- Email: [email protected]
A CASE OF HYSTERICAL PARAPLEGIA.
178 bowel and larger ones in the kidney pouches, iliac fossse, and pelvis. The coats of the small intestine feel thick and somewhat stiff. There is no intestinal ulceration. The liver is slightly enlarged ; the spleen is considerably increased in size and very congested, bearing a close resemblance to a "sago spleen." The kidneys are small and very congested; the capsule is not adherent, but the cortex appears slightly diminished in extent. In the skull the dura is thickened to a moderate degree. The pia-arachnoid is very considerably thickened and markedly adherent to the cerebral cortex, especially over the convexity of the brain. The vessels are very congested. The cortex cerebri is very pale and gelatinous in appearance and very soft. There is slight dilatation of the lateral On exposing the deep cervical glands it is ventricles. noticed that there is considerable and uniform enlargement, those along the sheath of the great vessels of the neck being fused into a more or less homogeneous mass. The glands are pale in colour and firm in consistence, and are so matted together that it is a matter of some difficulty to identify and isolate individual members of the chain. To the knife they feel tough and fibrous and do not cut easily. There is no evidence of caseation. The mediastinal glands are also much increased in size and have the same dense matted appearance, the right pretracheo-bronchial and right interbronchial groups being most affected. They are also firm and tough. They bear no microscopical evidence of tuberculosis. The abdominal glands are affected in a similar manner but only to a comparatively slight degree, the glands being not so much enlarged and not matted together. A Mesenteric fat is fairly abundant. detailed search fails to reveal in any part of the body any lesion similar to those usually associated with tuberculosis.
Kelly 1
From a study of his paper, to which an extensive bibliography is appended, it appears that some 39 cases had been recorded up to 1903. It. seems to have received considerable attention from Italian observers. It has usually been considered to. be the result of tuberculous infection, typhoid fever,. malaria, syphilis, or rheumatism. Among the cases. recorded by Kelly eight had obvious tuberculous foci in some part of the body-frequently a caseou& bronchial gland. Pathologists now consider most cases to be tuberculous, but the connexion between tuberculosis and such cases as do not show obvious tuberculous lesions does not appear to be always very well established in the absence of inoculation experiments. An interesting clinical feature of the case is that the history of the sequence of measles, pneumonia, and tuberculosis is found in this. atypical case, just as it is so often noticed in cases. with typical post-mortem tuberculous lesions. I am indebted to Dr. G. Brice for the clinical notes of the case, and to Professor Delepine for kindly performing the inoculation experiments. I also wish to thank Dr. C. C. Heywood, physician to the hospital, for permission to publish the case. Blackburn.
A CASE OF HYSTERICAL PARAPLEGIA. BY ADOLPHE
ABRAHAMS, M.D., B.C.CANTAB., M.R.C.P. LOND.,
REGISTRAR TO THE LONDON TEMPERANCE HOSPITAL; CHIEF As much of the three great gland groups as possible MEDICAL ASSISTANT, MEDICAL OUT-PATIENTS, ST. BARTHOLOMEW’S were removed from the neck, the mediastinum, HOSPITAL; TEMPORARY LIEUTENANT, R.A.M.C. and the mesentery, and subsequently examined A PRIVATE of the First East Lancs. was admitted histologically and bacteriologically in the laboratory. The three groups of glands were examined to the Connaught Hospital, Aldershot, in September, separately. A large number of sections were cut 1914, suffering from paraplegia. His history was and stained in the usual way. In all cases there that on Sept. 8th, whilst he was carrying food from were found considerable thickening