83. [Case 112] is the one noted above of infection of the spinal fluid. It is the only case of infected meningeal hemorrhage observed by Guillain and Barré in a wide experience. As a rule, these hemorrhages remain aseptic and have a favorable prognosis. The organism cultivated from the spinal fluid proved to be the pneumococcus. [Case 113] yielded a somewhat remarkable phenomenon and perhaps would be more logically considered in relation with the series of cases in [Section B] that show the picking up of ante-bellum weak spots ([Cases 287-301]); for this subject had had two serious affections of the brain ante-bellum. He had had a poliomyelitis at five, affecting the left leg, and he had had a right hemiplegia with aphasia following pneumonia, at 20. He was struck (but apparently not wounded) by shrapnel on the right shoulder, and developed athetotic movements of the right hand, as well as a general weakness of the left leg. In this case, according to Batten, the stress had been sufficient to bring into prominence symptoms due to an old cerebral lesion. Whether the mechanism in this case is hysterical is doubtful.
84. That not every case of hemianesthesia is hysterical is suggested by [Case 114], in which the diagnosis of hysteria was actually made; but the diagnosis was soon rendered doubtful by the fact that there was no evidence of autosuggestion or heterosuggestion. Other phenomena make a diagnosis of thalamic hemianesthesia more likely.
85. Although Shell-shock is not the subject of this section, yet a case of syndrome strongly suggesting multiple sclerosis is here inserted, following shell-shock ([Case 115]). The co-existence of hysterical and organic symptoms is illustrated in [Case 116], one of mine explosion, and [Case 117], one of injury to back. [Case 116] somewhat resembled another case of Smyly ([Case 219]).
86. Differential Diagnosis between Organic and Hysteric Hemiplegia. Babinski, 1900.
| Organic Hemiplegia | Hysterical Hemiplegia |
|---|---|
| 1. Paralysis unilateral. | 1. Paralysis not always unilateral; especially facial paralysis, usually bilateral. |
| 2. Paralysis not symptomatic., e.g., in unilateral facial paresis, the paresis occurs also when bilateral synergic movements are being performed. | 2. Paralysis sometimes symptomatic; facial paralysis almost always symptomatic. With complete unilateral paralysis, the muscles of the paralyzed side may function normally during the performance of bilateral synergic movements. |
| 3. Paralysis affects voluntary, conscious, and unconscious or sub-conscious movements; hence, (a) platysma sign,[12] (b) sign of combined flexion of thigh and trunk, and (c) absence of active balancing arm movements in walking contrasted with exaggeration of passive balancing movements (limb inert on sudden turn of body). | 3. Voluntary, unconscious, or sub-conscious movements not disordered. Absence of platysma sign and combined flexion of thigh and trunk. The active balance movements of arm may be lacking but there is no exaggeration of passive balance movements. |
| 4. Tongue usually slightly deviated to the paralyzed side. | 4. Tongue sometimes slightly deviated to the paralyzed side; but sometimes contralateral deviation. |
| 5. Hypertonicity of muscles, especially at first. The buccal commissure may be lowered, the eyebrow lowered; there may be exaggerated flexion of the forearm, and the sign of pronation may occur (hand left to itself lies in pronation). | 5. No hypertonicity of muscles. If facial asymmetry exists, it is due to spasm. No exaggerated flexion of forearm, and no pronation sign. |
| 6. Tendon and bone reflexes often disturbed at the beginning, either absent, weakened, or exaggerated (almost always exaggerated.) In many cases, there is epileptoid trepidation of the foot. | 6. No alteration of tendon or bone reflexes. No trepidation of the foot. |
| 7. Skin reflexes usually disordered. Abdominal and cremasteric reflexes, especially at first, weakened or abolished. On stimulation of sole, toes, and especially the great toe, are extended on the metatarsals. Babinski toe reflex. Extension of great toe often associated with abduction of other toes (fan sign). Sometimes exaggeration of reflexes of defence. | 7. No disturbance of skin reflexes. Abdominal and cremasteric reflexes normal. Babinski toe reflex and fan sign absent. Defense reflexes not exaggerated. |
| 8. Contracture characteristic and non-reproducible by voluntary contractions. The hand-grip yields a sensation of elastic resistance, automatically accentuated on passive extension of the hand. | 8. The contracture can be reproduced by voluntary contractions. |
| 9. Evolution of diseased regular contracture follows flaccidity. When regression of disorder occurs, it is progressive. Paralysis not subject to ups and downs (motor defect fixed). | 9. Evolution of disease capricious. Paralysis may remain indefinitely flaccid or may be spastic from the beginning.
Spastic phenomena may sometimes be associated (particularly in the face) with characteristic phenomena. The disorder may get better and worse alternately several times, alter rapidly in intensity, and present transitory remissions which may last even but a few moments (motor defect variable). |
[12] More energetic contraction of platysma on healthy side when mouth is opened or when head is flexed against resistance.
87. Differential between Reflex (Physiopathic) Contracture and Paralysis, and Hysterical Contracture and Paralysis. Babinski, 1917.
88. The [section on Shell-shock diagnosis] contains 102 cases ([Cases 371-472]). These cases differ in no respect from those of [Section B] except that many of them are more puzzling and dubious and have been presented by their reporters more from the standpoint of diagnosis than from that of etiology or therapeutics. In general arrangement, the cases roughly correspond to those of [Section B]. First are four cases illustrating the value of lumbar puncture data ([Cases 371-374]). There follow cases with either a mixture of organic and functional symptoms, or such a constellation of symptoms as might readily lead to erroneous diagnosis ([Cases 375-381]). Retention and incontinence of urine after shell-shock are illustrated in [Cases 382-384]. Crural monoplegia, monocontractures, and other affections of one leg are shown in [Cases 385-392]; but these monocrural cases are in many respects peculiar or even unique as compared with the monocrural cases of [Section B]. Peculiar paraplegias or spasms affecting both legs are found in the series [393-395]. Then follow ([Cases 396-400]) other cases of doubtful spinal cord lesion or shock, including several with dysbasia. Camptocormia, astasia-abasia and abdominothoracic contracture are found respectively in [401], [402], and [403]. Affections of one arm follow ([Cases 404-409]). An assortment of peculiar cases in which the differentiation between hysteria and structural disease is in question, is found in [Cases 410-415]. Peripheral nerve injuries of a sort which might be confused with Shell-shock phenomena, including one of light tetanus, are considered in [Cases 416-419]. A variety of cases bearing upon the question of the reflex or physiopathic disorders of Babinski is found in the series of [Cases 420-432]. Peculiar eye phenomena are presented by [Cases 433-438]; and cases of otological interest are [439] and [440]. Epileptoid, obsessive, fugue, and amnestic phenomena follow in [Cases 441-450]; [451] and [452] are cases of soldier’s heart. The simulation question is presented in a series of 20 cases ([Cases 453-472]).