Part 48

In May, 1916, the patient was invalided and found to be still in possession of the above-mentioned signs. Similar phenomena have been found in the _main figée_ acrocontracture, and _main d’accoucheur_, and belong, in the opinion of Babinski, to a group which is neither hysterical nor organic in the ordinary sense of the terms. Vasomotor and thermic phenomena are in the foreground of the picture, and are, in fact, practically constant, though they vary somewhat in degree. They react abnormally to the temperature of the surrounding medium; there is undoubtedly a local perturbation of the vasomotor and heat-regulating mechanism. There is also certain evidence of vascular spasm. The vasomotor and thermic disorders run parallel with the mechanical over-excitability of the muscles and the slowness of the response.

Chloroform to demonstrate asymmetry of reflexes.

=Case 423.= (BABINSKI and FROMENT, 1917.)

A soldier, 26, sustained, September 22, 1914, a bullet injury of the right calf. There was no fracture, as X-ray showed, but healing was slow, taking no less than three months. The right knee-jerk was a little stronger and a little sharper than the left, but the difference was controversial; and the difference between the two Achilles reflexes was still more doubtful.

Chloroformed October 10, 1915: As the patient was going to sleep, even before the phase of excitation and motor agitation had passed, the two knee-jerks and left Achilles jerk had disappeared. They grew rapidly less marked before disappearing, and none of the tendon reflexes presented any phase of exaggeration while the patient was going under. At this point anesthesia was arrested. The right Achilles reflex, which had not disappeared, was sharply defined. It was even stronger than in the normal state and polykinetic. During the whole phase of awaking from the chloroform, the right Achilles reflex remained strong and polykinetic, without, however, any ankle clonus. Thus, the difference between the two Achilles reflexes became indisputable; also the right knee-jerk reappeared before the left, and became stronger without any patellar clonus. At this time, the difference between the two knee-jerks was sharp and beyond cavil. This status, in which the knee-jerk and Achilles reflexes were asymmetrical, lasted about ten minutes after anesthesia ceased and lasted a little longer for the knee-jerks than for the Achilles jerks.

Reflexes under chloroform.

=Case 424.= (BABINSKI and FROMENT, October, 1915.)

A soldier sustained a clean-cut wound of the supero-external aspect of the right thigh without much destruction of tissue or any adherent scar. He showed marked lameness, September 15, 1915, walking with his right leg extended and the foot in external rotation. There was a slight limitation of the movements of the hip joint in respect to internal rotation and flexion of thigh. The right knee-jerk was a little stronger than the left, and this condition persisted several days. After a few tests, the knee-jerk became even slightly polykinetic. The Achilles jerks were normal and equal. There was no epileptoid trepidation of the foot, and no patella clonus. There was a slight hypothermia of right leg, with ill-defined muscular atrophy. Walking caused pain.

Chloroform anesthesia, September 20, 1915, yielded an exaggeration of the knee-jerks with a suggestion of patella clonus even before the phase in anesthesia of motor excitation had set in. As anesthesia proceeded the exaggeration was rapidly lost on the left side but progressively increased on the right. In the phase of complete muscular resolution, when all the other tendon reflexes (such as the knee-jerk, Achilles jerk on the left side, the radial and olecranon reflexes on the left side) were abolished, the patella clonus on the right side was perfectly distinct and could be elicited either by the usual method or by raising the thigh and letting it fall. On percussion of the patella tendon, a strong polykinetic reflex was obtained; right Achilles jerk preserved; right leg in external rotation. Internal rotation could be passively performed better than in the waking state, but this movement was still limited. As the man was waking from anesthesia, when reflexes were reappearing, there was a suggestion of left patella clonus--right clonus as strong as before. At no time any trepidation of the foot. The patella clonus on the right side lasted an hour after waking, at which time all the reflexes returned to their previous state.

Reflexes under chloroform.

=Case 425.= (BABINSKI and FROMENT, October, 1915.)

