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.
Another case was wounded in the right arm by a shell fragment September 7, 1914, and showed two scars above the epitrochlea and along the internal border of the triceps. Examination December 30 showed a normal elbow movement, pronation and supination, with slight flexion in repose of the palm of the hand and the fingers. Active flexion movements of the fingers could be performed only imperfectly, and the finger pad could only be brought within three fingers breadths of the palm, despite the greatest effort on the part of the patient. Minute passive movements were entirely possible. The fifth finger could not be abducted and both abduction and adduction of the third and fourth finger could not be made on account of the nerve lesion. The thumb was in a condition of contracture which placed it in abduction in front of the index finger, and the thumb could not oppose. Passive movements, on the other hand, were entirely possible. The hand was flexed upon the forearm through hypertonia of the flexors, which could be easily overcome with slight but distinct resistance. The hand was in the position of a radial paralysis. There was a slight degree of muscular atrophy. Tendon reflexes were normal. Electric examination showed that stimulation of the ulnar nerve at the elbow was unable to produce flexion of the last two fingers or any movement in the hypothenar eminence, of which the muscles were also not excitable. The interossei could, however, be made to contract. The median and radial nerves were normal electrically. The above examinations were with the faradic current.
With the galvanic current the ulnar nerve proved unexcitable at the elbow, and the muscles of the hypothenar eminence contracted more slowly. The median and radial nerves and their muscles were electrically normal.
In short, there was a complete R. D. of the hypothenar and partial R. D. of the interossei as a result of the lesion of the ulnar nerve. There was nothing abnormal in the other nerves or muscles of the arm. The attitude of radial pseudoparalysis is due to the contracture of the muscles of the thenar eminence.
As to therapy, the general movements of flexion of the fingers, thumb and hand yielded a marked improvement, but such results cannot be expected in like cases unless a physician or experienced masseur treats the case. Babinski and Froment have tried thermotherapy and diathermy in these cases, finding that the paralysis diminishes and becomes partial if the limb is warm, although it is important that it should not become too warm. Sometimes a few treatments with diathermy will produce movements in a case of long standing paralysis. Babinski and Froment counsel not only diathermy, but a general motor reëducation. The idea of the diathermy is that the deeply penetrating heat affects blood vessels and muscles, bringing about a vasodilatation or even a direct addition of needed calories. In like manner, galvanism, light baths, or simple baths in combination, and with diathermy, especially with the diathermy, act favorably. Casts and apparatus have also proved without avail, as well as faradic or galvanic reëducation.
The above two cases show how in one instance there may be no electrical change and in another instance a slight one. In these cases, reflex hypertonic contracture, hypotonic paralysis, vasomotor disorder, decalcification of the skeleton (X-ray), mechanical overexcitability of muscles, unmodified tendon reflexes (except elective exaggeration of reflex under anesthesia, e.g., a persistent unilateral patellar clonus when all other reflexes have been abolished), and disorders of electrical excitation are enumerated by Babinski and Froment.
Delherm sums up the electrical disorders as follows: Muscle faradized:
(a) No change.