After H. P. Wright
(a) Bullet-wound of forearm: Combination of hysterical (brachial) monoplegia, and reflex (physiopathic) disorders. (b) Refrigeration: Combination of hysterical paraplegia and reflex (physiopathic) disorders.
Case 421. (Babinski, 1916.)
The forearm of a soldier was pierced in its lower part by a bullet, which produced no lesion of large nerve trunks or blood vessels. A complete brachial monoplegia followed. Every movement of the different segments of the arm was abolished. The hand and forearm were slightly atrophied, and were of a reddish salmon color. The temperature of the affected hand and forearm was about three or four degrees lower than that on the other side. The sphygmometric oscillations of the forearm were twice as small in the paralyzed limb as in the healthy limb, but the systolic blood pressure was normal. There was a mechanical over-excitability of the muscles, and a slight exaggeration of the bone and tendon reflexes. The paralysis was in part of reflex (physiopathic) nature. On account however, of the completeness of the monoplegia, and the fact that the reflex paralyses as a rule affect only the distal portion of the limb, the diagnosis of hysteria had to be made in addition to the diagnosis of reflex disorder.
As a result of freezing, this patient had also a complete crural paraplegia. He showed vasomotor disorders and hypothermia of both feet, together with mechanical over-excitability of the muscles; and these latter disorders appeared to be of a reflex nature. The paraplegia, however, was of a hysterical nature.
Re refrigeration, see [Case 309] (Binswanger) of glossolabial spasm.
Differential diagnosis of organic (central) monoplegia and reflex (physiopathic) contracture and paralysis. (Babinski-Froment.)
| Organic Monoplegia | Reflex Contracture and Paralysis |
|---|---|
| 1. Paralysis often affects the whole extremity, either arm or leg. | 1. Paralysis almost always partial. In arm paralysis, affects as a rule fingers and hand. The leg is often affected at its origin, and then only partially. |
| 2. After several weeks of flaccid paralysis, as a rule contracture occurs. | 2. Paralysis may remain flaccid for a long time, and frequently coexists with contracture, hypertonicity and hypotonicity of different muscular groups. |
| 3. The upper extremity shows flexion with clawhand. The lower extremity shows contracture of extensors. The patient walks throwing his leg sidewise (Démarche helicopode). | 3. The upper extremity in hypertonic cases often shows the main d’accoucheur, the main en bénitier (holy-water vessel hand), the doigts en tuile (crowded fingers). The lower extremity does not exhibit the sidewise movements. |
| 4. Tendon reflexes, a few weeks after paralysis begins, exaggerated. | 4. Reflex status variable. Hyperreflexia often absent even in hypertonic forms. |
| 5. Babinski sign in crural monoplegia. | 5. Babinski sign absent. The skin reflex may be abolished but may be reproduced on warming the foot. |