumatic” hysteria WITHOUT somatic TRAUMA.

=Case 248.= (NONNE, December, 1915.)

An artilleryman (without hereditary or acquired neuropathic taint) underwent much stress and strain in the war in Belgium, Lorraine and Flanders. One night, on leaving his observation post, he fell into a trench filled with water. He felt pricks in the groin and gradually developed a pseudospastic tremor of the lower extremity, paraparesis inferior, depression, irritability, pressure sensations in the head, and sleeplessness. He passed through three hospitals before arriving at Hamburg and received the diagnosis of concussion of the brain and cord.

Nonne found an emotional state of depression with hypochondriacal fear, disturbance of sleep, deficient appetite, constipation and pollakisuria. He walked upon two crutches, dragging his legs inertly after him. There was marked cyanosis, lowered temperature and hyperidrosis of the feet and lower legs; exaggeration of tendon and skin reflexes and pseudoclonus; no Babinski or Oppenheim reaction. There was anesthesia of the lower extremities and of trunk as high as the ribs. Pulse 130. Visual fields normal. Sensory disorders absent.

After the first hypnotic treatment the patient was able to stand and take a number of steps, and the tremor gradually diminished. After two treatments standing became normal and walking was much improved, the tremor ceased, cyanosis and hyperidrosis disappeared, and the movements of the bowels and urination became normal. Thereafter the patient had no attention paid to him deliberately and in a week’s time became well.

Here is a case in which, as Nonne states, the somatic trauma required by Oppenheim as the basis of every traumatic neurosis did not occur. Moreover, the sudden cures by hypnotism, or by any other method in these cases, warrant us in supposing that there are no such fine molecular changes as Oppenheim and von Sarbo assert. Such experience as the cures in this group of cases confirms, according to Nonne, the surprising result first achieved in this war (Bonhoeffer, Wagner von Jauregg, Karplus, Wollenberg, Westphal) that the most severe neuroses produced by somatic and psychic traumata can be cured in an astoundingly rapid manner without residuals.

_Re_ the controversy over Oppenheim’s traumatic neurosis, Nonne holds with the Charcot school that traumatic neurosis is clinically identical with hysteria. Oppenheim admits the part played by psychogenesis, but has always laid a greater emphasis upon the actual injury of the neuronic apparatus in which he believes. He thinks that small hemorrhages, inflammatory processes, and degenerative processes affect the neurones unfavorably, and permit the psychogenic effects to occur more readily. Of course the insurance-company attitude and the attitude of railway corporations saw malingering in all cases, and to this day, neurologists are inclined to see a great deal of “indemnity neurosis” in these cases. Opposed to the corporation men and the neurologists were the psychiatrists, who chiefly upheld an emotional theory of genesis--whence we began to hear of the neuroses of fright and of accident.

Oppenheim claims to have established with war cases the fact that an entirely normal person without heredity and without antebellum acquired soil, may develop a neurosis through war stress. Oppenheim concedes that there may be purely psychic cases, but holds that there are nevertheless, numerous purely physical cases and a great number of cases of a compound nature, which are both physical and psychical in their etiology. Oppenheim’s point is not that every single symptom described _may_ not be upon occasion psychogenic, but that the data of this war prove that neuronic injury, particularly injury of the peripheral neurones, can also produce these effects. Nonne, Forster, Lewandowsky, and others, opposed Oppenheim’s views vehemently. See especially comments by Zeehandelaar.

Shell-shock; BURIAL HEAD DOWN: Brachial monoplegia, head-shaking, speech disorder, corneal and conjunctival reflexes absent. Determination of hysterical phenomena to parts buried.

=Case 249.= (ARINSTEIN, 1916.)

A Russian private was buried after a shell explosion, September 13, 1915, head down, so that only his legs stuck out of the débris. Afterward his right hand refused to move, and there was edema of the right wrist, with pain referred to the shoulder joint. The head shook and made jerky movements during the day, but ceased them in sleep. Speech was retarded; words were uttered clearly enough but in a sing-song fashion; sometimes the man stammered. Hearing was diminished in the right ear. Pupillary responses were lively, but the swallowing reflexes were diminished, and the corneal and conjunctival reflexes were absent. The tendon reflexes were lively on both sides. There were no pathological reflexes.

At the end of October--six weeks later--the patient was sent home on convalescence for three months, and improved rapidly after a short time in family surroundings. He was examined again, two months after discharge, and found normal in all respects. He returned to the ranks.

_Re_ Shell-shock in Russians, Arinstein concludes that concussion hysteria may occur in a perfectly normal person, yet be innocent of all organic signs indicating destruction of peripheral or central neurones. Rifle or machine-gun fire had not in his experience brought about concussion hysteria, which was invariably due to the bursting of a large projectile. With reference to Schuster’s remark that a sleeping man never acquires hysteria from the bursting of a shell near by, Arinstein confirms Schuster, finding amongst 2000 cases no instance in a soldier sleeping at the time the shell burst.

_Re_ effects of cannonading, Gerver reports Russian instances of a kind of hysterical _clavus_, or sensation of a nail being driven into the back of the head, in men who have been a number of days under stiff shelling.

