Part 46

On the suspicion of an abdominal form of local tetanus, chloral was given; but the condition grew worse. The sudden contractions spread from the waist to the feet, from November 20 onward, and were felt by the patient as electric shocks. The arms were not affected. Trouble with breathing supervened on the night of December 3. Sometimes there were respiratory pauses for as long as 15 seconds, followed by a slight polypnea. December 6 the man presented an intense contracture of the lower part of the trunk. The slightly retracted abdominal wall was of marbly hardness, but quite painless. Analgesic muscular rigidity took the place of the former crises of pain. The dorsolumbar contracture was so marked as to make an appreciable hollow in the back. The patient could pick up an object from the ground only by flexing his knees to the maximum, as the trunk could not be flexed. There was a very slight trismus, but he could open his mouth, drink, eat and talk without difficulty. There was no trace of neck stiffness or of Kernig’s sign. The tendon reflexes, normal in the arms, were exaggerated in the lower extremities, especially on the left (wounded) side. The skin reflexes were also more marked on the left side, especially the reflex of the tensor of the fascia lata. There was no longer any evidence of suppuration of the wound of the left thigh, which had been dried up for a fortnight. The pulse was somewhat exaggerated (92) and there was a general hyperidrosis, especially of the face.

Forty c.c. antitetanic serum were given without reaction, and 4 grams of chloral; five days later, 30 c.c. more serum. After ten days the abdomen remained hard, though there was a trifling improvement of the lumbar contracture. There were no longer any spasmodic crises or respiratory disturbances. There was a slight serous exudation from the wound. X-ray showed a small shell fragment 6 cm. below the orifice of the wound.

The third injection was given December 27 to prevent mobilization of the bacilli at operation, and on the 28th, the projectile was removed under local anesthesia from a small, walled-off, old pus pocket, from which were cultivated bacillus perfringens and other organisms.

December 31 a distinct improvement set in and January 13 there was little or no trace of previous disease, except that testing the plantar cutaneous reflex on the left side produced an exaggerated contraction of the tensor of the fascia lata. February 15 he was reëxamined and found quite normal.

This case of tetanus limited to the abdominothoracic muscles (except for a very mild contracture of the masticators) had as its locus of origin, doubtless, a wound of the thigh from which the toxin rose along branches of the lumbar plexus to impregnate the corresponding level of the spinal cord. Although there was no stiffness of the wounded leg, yet there was an exaggeration of the tendon reflexes thereof. The first phase of painful contractures and spasms with respiratory disorder was succeeded by an analgesic phase of characteristically tetanic rigidity. The nonfebrile nature of the disease and the preservation of good general health are worth noting.

Shoulder blade unslung in knock-down by shell splinter: Hysterical (!) paralysis of arm with anesthesia. Recovery by electricity, massage, and reëducation (dislocation remaining).

=Case 404.= (WALTHER, December, 1914.)

A soldier was struck September 27, near Berry au Bac, by a shell fragment in the right scapular region and was thrown, according to his story, 15 meters. Upon entrance at Val-de-Grâce, October 13, the shoulder-girdle was found intact. There was a very painful point in the spinous process of the scapula, suggesting a fracture; but the bone was proved intact on X-ray. The scapula was very mobile, as if unslung from the thorax. The arm was paralyzed. On raising the arm the scapula followed its movements and detached itself completely from the thorax, dislocating upwards with lively pain. The fingers could be pushed under the anterior surface of the scapula, and its internal border proved to be entirely free of attachment. Pressure along this internal border was very painful. It seems as if there had been a tearing of the rhomboid and serratus magnus muscles and probably a part of the latissimus dorsi under the influence of the violent shock conveyed by the shell fragment, which had pushed the scapula forward and upward without injuring the skin.

There was also a complete paralysis of sensation. Paralysis of motion was complete except for the extensor longus of the thumb. This motor paralysis had come on progressively three days after the accident. A radicular paralysis from an evulsion of the plexus was suspected.