A soldier sustained a bullet wound, September 22, 1914, in the right calf. There was no fracture, as X-ray showed. Cicatrization was slow and took at least three months. He was examined October 2, 1915, at the Pitié,--not complaining of pains, but lame. There were no pains, limitation of movement, or joint sounds in the hip joint, and X-ray was negative. There was a slight atrophy of the limb, 1.5 c.m. less in circumference on the right. There was a sharply defined local hypothermia of the right leg up to the knee. The right knee-jerk was a little stronger and brisker than the left, yet it was difficult to be sure of this, and there was a still more doubtful difference between the Achilles reflexes.

The man was anesthetized with chloroform, October 10. As he was going to sleep, before the phase of excitement and agitation had ceased, the two knee-jerks had disappeared. At the same time, the left Achilles jerk vanished, followed by the plantar cutaneous reflexes. Anesthesia was then stopped. The right Achilles jerk, which had not disappeared at any time, remained distinct. It was stronger than in the waking state, and polykinetic. During the waking phase, this reflex remained strong and polykinetic, but there was no epileptoid trepidation of the foot. Accordingly, under chloroform, the difference of the two Achilles reflexes had become very sharp. The right knee-jerk reappeared before the left and became stronger, though without patella clonus. This difference was much more striking than in the waking state. This asymmetry of the patella and Achilles reflexes lasted about 10 minutes after anesthesia was stopped, and lasted a little longer for the patella reflexes than for the Achilles reflexes.

Shrapnel wound above clavicle: Brachial monoplegia, partly hysterical, partly organic.

=Case 426.= (BABINSKI and FROMENT, 1916.)

Babinski speaks of certain symptomatic incompatibilities which emerged in the study of cases of combinations of hysteria, organic nervous disease, and the so-called physiopathic disorders. An example of such an incompatibility might be that of a patient who should, three months after a sudden hemiplegia, show complete or almost complete flaccid paralysis and but slight exaggeration of tendon reflexes--yet the Babinski reflex. Of course, the Babinski reflex would permit a diagnosis of pyramidal tract disease. Yet a sudden intense hemiplegia lasting three months, if it were merely a matter of pyramidal tract disorder, ought to show hyperreflexia of a pronounced degree as well as contracture. An example from the arm is as follows:

A soldier got a shrapnel wound in the left supraclavicular region, and had a complete paralysis of the arm, which had lasted more than a month. Electrical examination showed marked reaction of degeneration in the muscles controlled by the musculo-cutaneous nerve, as well as a diminution of electrical excitability in the muscles innervated by radial branches. On the contrary, in the circumflex territory, ulnar and median, electrical excitability was normal. There were no vasomotor disorders. The diagnosis of an association of hysteria and organic disease was made. Babinski affirmed that electrification would effect a partial cure; and in point of fact, the patient, after having submitted to the current for several minutes, was able to use all the muscles whose faradic contractility was normal or almost normal. Thus, he could raise his arm, flex the thumb, flex the fingers, close the hand, and extend the hand and fingers. Flexion of the forearm on the arm was still difficult, since there was, in fact, a reaction of degeneration in the muscles of the anterior region of the arm. The fact that the movements could be partially executed was dependent upon action of the supinator longus.

Gunshot fracture of upper arm; recovery with motor power in five weeks: Six weeks later, Erb’s palsy (plus). Hypothesis: “Reflex paralysis” preferred.

=Case 427.= (OPPENHEIM, January, 1915.)

A reservist, 26, was shot through the middle of the left upper arm, sustaining an oblique fracture of the humerus, August 26. The external wounds healed in a month; the fracture somewhat later. The left arm was at first stiff and motionless, but in five weeks it could again be moved. Pains disappeared with return of motility.