of the gland a wagon to the firing line, a shell burst close to capsules and very marked infiltration of the him and a companion who was close beside him. gland substance with fibrous tissue, but there He remembered the shell bursting and striking the could be found no tendency to the formation of wagon, but a period of unconsciousness of four or tubercles, and epithelioid cells could not be identi- five days’ duration then elapsed, on recovery from fied. The changes were less marked in the mesen- which he was suffering from a shell wound in the In no case were tubercle bacilli left buttock and complete paralysis of both legs, teric glands. found in the sections. Numerous coverglass pre- with pain in the back in the region of the fourth parations were made from the cut surfaces of the lumbar vertebra, due in his opinion to the fall of a. different gland masses and stained for tubercle spare wheel of the wagon upon him. According to bacilli, but none were found. Others were made his account he suffered also from paralysis of the. from the mixed juice and pulp obtained by crushing sphincters for 11 days after the accident. Whether numbers of the glands in a crushing machine this was so or not, control had certainly been specially devised for such purposes by Professor resumed on his arrival in England on Sept. 25th. A Sheridan Delepine. Tubercle bacilli were not found. note of his condition soon after admission states: There is complete paraplegia below both hips. As regards Emulsions were prepared of the crushed glands of each group and 0’75 c.c. injected into a sub- sensation in the legs, there is complete loss to all forms of cutaneous pocket in the inner side of the thigh of a sensibility including deep touch in the right leg below ligament and behind as high as the iliac crest. In guinea-pig according to the method adopted by Pro-: Poupart’s the left leg there is complete anaesthesia to all forms of fessor Delepine. Well-marked tuberculosis resultedl. sensibility of the foot, including the heel and sole. There in each of the three guinea-pigs inoculated. is loss of sensibility to light touch all over the limb, but Tubes of glycerine egg medium and glycerine’. pain (pin prick) is appreciated apparently normally as far potato were inoculated with material from thej down as the ankle, where there is an abrupt change to total caseous glands in the guinea-pigs, and well-formedL anaesthesia. There is some weakness of the right arm and growths of tubercle bacilli of the human type were; of the muscles supplied by the ulnar nerve, and there is. to touch and pain over the area of distribution subsequently obtained. Virulence tests were notb anaesthesia the ulnar nerve in this hand. of Sphincters normal. made. It is thus seen that evidence of tuberculous3 E. C. Stabb, surgical specialist infection could only be obtained by inoculation, foi Temporary Captain macroscopic lesions of the type usually associated1 to the Connaught Hospital, very kindly asked me to with the tubercle bacillus could not be found, and1 see the patient on April 20th last. The patient was a microscopic evidence of its presence as demon. man aged 25, of rather slow cerebration and slightly trable by the usual methods was also negative. micrencephalic, but of robust appearance. His This case appears to be an example of th(e previous history and family history, with the excep condition known as polyorrhomenitis, multipl< e tion of one point which appears below, were quite On examination the lower extremities It indifferent. serositis, polyserositis, Concato’s disease, &c. to be in a condition of total flaccid has given rise to a good deal of controversy an(d appeared 0. A. J and described 1 American Jour. of Med. Sciences, No. 125, New Series, 1903, p. 116. has been very ably by fully .
-
179 The
knee-jerk was definitely present on on the right side was on the whole slightly exaggerated. No plantar response was
paralysis.