Babinski, however, made the diagnosis of psychic paralysis, finding the muscles reacting perfectly to percussion. After a few electric tests with the faradic current voluntary movements were obtained in all the muscles of the arm and hand.

Treatment was then continued by electricity, massage and reëducation, so that all movements soon regained strength. The patient can now himself, by raising his arm, still produce his dislocation, which still provokes a lively pain.

Gunshot wound of left forearm: PARALYSIS of the arm gradually INCREASING IN DEGREE and extent and associated with pains and anesthesias.

=Case 405.= (OPPENHEIM, July, 1915.)

A reservist sustained, October 2, 1914, a gunshot wound of the left forearm from a distance of about 1400 meters. He fainted, lost much blood, and was treated surgically, October 7, in hospital (at this time no complete paralysis of the arm).

In November, however, an incomplete paralysis at first developed. November 12, the patient was able to flex his thumb but showed some anesthesia.

Transferred to nerve hospital in December, the patient said that at the first change of dressings, October 10, he had not been able to move his arm, and said that pains and paresthesia had existed in the arm ever since the injury. There was still some evidence of suppuration at the exit orifice of the bullet. The left arm was now completely paralyzed and atonic, and hung down in walking, without swinging. The supinator phenomenon, though present on the right side, was absent on the left. The triceps reflex was present. The shoulder acted like a flail joint. On passive elevation of the left arm, the deltoid seemed to contract slightly at first; later it failed to contract. Fibrillary tremor of the left thumb.

Suggestive therapy was unsuccessful. There was an anesthesia of the left arm and the left trunk. The disorder diminished proximally, being most severe in the hand and the arm. The legs were normal. The electrical irritability of the left arm was only slightly diminished. There was a well-marked hypertrichosis of the left forearm, the skin of which was slightly purple and discolored. The patient himself made an attempt to burn his arm with a lighted cigar, to see if he could feel the pain. He showed the scar but had felt nothing. The pectoralis major muscle did not contract. If the left arm was started actively swinging, it kept on swinging inertly. The left hand showed hyperidrosis. The small hand muscles were emaciated but electrically normal.

Glass wound of wrist: Differential glove anesthesias (cold to mid forearm, pain somewhat higher, touch as far as elbow).

=Case 406.= (_Romner_, March, 1915.)

A German soldier, 37, wounded his right wrist in the glass of a door. The hand was put up six weeks long with very few changes of the bandage on account of suppuration, and he noticed that the arm was getting weaker and weaker, that he was losing feeling in it, and that it was beginning to sweat a good deal, so that now and then drops of sweat would stream off. The right hand was found markedly congested and 1.5 cm. larger in circumference. The fingers and hand were especially weak. There was a marked tremor of the arm. Electric excitability normal. The sensory disorder was in glove form. Hypesthesia to touch reached the elbow, analgesia to a point three fingers’ breadth below the elbow, and anesthesia to cold to a point two fingers’ breadth still lower, a sort of stepwise dissociation of sensibility resembling what is found in spinal lesions. The case was presented as one of local traumatic hysteria.

_Re_ hysterical anesthesia, the rule is that it obeys no definite rule; that is, it may be a hemianesthesia, a segmentary, an isolated, or even a pseudo-peripheral anesthesia. It is a question whether Babinski would attempt to explain Romner’s case on the basis of medical suggestion, hetero-suggestion, or autosuggestion.

Myers has had a few instances in which anesthesia spread gradually, and in which analgesia increased after its onset.

_Re_ reëducation of cutaneous sensations, Chavigny recommends the faradic current in successive applications, marking the extent of the zone of anesthesia with ink upon the skin. Each time the current is applied, the inked limits of the area are lessened. By this form of suggestion, not only does the anesthesia disappear, but very often the accompanying paralysis also.

Hysterical contracture, edema and vasomotor disorder.

=Case 407.= (BALLET, July, 1915.)