About the middle of November the arm began to lose power to move again, especially the muscles of the upper arm. November 20, the patient showed atrophic paralysis (left deltoid, biceps, brachialis internus, and supinator longus) suggesting at first glance the appearance of an Erb’s palsy; but the triceps and the adductor of the upper arm were also unable to move and there was a slight paresis in the distal muscles of the extremity. There were no pains or other objective disorders.

The diagnosis of subacute poliomyelitis was considered. Electric excitability, however, was found to be normal, both faradically and galvanically.

When patient walked, the left arm swung helpless without sign of innervation or any tonus. Abduction of the shoulder could also not be performed, though a slight flexion of the forearm shortly began to be demonstrable. If the patient inclined his head to the right, extended his hand at the wrist, and flexed the fingers forcibly, he could then flex the forearm somewhat, and a slight tension of the biceps and supinator longus developed. Sometimes fibrillary tremors developed in deltoid and biceps.

Of course a transient peripheral palsy can be produced by pressure of the radial nerve without any change of electrical excitability, but such a change is not associated with atrophy.

Neuritis and poliomyelitis producing an Erb’s palsy without any effect upon the electrical reactions is an hypothesis not to be entertained.

Accordingly, the hypothesis of psychogenic or hysterical palsy may be set up. Yet an atonic atrophic palsy with loss of tendon reflexes (supinator) is inappropriate. According to Oppenheim, this case falls into the category of the arthrogenic atrophies. A simple muscular atrophy may follow disease of joints and bones. However, such cases have rarely shown a complete palsy, as in Oppenheim’s case.

In short, we return to the old doctrine of reflex paralysis, conceiving that a stimulus passing from the periphery influences the gray matter in its trophic functions.

How much effect had the psyche upon this condition? The patient had stuttered from childhood and had sustained a fracture of the skull at 9, following which his school work, especially mental arithmetic, had been poor. The lack of psychic inhibitions may play some part in the situation, but on the whole, the reflex hypothesis is preferred by Oppenheim, the nerve conceived to be dynamically affected, the muscles organically.

Paralysis: Hysterical? organic?

=Case 428.= (GOUGEROT and CHARPENTIER, May, 1916.)

A soldier, 20, was wounded May 15, 1915, by a large number of shell fragments, 15 of which struck the right leg, two producing serious injuries,--the one, a penetrating wound of the popliteal space followed by stiffness of the knee, later cured by extraction of the fragments; the other, causing a deep wound at the internal malleolus. The fragment was extracted June 3, but osteomyelitis persisted and a fistulous contraction was developed in January, 1916. There was a slight equinism.

By contrast with these deep bony lesions of the right leg, on the left side a fragment had struck the dorsum of the left foot at about its middle point, along the extensors of the fourth and fifth toes. The fragment was removed toward the end of June, 1915. The wound closed in a fortnight, leaving a loose 20 mm. scar. The man complained of pains, which he called electrical, in the third and fourth toes, if one bore down on this scar, a symptom suggesting that the dorsal nerves had been injured. Immediately after the wound both legs had been paralyzed, according to the soldier. He had been able only to drag himself along on his shoulders. This indeterminate paralysis lasted three days. It may have been hystero-traumatic, or it may have been a sort of diffuse inhibition. Just after the injury, the left foot was in contracture, which gave place a month later to paralysis. Only the great toe was still able to move a little. In December, 1915, the patient still could extend and flex the toes on the left side very badly, though he could execute movements easily on the right side. There was no stiffness of joints; there were no tendon reflex disorders. There were no trophic vasomotor or secretory disturbances.

The diagnosis of hysterical paresis seemed warranted, but electrical examination showed that the troubles were organic. There was an increase in the faradic and galvanic excitability of the external popliteal nerve. The response was more sudden than normal, and there was an increase in faradic and galvanic excitability in the tibialis anticus. There was a decrease of faradic and galvanic excitability in the extensor communis of the toes and in the external peroneus.

