Forearm wound: Hysterical edema?
Case 456. (Lebar, July, 1915.)
A corporal, 26, formerly a farmer, was struck in the forearm by a shell fragment on the mid-portion of the radial border. The wound was slight (the fragment entering and emerging hardly 2 cm. apart) but bled profusely, according to the patient, who was evacuated next day but one to a hospital in the interior. By this time the right hand was swollen, nor could any movement of hand or fingers be made. Massage, mechanotherapy, passive movements did no good.
The man entered the neurological center of the Eighth Region, July 7, 1915, when there were already a few skin changes with dorsal thinning and palmar thickening. There was cutaneous anesthesia not only of hand and fingers but of the forearm to the elbow, and this anesthesia included heat and cold. Position sense was preserved. There was no evidence of atrophy except for the skin changes. An electrical examination showed normal conditions.
July 13, a sealed bandage was put on, but at the end of five days the hand looked as before. July 19, a new treatment was announced to the patient. With a hot needle a number of pricks were made on the dorsal surface of the hand and a few c.c. of fluid were withdrawn (containing a slight amount of albumin and a few lymphocytes), whereupon a dry bandage was put on. The next day a few finger and thumb flexion movements could be made and sensation had returned. Sensation completely returned July 21. The flexion movements were still incomplete, by reason of the edema and dryness of the skin. However, July 22, flexion was better and the swelling had gone down sixty per cent. Jacquet’s biokinetic treatment (active gymnastics of the hand and fingers) was given for four hours. July 25, the edema had greatly diminished and normal motion had returned.
Examination excluded renal disease. There was no sign indicating phlegmon. Quincke’s disease had other features. Fraudulent application of a bandage might be considered, but the course of the disease under sealed conditions seems to exclude this hypothesis also. May it, therefore, not be a case of hysterical edema?
Re hysterical edema, see remarks under [Case 407]. In the case above, of Lebar, Babinski calls attention to the fact that the edema and the contracture diminished though they did not entirely disappear after the scarifications. This physical treatment did not act, according to Babinski, wholly as a matter of suggestion, and he fears that some cases of so-called hysterical edema are really cases of physiopathic vasomotor disorder; in fact, three of the cases published (and amongst them, the present case of Lebar), were cases of edema associated with contracture and developing in an injured limb. To prove a case of anything to be hysterical is, of course, according to the Babinski school, to submit it to a therapeutic test and cure it by suggestion.
Shell splinters in head: Suspicion of (a) simulation, (b) hysteria. Case actually surgical.