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.