Thus, this patient after being wounded in both feet May 15, 1915, paralyzed in both feet for a period of three days, undergoing a contracture of the left foot for a month, giving place to paralysis of foot and toes, with slow improvement from the end of July, 1915, was still in this latter state in March, 1916; though without trophic disorder, he showed faradic and galvanic over-excitability of the external popliteal nerve and of the tibialis anticus, _pari passu_ with diminished electrical excitability for other muscles.

Paralysis: Hysterical? organic?

=Case 429.= (GOUGEROT and CHARPENTIER, May, 1916.)

A man was wounded Oct. 11, 1914, on the back of the right hand. Two hours later, he was attended at the relief post. At this time, his hand was straight, with fingers extended. He said that he could not move his fingers, although there was no pain in them. Three hours after the wound, the hands swelled and the edema spread as far as the middle of the forearm. There was a long suppuration, complicated by lymphangitis. All of the fragments were removed October 26, 1914; healing was complete in three months. The swelling, however, persisted to June, 1915, and when the swelling disappeared, the hand began to show drop-wrist. The wound was sutured between the second and third metacarpals, and the X-ray showed that the bones had not been injured, nor had the nerves of the forearm muscles been touched. The situation was such that the case was catalogued “functional paralysis.”

October 5, 1915, the hand was still drooping, fingers extended, and middle finger and ring finger trembling. A slight stiffness of wrist and fingers did not interfere with movements. Extension of the wrist could be made very slightly above horizontal. Flexion was not quite complete, nor were adduction or abduction. Extension of the fingers could be performed normally, as well as that of the thumb, but flexion was not quite complete. There was a slight palmar retraction. Such were the movements that could be produced electrically. Voluntarily, flexion of the wrist was good, abduction and adduction incomplete; extension could not be executed to the horizontal position. There was a tendency to flexion of the ring finger. When the patient tried to flex the middle and index fingers, these fingers trembled but did not flex. Weak extension and abduction of the thumb but without opposition could be voluntarily performed; adduction good; flexion of the first phalanx, weak; of second phalanx, better. Slight muscular atrophy of the forearm, which was one centimeter less in circumference than the left. The hand was subject to a general atrophy; the skin reddish and moist. The X-ray showed a decalcification of all the bones of the hand and wrist; trophic disturbance of the small carpal bones although the trauma had affected only the second interosseous space. No joint lesions or periosteal thicknesses were found by X-ray. There was a slight hypesthesia of the palmar surface of the middle finger and of the index finger. The patient complained of sharp transient pains in hand and fingers.

In this case, therefore, a wound of the back of the hand produced an immediate inhibition of muscular action in the forearm, a rapid edema of the hand and arm, lasting for eight months and followed by reflex disorders.

There was a considerable diminution in faradic excitability of the flexor brevis of the thumb, the anterior cubital, the flexor brevis minimi digiti, and of the dorsal interossei, and slighter evidence of diminution of galvanic excitability in some of the muscles.

Sollier is said to have been the first to remark trophic bone disorders in cases of neuropathic contracture.

_Re_ bone changes, Babinski enumerates trophic changes in the tissue of bones and joints amongst objective signs that permit us to distinguish the reflex or physiopathic disorders from the hysterical or pithiatic disorders. Objective signs of this group (indicators of reflex or physiopathic disorders) are: (_a_) Well-marked and persistent vasomotor and thermic disorder; (_b_) alterations of muscular tone (either hypotonus, hypertonus, or a combination of the two); (_c_) increase in the mechanical excitability of the muscles and sometimes nerves; (_d_) quantitative changes in the electrical excitability of the muscles, but without R. D.; (_e_) muscular atrophy and atrophy of skin, bones, and joints. For cases of this nature, see especially Cases 431 and 432 of Delherm.

Paralysis: Hysterical? organic?

=Case 430.= (GOUGEROT and CHARPENTIER, May, 1916.)