For some unknown reason, a soldier developed a contracture of the right upper and lower extremities at a time when a basin of water was offered to him for toilet purposes. Three days later, this contracture disappeared in the leg but persisted in the arm at the radiocarpal joint and in the finger joints. There was also an anesthesia to touch and pain and temperature which ran up the arm to the shoulder. The tendon reflexes were normal. On the whole, there seemed to be no doubt that the case was one of hysterical arm contracture. Associated with this contracture was a white edema of the hand. On account of the chances of simulation, the hand was done up and sealed in such wise that the seals would have been broken if the splint had been lifted down during the night. The bandage was in place from June 25 to June 29. Upon its removal, there was no edema, but the contracture was still there. The arm was put up upon a cushion so that the hand would drain to the forearm. The edema was found capable of returning when the hand was placed below the level of the shoulder, disappearing when the hand was raised. The contractured hand was warmer than its fellow. According to Ballet, we here have an anesthetic instance of contracture associated with edema and vasomotor disorder.

_Re_ edema, Babinski states that no case of hysterical edema has stood the test of scientific critique. Sometimes a case turns out one of tuberculous synovitis. Sometimes the patient is shown artificially to have brought about the edema. The hysterical “blue edema” of Charcot has not been proved to exist. Some during the war have been found due to voluntary constriction. Some of these constriction edemas even become relatively permanent. Babinski regards the above case of Ballet, as well as cases of Lebar and of Raynaud, as not true cases. Raynaud’s case was probably vascular.

_Re_ vasomotor disorders in Ballet’s case, the Babinski school, of course, holds that hysteria cannot cause such disorders.

Hemiparesis with syringomyelic dissociation of sensations.

=Case 408.= (RAVAUT, August, 1915.)

A road-laborer, 42, in the 268th Infantry, had a bomb burst about a meter away, March 4, 1915. Three men nearby were killed, and two wounded. The laborer himself was turned over, covered with earth, and stunned. He could hardly get up. He was carried to shelter and found paralyzed on the left side, and unable to speak.

Next day, he was carried to the ambulance, and hemianesthesia was found to exist in addition to the hemiplegia. He could now speak with some difficulty and stammered. Vision and hearing were also impaired on the left side. Reflexes weak; no sign of wound. There was a convulsive crisis of some sort during the day, and afterwards the man complained of a violent headache, whereupon a lumbar puncture showed a clear fluid and a marked excess of albumin by the heat test.

The following day, March 6, the patient had much improved; his hemiplegia was less marked and the arm paralysis had almost entirely disappeared. He still stammered.

Upon the next day, vision and hearing were normal, and the sensation was practically normal. A second lumbar puncture, March 8, showed a diminution in the amount of albumin, although it was still supernormal.

March 9, leg contractured in extension; stammering.

March 12, there was no evidence of disease. March 13, albumin was very slightly increased over the normal in the puncture fluid. March 16, there was a slight trace only of weakness in the left leg. The urine was throughout normal. The patient wrote _Bavo_ April 12, and May 7 he was well but still felt heaviness and pulling sensations.

July 15 it was reported at Tours that he was not yet well, presenting a left-sided hemiparesis, especially in the leg, with a syringomyelic dissociation of sensations, with atrophy of the quadriceps and diminution of reflexes on the left side. The patient had had a hematomyelia (Laignel-Lavastine).

Brachial monoplegia, tetanic.

=Case 409.= (ROUTIER, 1915.)

A soldier sustained a penetrating wound of the back of the thorax on the left side and received an injection of antitetanic serum. A few days later, May 18, 1915, he came on hospital service very sick, with high temperature and marked suppuration. The next day he had an anxious facies, temperature of 40 degrees, and sharp pains in the left arm. This arm May 21 was still very painful and then began to make involuntary movements in the shape of incessant clonic contractions. The forearm would suddenly flex upon the upper arm, and the upper arm itself would violently push itself forward and outward. Meantime, the wrist and fingers were not involved in the contractions. The movements were continuous, but paroxysmally increased in extent.