Clinical Notes :
both sides ; that
obtainable on either side. Cutaneous sensation was MEDICAL, SURGICAL, OBSTETRICAL, AND entirely absent in the right lower limb, doubtfully THERAPEUTICAL. present in the left lower limb and in both arms. There was a suggestion on the whole of glove and TWO CASES OF stocking anaesthesia. There was no evidence of trophic change in anypart of the body ; the electrical TRAUMATIC DOUBLE HEMIANOPSIA, WITH PARTIAL RECOVERY. reaction of the muscles was not investigated. There was no evidence of any differences in the power or BY C. E. H. MILNER, M.R.C.S., L.R.C.P. LOND., muscular condition in the upper extremities. Perfect LIEUTENANT, R.A.M.C. (T.). control of the sphincters was present. The scar of THE two following cases, which have been a healed bullet wound was;visible in the left buttock under my care at the 4th London General over the main trunk of the sciatic nerve. Such a condition of affairs pointed almost beyond Hospital, resemble one another so closely that the slightest doubt to a functional paraplegia. A they seem to me to be worthy of simultaneous The essential features presented by the more minute cross-examination was not without record. interest in defining some cause for the condition of two cases are as follows. The occurrence in the nature of a psychic trauma. The companion both of bullet wounds in the occipital region by his side suffered a severe injury at the same immediately followed by complete blindness; and time, his legs being blown off. At one interview of subsequent recovery of vision except in one -the patient stated that he had actually seen the direction, which has been identical in both-the legs blown off; this he contradicted on another left lower quadrant of the visual field. And occasion, saying that whilst in hospital in France perhaps the chief interest is a psycho-anatomical he had heard that this particular injury had one, namely, a consideration of the question why occurred. There was at least a strong suspicion of there existed a condition of total blindness, and psychic trauma. The patient has a paralysed sister, why there has been recovery. - and there was an anxiety-neurosis that the burden of was wounded on Feb. 20th, CASE I.-Private .n additional cripple should not be laid to his charge. being struck in the occipital region by a bullet at a range On April 30th the patient was anaesthetised with of about 700 yards. Immediately he lost his sight com.nitrous oxide. During the slight temporary rigidity pletely, but was not unconscious. Twenty-four hours later which occurred the lower limbs were seen to parti- he was trephined; and on recovering from the anassthetic his sight began at once to improve, so that he could just cipate in the change. Before consciousness returned see objects moving in the room. the legs were flexed and placed in a position in On admission to the 4th London General Hospital the which the change could readily be seen by the patient presented a horizontal scalp wound 1 inch long, patient, who, upon the return of complete con- crossing the middle line 1 inch above the external occipital sciousness, was persuaded that the legs had moved protuberance. There was a large, healed, irregular operaduring the anaesthesia and commanded to replace tion wound at the back of the head and extending along them in a more convenient position. Slight volun- the right side, the original flap of which included the A large gap in the skull could be felt, tary movement of the thighs immediately took bullet weund. to the right of the middle line, with its long axig mainly place, and suggestion was continued throughout running horizontally. He was intelligent, and speech and the day, movements being encouraged against articulation were normal-as was the whole of his central resistance which the patient did not realise. On nervous system, including optic discs, pupils, and cranial the following day he was gradually raised to the nerves. But vision was markedly impaired, and he could vertical position and supported upright. At this only count fingers at a few feet. Examination of the - stage his mental condition was one of resistance visual field revealed a condition of quadrantic hemianopsia. The patient improved rapidly, and a month after admis.and resentment and reluctance to admit that any sion (two months after the date of his original wound) his movement was the possible. During day voluntary the upright position was resumed at intervals and field of vision was quite normal except in the direction of the left lower quadrant. As he put it himself, he was the patient made to walk between two attendants. "afraid of into on the left, especially On the following day he walked alone. By this chairs and walkingand he things had some difficulty in finding dogs," time his attitude of resistance had broken down, the beginning of a line while reading the newspaper. his movements were now made without any CASE 2.