Multiple wounds and bullet wound of palm: ACROPARALYSIS. Cure, five months.

=Case 250.= (ROUSSY AND LHERMITTE, 1917.)

A patient was observed at Villejuif, February 5, 1915. He had been wounded, January 2, 1915, and showed scars of a bayonet wound on the anterior surface of the right thigh, of a lance wound on the dorsal surface of the right foot, and of a bullet wound in the palm of the left hand.

There was left wrist drop with fingers extended. On the sensory side, there was a glove anesthesia and analgesia up to the bend of the elbow. The right leg showed a paresis and contracture, but there were no sensory disorders in the legs. Reflexes were normal. The patient was discharged cured, in May, 1915 (psychoelectric method).

This is an example of the so-called acroparalyses, paralyses limited to the hand or foot, many of which have developed in this war, after grazing wounds or more severe injury. More rarely they appear as if spontaneously. Sometimes they are preceded by slight arthralgia or vague pains.

The condition in the hand suggests a radial paralysis. The patient is unable to flex his fingers, though he probably is able to make some movements with his thumb. Sometimes, on request to move the hand, a series of coarse oscillations follows, somewhat like a tremor. These oscillations are, according to Roussy and Lhermitte, apparently pathognomonic, and depend upon the contraction of the muscles antagonistic to those whose movement has been requested. These antagonistic muscles, themselves entirely incapable of voluntary movement, are seen to be contracting effectively and jerkily to meet the action of the agonists, also seen making jerky movements. If the forearm is moved passively and rapidly, the hand flops about inert, like the hand of a marionette, although not to the degree of hypotonia in organic paralysis. The hand is often cold, moist, and cyanotic, and even possibly analgesic and hypesthetic.

Bullet wound of arm: Apparent radial paralysis, not resolved by self-preservative swimming movements. Paralysis actually hysterical.

=Case 251.= (CHARTIER, October, 1915.)

A professional acrobat, 22, Corporal in an African Chasseur regiment, was rather instructively tattooed and had apparently performed some of his service in disciplinary companies. In short, one might have a legitimate suspicion of the objective value of any manifestations he might present. However, one of his chiefs had written a favorable letter concerning his services. He had had various crises of a hysterical character since adolescence, and there was alcoholism in the family.

He was wounded May 4, 1915, by a bullet which passed through the outer and lower part of the right upper arm, and thereafter the forearm and hand became completely inert, both for flexion and extension. There was a considerable hyperesthesia. The wound healed quickly, without complications.

August 5, about 10 o’clock at night, the man--then at his dépôt--tried to commit suicide (motive not related with the war). He threw himself into the Rhône from a height, where the water was deep and the current rapid. His brother and a comrade, who knew that he was going to make the attempt, saved him. Chartier himself happened to see the whole scene, and noted that throughout the affair the forearm and hand of the patient remained inert. It seemed as if there was a radial paralysis. This was the more likely as the man had been wounded in the arm. First care was given. The man had not known of Chartier’s presence. He had been under water about two minutes.

From hospital he was evacuated three weeks later with a diagnosis of radial paralysis, coming on service September 11. Examination showed a slight paralysis of the extensors and flexors of hand and fingers, and of the hand muscles. There was also a slight contracture of these muscles, more marked in the flexors. There was pain upon reduction, with some jerking of the muscles. Electrical reactions proved normal in nerves and muscles. There was a segmentary anesthesia to pin prick, reaching to the level of the elbow; deep hyperesthesia of the finger joints. There was no trophic or vasomotor disorder.

In short, here was a case of functional paralysis with contracture of the right hand, to be regarded as hysterical in the classical sense of the term, both by reason of the anesthesia and absence of trophic disorder, and on account of the hysterical history of the patient. Functional reëducative treatment quickly improved the paralysis, so that two weeks later the patient was able to extend fingers and hand. His total recovery was hoped for, when, September 26, wishing to get out of the hospital without leave, the patient jumped from a window and broke his right leg. The functional paralysis of the hand persisted and even grew more marked.

The interesting point in this case is that despite the powerful nature of instinctive efforts with drowning persons, this patient, subject to an hysterical arm paralysis, did _not_ make defensive movements with the paralyzed arm; yet this paralysis was such as to be greatly improved by psychotherapy.

Bullet wound in brachial plexus region: SUPINATOR LONGUS CONTRACTURE, hysterical-looking. Callus of fractured rib probably at fault: Treatment surgical.

=Case 252.= (LÉRI and ROGER, October, 1915.)

A man was wounded, December 21, 1914, by a bullet which entered about the middle of the spinous process of the left scapula and was extracted a few days later from the posterior border of the sternocleidomastoid muscle, two finger-breadths from the left clavicle, that is, at about Erb’s point. The left upper extremity was inert for ten days, but then began to move again, although extension and flexion of the fingers did not begin at once.

October, 1915, movements were normal, except those of extension of the forearm, due to contracture of the supinator longus muscle, a contracture that had developed about three weeks after the wound and stood out along the external border of the forearm, almost suggesting a musculotendinous retraction. There was a palpable, hard callus of a fractured rib, presumably a cause of the permanent irritation of the supinator longus, being precisely at the point where lesions usually produce superior brachial plexus palsy.