Babinski, called in consultation, confirmed the diagnosis of an anomalous form of tetanus. Next day trismus, pleurosthotonos, and stiff neck developed. Antitetanic serum and chloral had been given from the beginning, with morphine at night. The patient, however, died with asphyxia June 3.

_Re_ brachial monoplegia, the hysterotraumatic form first observed by Charcot has an anesthesia with the shoulder of mutton distribution, slightly affecting the thorax in front and behind, in addition to the paralysis.

Paralysis of right leg: Hysterical? Organic? “Micro-organic?”

=Case 410.= (VON SARBO, January, 1915.)

A Lieutenant, aged 28, lost consciousness September 6, 1914, as the result of a shell explosion. When consciousness returned in the hospital, he could not remember what had happened. The last he remembered was that he had been pushing forward with his troop. There had been no psychic shock whatever. Examined September 15, he showed a right-sided hemiplegia with stiffness of the right lower extremity so that it could not be even passively flexed. It was with difficulty he could walk and he dragged his right foot. Patellar reflex could not be elicited on the right. Oppenheim and Babinski were absent. There was a slight nystagmus on looking to the right. Pupils normal. Tongue deviated to the left. Speech was slow and the man had to think a little over some expressions. He could not feel touch so well on the right as on the left and this hypesthesia grew more marked distally. He was greatly bothered because certain words did not come to him readily, especially names.

The absence of the Babinski and Oppenheim reflexes was against an organic hypothesis and the absence of hysterical stigmata and the non-characteristic sensory disorder, as well as the absence of any psychic shock in the history, spoke against hysteria. The hypoglossus paralysis spoke in favor of the organic nature of the disease.

According to von Sarbo we must look for the background of so-called functional nervous disorders, hysteria and neurasthenia, in structural changes of the nervous system, the changes that Charcot called molecular. But the lesions, he believes, do not lead to a degeneration of neurons. Accordingly we get only the external form of organic paralysis without concomitant symptoms, such as Oppenheim and Babinski reflexes. Von Sarbo terms his hypothesis that of “microörganic” changes. To prove the hysterical nature of a condition we must show first that the symptoms have taken their rise on a mental or moral basis.

Shell-shock and momentary burial: Muscular weakness, followed (third day) by complete paralysis (save neck and head). Diagnostic hypotheses.

=Case 411.= (LÉRI, FROMENT and MAHAR, July, 1915.)

A big shell burst October 3, 1914, a little over 3 meters from a soldier crouching in a shallow Saint Mihiel trench. The shell made a hole two meters in diameter and 1.5 meters deep, and covered the man with loose earth, from which he was readily released. During the next few days, the man found difficulty in following his comrades on short marches (1 to 4 kilometers). He was unable to buckle on his knapsack. The patient was himself not alarmed at his condition.

Up to the time of his accident, this man, a farmer, had never had any motor trouble, nor was there any nervous disorder in any of his relatives. He had been in several conflicts, August 24-25, September 4-6, in the Argonne and in the Haute Meuse, and he had never found it hard to keep up with his comrades. In fact, once in the Haute Meuse, he took part in an exceedingly difficult and hasty retreat, and only a week before the shell-shock above described he had put in a very long march. Thus a man, perfectly normal before the shock, had fallen into a general state of slight muscular paralysis.

On the third day very suddenly this paralysis became complete. The wounded man, while sitting in the trench, found that he could not stand up either with or without the use of his hands. Now, that very morning he had marched three kilometers from his cantonment to the trench. He was supported on the way to the relief post, hardly 200 meters away, and was then sent to the hospital at Bar-le-Duc. At this time he was so weak that he had to be fed like a child.

For a period of three weeks he lay, unable to rise or sit up. There was one exception to the generalization of the paresis: the movements of the head and neck were normal. A general muscular atrophy set in during the three months, but gradually diminished in amount. The diagnosis of myopathy was made, based upon the evident degree of lumbar wasting, kyphosis, the man’s attitude, gait, manner of rising, galvanotonic contractions.