-Between 12th and 16th Private demonstration of the great exhaustion which received a bullet woundMay of the mid-occipital region. He characterised his first efforts, and he began to was unconscious for, he believes, 24 hours. On recovering consciousness he found himself totally blind, and was - express interest and pleasure in his recovery. Henceforth improvement was steadily progres- forced to lie where he was until found by stretcher-bearers. sive. His coordination and strength increased so He was trephined the same night, and immediately he -that he was soon able to walk 100 yards with a began to be conscious of the difference between day and and later of people moving about him. When he =stick, and then unsupported. A pronounced night, reached us on June lst, about a fortnight after being hysterical element persisted, encouraged by the he had a circular, rather septic wound about almost perpetual attention he received from visitors wounded, 1 inch above the external occipital protuberance, nearly .and other patients. When he left for an auxiliary in the middle line but inclined slightly to the right. hospital on May 25th there was sharply defined Beneath this the edges of the trephined wound could be 4iemianaBsthesia on the right side throughout the felt. Like the patient in Case 1, he also was normal in every body to light tactile sensation (cotton-wool) and to way except for a similar restriction of the visual field. Incidentally, about a week after admission, he became .slight painful sensation. On the left side sensation was perfect, with the exception of a doubtful drowsy and irritable, and his temperature (which, owing to local sepsis around the wound, was always somewhat patch of aneasthesia on the dorsum of the foot, the raised) reached a level of 101° and 102° F. on successive sole, and the plantar surface of the heel. In the absence of localising neurological evenings. I am greatly indebted to Lieutenant-Colonel W. symptoms a diffuse meningitis was suspected, lumbar ’Turner, commanding officer to the Connaughtj puncture was performed, and the fluid examined. But the evidence of a sterile culture and a normal cell-count Hospital, for permission to publish these notes. -
-
,
, ’
,
Kelly 1
From a study of his paper, to which an extensive bibliography is appended, it appears that some 39 cases had been recorded up to 1903. It. seems to have received considerable attention from Italian observers. It has usually been considered to. be the result of tuberculous infection, typhoid fever,. malaria, syphilis, or rheumatism. Among the cases. recorded by Kelly eight had obvious tuberculous foci in some part of the body-frequently a caseou& bronchial gland. Pathologists now consider most cases to be tuberculous, but the connexion between tuberculosis and such cases as do not show obvious tuberculous lesions does not appear to be always very well established in the absence of inoculation experiments. An interesting clinical feature of the case is that the history of the sequence of measles, pneumonia, and tuberculosis is found in this. atypical case, just as it is so often noticed in cases. with typical post-mortem tuberculous lesions. I am indebted to Dr. G. Brice for the clinical notes of the case, and to Professor Delepine for kindly performing the inoculation experiments. I also wish to thank Dr. C. C. Heywood, physician to the hospital, for permission to publish the case. Blackburn.
A CASE OF HYSTERICAL PARAPLEGIA. BY ADOLPHE
ABRAHAMS, M.D., B.C.CANTAB., M.R.C.P. LOND.,
REGISTRAR TO THE LONDON TEMPERANCE HOSPITAL; CHIEF As much of the three great gland groups as possible MEDICAL ASSISTANT, MEDICAL OUT-PATIENTS, ST. BARTHOLOMEW’S were removed from the neck, the mediastinum, HOSPITAL; TEMPORARY LIEUTENANT, R.A.M.C. and the mesentery, and subsequently examined A PRIVATE of the First East Lancs. was admitted histologically and bacteriologically in the laboratory. The three groups of glands were examined to the Connaught Hospital, Aldershot, in September, separately. A large number of sections were cut 1914, suffering from paraplegia. His history was and stained in the usual way. In all cases there that on Sept. 8th, whilst he was carrying food from were found considerable thickening of the gland a wagon to the firing line, a shell burst close to capsules and very marked infiltration of the him and a companion who was close beside him. gland substance with fibrous tissue, but there He remembered the shell bursting and striking the could be found no tendency to the formation of wagon, but a period of unconsciousness of four or tubercles, and epithelioid cells could not be identi- five days’ duration then elapsed, on recovery from fied. The changes were less marked in the mesen- which he was suffering from a shell wound in the In no case were tubercle bacilli left buttock and complete paralysis of both legs, teric glands. found in the sections. Numerous coverglass pre- with pain in the back in the region of the fourth parations were made from the cut surfaces of the lumbar vertebra, due in his opinion to the fall of a. different gland masses and