A soldier, 21 years, was observed at the Centre Neuropsychiatrique, August 30, 1916. He had been wounded in battle, March 16, 1916, near the left internal malleolus. Infection followed and inguinal adenitis, for which he was in hospital a month.
Even before the abscess began, the foot had begun to twist inward. After the abscess had been cured, a contracture set in permanently, and at entrance to hospital was irreducible. The knee-jerk and Achilles jerk were more active on the side of the equinovarus contracture. There was even a slight amyotrophy of the calf. There was no appreciable vasomotor disorder. The foot and lower part of the leg were a little warmer on the left side.
Cure followed a single sitting with psychoelectric treatment, at least so far as the contracture went. Pain and swelling remained in the evening, followed by fatigue. The patient was discharged cured, October 12, 1916.
Hysterical pes equinovarus shows the foot immobile as if frozen (figé). The foot is extended with the toes lowered and the internal border incurved, as if revolved about the axis of the leg. The surface of the sole is directed inwards and much furrowed. The tendon of the tibialis anticus is very prominent. The internal malleolus is hardly visible, while the head of the astragalus is easily made out. No passive movement is possible and the tibiotarsal and mediotarsal joints are quite out of function. Upon palpation, the excessive contracture of the anterior muscles of the leg is striking. Upon request to move the foot, the foot is not moved, but muscles of the lower leg may contract, and even those of the thigh.
There were no sensory disorders in the present case, though they often do occur in this form of acrocontracture. It is doubtful whether the skin changes sometimes seen, such as hypothermia, hyperidrosis, cyanosis, and glossiness are due to circulatory disorder induced by the contracture or to the prolonged immobility. It has been proved by Meige, Benisty and Lévy, that even in a normal subject prolonged immobility may cause a difference of temperature of several degrees. Circulatory disorders sometimes cease immediately upon cessation of the contracture. Roussy and Lhermitte insist upon energetic and early treatment of these psychoneuropathic acrocontractures, which are apt to proceed less favorably than the acroparalyses. If not treated energetically and early, actual nerve, tendon, and bone lesions may ensue.
Shell-shock; shell-wound; emotion: Hysterical paraplegia. Approximate recovery.
Case 236. (Abrahams, July, 1915.)
A private of the First East Lancs could remember a shell’s bursting and striking a wagon near him when he was carrying food to the firing-line. He also thought a spare wagon wheel might have fallen on him. A period of unconsciousness of four or five days duration elapsed, on recovery from which he found himself suffering from a shell-wound in the left buttock, complete paralysis of both legs, and pain in the back, by the fourth lumbar vertebra. He thought that he had suffered from sphincteric paralysis for eleven days after the accident; but by September 25, there was no sign of this. Besides the paraplegia, there was complete loss of sensation below Poupart’s ligament in the right leg, reaching as high as the iliac crest behind; and an anesthesia of the left foot including heel and sole, with anesthesia to light touch throughout the limb (pin-pricks being appreciated in a normal way as far as the ankle); and there was an anesthesia to touch and pain in the ulnar distribution.