The history was, of course, rather against the diagnosis of myopathy, as well as the marked atrophy of the hands and the existence of an incomplete R. D. Moreover the fact that he improved may be regarded as rendering the diagnosis of myopathy doubtful.

Other diagnoses, less likely than that of myopathy, may be considered,--hematomyelia, recurrent traumatic poliomyelitis affecting the anterior horns, polyneuritis.

Without making decision as to the nature of this case, Léri proposes the question whether there is a shell-shock myopathy and whether there is a myopathy due to gas or to hemorrhage?

Shell-shock: Right hemiplegia with contracture and mutism. Cure by isolation and suggestion. Question of the relation between plantar areflexia and (_a_) anesthesia (hysterical) or (_b_) contracture.

=Case 412.= (DEJERINE, February, 1915.)

A territorial infantryman, 36, of a nervous and impressionable temperament (father alcoholic), was blown up by a bomb October 3, 1914, between Bapaume and Arras. He was evacuated forthwith to the relief post. According to his own story, he spat blood, could not talk, and felt his right side weak. He was three weeks at a hospital in Paimpol, with the diagnosis of right hemiplegia with contracture and mutism. At Guingamp, an electrical treatment was followed by a gradual disappearance of the arm contracture.

Examined by Dejerine, January 2, 1915, he was found to be a tall, stalwart man with right leg contractured in extension, foot in equinovarus, heel raised. He walked, dragging the leg, which trembled; the trembling then extended to the rest of the body. In dorsal decubitus, the leg lay in adduction and internal rotation. He could lift the leg only 5 cm. above the bed, could only slightly flex leg on thigh, and could not at all flex thigh on hip. The leg could not be bent at all if he was requested to hold it stiff. Ankle joint movements were impossible from contracture. The equinovarus was in contracture which could not be corrected. Right hip movements were limited and painful. Muscular atrophy absent.

Whereas on the left side plantar stimulation produced not only the normal flexor reflex but also the classical defense movements of flexion of leg on thigh and thigh on hip,--on the right side neither a needle nor a match, nor any other form of stimulation of the sole, produced any kind of reaction on the part of the toes, the fascia lata, or any leg muscles. Tested every day for some weeks, the result was always the same. The cremasteric reflex was weak on the affected side. Abolition of the plantar reflex and of the defense movements on the right side was associated with an anesthesia and a hypesthesia of the right side of the body, involving complete anesthesia below the knee and hypesthesia of superficial and deep sensation above the knee. The buccal and lingual mucous membranes were also hypesthetic. The bony sensibility was lost in the foot and lower leg, and was diminished in all of the bones of the right side of the body. There was no contraction of the visual fields. The right corneal reflex was diminished. There were no other sensory defects.

The man was also aphonic, being unable to utter a word or a sound except a jerky whistling sound like the letting off of steam. He was able to write out his history intelligently. He was very emotional, wept, and trembled all over when talking of wife and children. The spinal puncture fluid was in all respects normal. A laryngoscopic examination showed that the vocal cords were functioning normally. The long _a_ could be pronounced distinctly, at the expense of great effort so that the larynx would finally be blocked. The laryngeal reflex was abolished. The laryngeal mucosa could be touched with a probe without producing the slightest pain or coughing reflex. By way of treatment, this case of hysterotraumatism was given isolation and psychotherapy for two months without effect. But about the middle of March he began to get better, the symptoms rapidly faded, cure was effected at the end of March, and the man was evacuated to his dépôt.

_Re_ reflexes and contracture, see the views of Babinski reproduced under Case 385 of Paulian.

Shell-shock: Tic VERSUS spasm.

=Case 413.= (MEIGE, July, 1916.)

A soldier was bowled over in a trench by a big shell that burst nearby. He lost consciousness and was carried to the ambulance. But he came to, and was so absolutely well with a few hours’ rest that he took part in a lively attack shortly thereafter and got a wound in the left arm, affecting slightly the ulnar nerve. He was sent to the Salpêtrière for this ulnar nerve affection, when certain movements of his scalp were incidentally noted.