Why should the supinator longus alone of the Duchenne-Erb group be affected? Perhaps a single root was involved in the irritative lesion. The biceps showed also a partial R. D. The deltoid was normal electrically and in contraction.

The treatment planned for this case of isolated contracture of the supinator longus was surgical operation of the irritative focus. According to Léri and Roger, it is sometimes dangerous to use such measures as massage and electric baths for a paralyzed limb, since the massage or electricity excite not only the affected muscles, but also the other sound muscles,--muscles that are already more powerful than the paralyzed muscles and may go into antagonistic contracture. Even in limited galvanization, it is desirable to work with weak currents, so as not to diffuse the current into non-paralyzed muscles. In case of radial or sciatic paralysis, apparatus permitting the extremities to rest without over-action of the muscles antagonistic to the paralyzed ones may well be applied.

We here deal with a case, therefore, which looked purely functional, but in which careful examination and X-ray served to show an organic focus of irritation.

_Re_ nerve concussion, Tubby offers the following definition: Nerve concussion is damage to a nerve trunk without actual destruction of the axis cylinders. The damage may consist of an effusion of blood between the nerve fibres following compression of a nerve against the bone by rapid passage of a foreign body near the nerve. Sometimes, however, the lesion which causes damage to the nerve trunk without actual destruction to the axis cylinders is nothing more than a temporary anemia or hyperemia. In most instances, both motor and sensory function are together interfered with, but in the case of large nerve trunks, _e.g._, the popliteal, there may be a separate concussion of motor or sensory bundles.

Contusion may effect a sort of STUPEFACTION OF MUSCLE and paralyze it by a non-psychic process: The SYNERGY in contraction of biceps and supinator longus is thus SPLIT. Biceps restored to synergy with the supinator by massage and faradism.

=Case 253.= (TINEL, June, 1917.)

A man was wounded at about the middle of his biceps and three weeks later was found to be able to flex the forearm only by means of the supinator longus. The biceps remained absolutely flaccid and soft, so that the diagnosis of a lesion of the musculocutaneous nerve (unlikely as this seemed on account of the low site of the wound) was entertained.

However, the biceps and the musculocutaneous nerve proved electrically normal. In short, this paralysis of biceps was functional in nature. But, according to Tinel, there could be no voluntary suggestive or hysterical element in such a paralysis, since flexion of the forearm is normally produced by a synergic contraction of biceps and supinator longus that cannot be separated voluntarily.

Treatment by massage and rhythmic faradization caused the biceps function to return to normal, so that voluntary synergic contractions of the biceps took place along with those of the supinator longus.

We here deal, according to Tinel, with a genuine functional paralysis, nonhysterical--a paralysis due to a kind of stupor of the muscle. Such paralyses due to muscular stupor ought to get well in a few days or weeks. Should they persist, it is clear that a stuporous paralysis might be transformed into a hysterical paralysis. In short, the direct contusion of a muscle or group of muscles may be the point of departure for various persistent paralyses.

Wound of arm: Blocking of impulses to certain hand movements. Recovery with splint.

=Case 254.= (TUBBY, January, 1915.)

A private was wounded by a shell fragment, September 16, 1914, and admitted to the London General Hospital, September 27. A high-velocity shell fragment had passed through the soft parts of the left arm at a spot exactly corresponding to the musculospiral groove. He could extend the middle finger of the left hand, but the other fingers were held in flexion. The last two phalanges of index finger could not be moved, it was found, on account of severance of the extensor tendon some years previously. Accordingly, the loss of function due to the shell injury was that of thumb, ring, and little fingers. Supination could not be executed completely to the extent of 15 degrees; there was no R. D. upon electrical test, October 2. The sensation of affected fingers was woolly. November 3, the little finger had recovered, but supination could not be completely executed.

The treatment consisted in a bent malleable iron splint, with the wrist and affected fingers hyperextended. November 20 all power had returned with full supination, except for the two phalanges of index finger previously injured.

Major Tubby thinks this a case of physiological blocking, as from a small hemorrhage amongst the fibers or around the nerve.

_Re_ inhibition, Myers thinks it is the functional cause of the effects of shell-shock. He thinks it is not a fixation of the _idea_ of the paralysis of volition, but that it is a fixation of the _process of inhibition_ itself that produces the effects we see in Shell-shock. It is a block of ascending paths that produces the anaesthesia so characteristic of Shell-shock. It is a blocking of sensory paths that produces mutism or aphonia. But according to Myers, there is also a block in certain cases of _descending paths_ that control and coördinate various mechanisms. The result of a block in the descending paths is shown in spastic, clonic, or ataxic phenomena of, _e.g._, functional dysarthria. See also Case 253 (Tinel).

Eight months of war experience (often under heavy fire) without reaction; then, shell-shock; unconsciousness: Right hemiparesis; pain in the left side of head; heat sensations of right half of body; diminution of hearing in left ear; a variety of asymmetrical bilateral phenomena.

=Case 255.= (GERVER, 1915.)