A man, 22, was wounded September 17, 1914, in the left hand, the bullet passing from the lower part of the fourth interosseous space out through the palmar face. The bones were not injured, and it was evident that only a few nerve filaments could have been injured; but he had a paralysis extending far beyond this region, which increased little by little from November, 1914, to August, 1915. Babinski, examining him in November, 1914, had made the diagnosis of psychic paresis of the extensors with diminution of electric excitability, with a very slight slowing of the contraction of the last two interossei and the hypothenar eminence, connected with lesion of the branches of the ulnar nerve. The disorder spread to the flexors of the fingers and the thumb muscles. The fifth finger was flexed at rest; there was no stiffness of joint or tendon retraction. The extensors and flexors of all the fingers and the thumb, and the abductor of the thumb showed paresis. The thumb was able to oppose; the hands were cyanotic. Augmentation of these phenomena in a period of months, their bizarre distribution, and the preservation of the opposing power of the thumb suggested a hystero-organic disease, and Babinski’s notes read, “Partial and incomplete paralysis of the ulnar nerve, attacking slightly the hypothenar eminence and the last two interossei; psychic paresis of the extensors and flexors of the fingers and thumb and of the abductors of the thumb.” Electrical examination showed, however, that there was not only electrical disorder of the common extensors of the fingers, the extensor proprius of the index and of the ring fingers, of the long and short extensors of the thumb, but also there was a considerable diminution to faradic and galvanic reaction in extensor ossis metacarpi pollicis, the radials, the supinator longus, the pronator teres, the large and small palmar, the common and superficial flexors of the fingers, the muscles of the thenar eminence, the anterior ulnar, and the anterior biceps and brachial. In short, there was an irradiation of seemingly organic phenomena in the domain of the radial, median, and the non-injured part of the cubital distribution, as well as in the distribution of the musculo-cutaneous. Apparently, organic paralytic disorder had spread even to the biceps and had increased over a period of many months after the wound had healed.

_Re_ what he terms _organo-hysterical association_, Babinski proposes to distinguish it from hystero-organic association. In Babinski’s organo-hysterical association, the organic symptoms are preceded by hysterical symptoms. These cases of organo-hysterical association,--_e.g._, a case in which a hysterical monoplegia is followed by a musculospiral crutch paralysis,--are one of the mainstays of the proof that hysteria and simulation cannot be confounded. Babinski concedes that he has sometimes said that hysteria was a sort of semi-simulation; yet a semi-simulation is not a simulation.

As for Babinski’s _hystero-organic association_, we here deal with cases of organic paralysis or contracture in which the fundamental disorder is organic, and the psychic disorder is grafted upon it. Both the fundamentally organic and the fundamentally hysterical associations are instances, according to Babinski’s phrase, of symptomatic incompatibilities. In such instances, the hysterical part of the disorder, whether grafted or original, is dissolved by psychotherapy. There is a third group of symptomatic incompatibilities, namely, the _hystero-reflex associations_, in which, _e.g._, a hysterical gait is combined with vasomotor and thermal disturbances. There may even be combinations of all three types of disease, namely, the type of structural disease, of vasomotor disorder, and of hysteria, in what would then be termed a _hystero-reflex-organic association_.

Wound of toes--Wound of arm: Reflex or physiopathic paralyses, diagnosis and treatment.

=Cases 431 and 432.= (DELHERM, September, 1916.)

A soldier was wounded in the soft parts of the last two toes and in the furrow between toes on the left side, September 15, 1914, arriving in the Central Physiotherapeutic Service of the 17th Army Region, December 27, 1915, left foot in varus, with marked contracture of tibialis anticus, though passive movements of flexion, extension, adduction and abduction were well performed. There was a slight atrophy of the leg (33 cm. left to 34 cm. right). The scar was a little painful, and there was a slight degree of hypesthesia of foot and lower leg. The foot was cold and cyanotic; the reflexes were normal. An electric examination in the region of the external popliteal branch of the sciatic nerve showed that there was no electrical disorder either faradic or voltaic.