Shell explosion near by: Paraplegia, interpreted as due to windage. Two foci of HEMORRHAGE (SPINAL CANAL, BLADDER) clinically proved to exist in a case without external sign of injury.
Case 202. (Ravaut, February, 1915.)
An infantry sergeant was brought to the ambulance, one day in November, 1914, with a paralysis which had set in immediately upon the explosion of a large shell a short distance away. Both legs were paralyzed and there was anesthesia to the navel. He could not urinate. It was early in the war, and Ravaut thought he would find an injury to the vertebral column, but on undressing the soldier there was no wound. The skin was intact, and there was not even an ecchymosis. The patient was suffering not at all, but said that after the shell exploded he felt a forcible shock, was stunned for a moment, and when he wanted to rise, found that his legs were inert. His state did not change during the day and he did not urinate. Catheterization showed a urine full of blood. This indicated a lumbar puncture, and a bloody fluid emerged under great pressure. Thus two foci of hemorrhage were proven to exist in this patient despite the fact that there was no external lesion.
Re windage effects, see suggestions of Ravaut under [Case 201]. Ravaut also suggests that certain cases of emotional jaundice may be similarly explained on the basis of internal lesion due to windage. Sundry cases of gastro-intestinal disorder and of hemoptysis fall into the same class; possibly the cases of death in a fixed posture belong there, too. Ravaut thinks, despite the look of hysteria about the shell-shock cases of paraplegia, deafness, mutism, and the like, that the cases are actually ones in which there has been at the beginning a slight or severe hemorrhage, clearing up in a few days. He states that there is a pretty definite parallelism between the course of the clinical symptoms and the chemical characteristics of the spinal fluid.
Shell-explosion in confined space; paraplegia after fifteen minutes; slight hemorrhage and LYMPHOCYTOSIS of spinal fluid; Hematomyelia.
Case 203. (Froment, July, 1915.)
A Sergeant lying down in a small dugout space, 2 × 1 m. high, had a 77 shell burst behind his head and between his head and the back of the dugout. The patient was not moved by the explosion, but was buried in a small amount of earth and stones to a depth of about 20 cm. He was not wounded and showed no ecchymoses either then or later. Aided by stretcher bearers, he was able to walk to the relief post about 400 meters from the trench. He did not lose consciousness, and got to the relief post about a quarter of an hour after the shell burst. Thereafter, however, he was unable to move his legs. The accident happened February 6 at 4 o’clock. He was examined 24 hours after the trauma. The accompanying diagrams show the variations in sensory disorder at intervals during six months.
A lumbar puncture, February 8, 1915, showed hypertensive clear fluid without macroscopic clot on centrifuging, but showing a number of red blood cells and lymphocytes—3 or 4 to the microscopic field. There was a slight hyperalbuminosis. The development of the muscular atrophy and hypo-excitability of the left lower extremity, the exaggeration of the left knee-jerk, together with the spinal fluid appearances, seemed to prove the organic nature of the paraplegia. There was an intense rhachialgia, with radiation along the sciatic nerve. This outlasted all other symptoms. Thermo-analgesia was the most prominent sensory disorder. There were no sphincter disorders.
During the first days, the anesthesia was of a pure segmentary type, with nothing about it to suggest that it was later to be supplanted by a radicular type of disorder. Hematomyelia was, years ago, thought—according to Froment—to tend to yield sensory disorders of a segmentary nature. At the outset this anesthesia was total, though there was a vague, poorly localized feeling on intense painful excitations,—as with energetic pricking or burning. Thus the protopathic sensibility of Head had remained, whereas the epicritic sensibility had disappeared.