stained for tubercle spare wheel of the wagon upon him. According to bacilli, but none were found. Others were made his account he suffered also from paralysis of the. from the mixed juice and pulp obtained by crushing sphincters for 11 days after the accident. Whether numbers of the glands in a crushing machine this was so or not, control had certainly been specially devised for such purposes by Professor resumed on his arrival in England on Sept. 25th. A Sheridan Delepine. Tubercle bacilli were not found. note of his condition soon after admission states: There is complete paraplegia below both hips. As regards Emulsions were prepared of the crushed glands of each group and 0’75 c.c. injected into a sub- sensation in the legs, there is complete loss to all forms of cutaneous pocket in the inner side of the thigh of a sensibility including deep touch in the right leg below ligament and behind as high as the iliac crest. In guinea-pig according to the method adopted by Pro-: Poupart’s the left leg there is complete anaesthesia to all forms of fessor Delepine. Well-marked tuberculosis resultedl. sensibility of the foot, including the heel and sole. There in each of the three guinea-pigs inoculated. is loss of sensibility to light touch all over the limb, but Tubes of glycerine egg medium and glycerine’. pain (pin prick) is appreciated apparently normally as far potato were inoculated with material from thej down as the ankle, where there is an abrupt change to total caseous glands in the guinea-pigs, and well-formedL anaesthesia. There is some weakness of the right arm and growths of tubercle bacilli of the human type were; of the muscles supplied by the ulnar nerve, and there is. to touch and pain over the area of distribution subsequently obtained. Virulence tests were notb anaesthesia the ulnar nerve in this hand. of Sphincters normal. made. It is thus seen that evidence of tuberculous3 E. C. Stabb, surgical specialist infection could only be obtained by inoculation, foi Temporary Captain macroscopic lesions of the type usually associated1 to the Connaught Hospital, very kindly asked me to with the tubercle bacillus could not be found, and1 see the patient on April 20th last. The patient was a microscopic evidence of its presence as demon. man aged 25, of rather slow cerebration and slightly trable by the usual methods was also negative. micrencephalic, but of robust appearance. His This case appears to be an example of th(e previous history and family history, with the excep condition known as polyorrhomenitis, multipl< e tion of one point which appears below, were quite On examination the lower extremities It indifferent. serositis, polyserositis, Concato’s disease, &c. to be in a condition of total flaccid has given rise to a good deal of controversy an(d appeared 0. A. J and described 1 American Jour. of Med. Sciences, No. 125, New Series, 1903, p. 116. has been very ably by fully .
-
179 The
knee-jerk was definitely present on on the right side was on the whole slightly exaggerated. No plantar response was
paralysis.
Clinical Notes :
both sides ; that
obtainable on either side. Cutaneous sensation was MEDICAL, SURGICAL, OBSTETRICAL, AND entirely absent in the right lower limb, doubtfully THERAPEUTICAL. present in the left lower limb and in both arms. There was a suggestion on the whole of glove and TWO CASES OF stocking anaesthesia. There was no evidence of trophic change in anypart of the body ; the electrical TRAUMATIC DOUBLE HEMIANOPSIA, WITH PARTIAL RECOVERY. reaction of the muscles was not investigated. There was no evidence of any differences in the power or BY C. E. H. MILNER, M.R.C.S., L.R.C.P. LOND., muscular condition in the upper extremities. Perfect LIEUTENANT, R.A.M.C. (T.). control of the sphincters was present. The scar of THE two following cases, which have been a healed bullet wound was;visible in the left buttock under my care at the 4th London General over the main trunk of the sciatic nerve. Such a condition of affairs pointed almost beyond Hospital, resemble one another so closely that the slightest doubt to a functional paraplegia. A they seem to me to be worthy of simultaneous The essential features presented by the more minute cross-examination was not without record. interest in defining some cause for the condition of two cases are as follows. The occurrence in the nature of a psychic trauma. The companion both of bullet wounds in the occipital region by his side suffered a severe injury at the same immediately followed by complete blindness; and time, his legs being blown off. At one interview of subsequent recovery of vision except in one -the patient stated that he had actually seen the direction, which has been identical in both-the legs blown off; this he contradicted on another left lower quadrant of the visual field. And occasion, saying that whilst in hospital in France perhaps the chief interest is a psycho-anatomical he had heard that this particular injury had one, namely, a consideration of the question why occurred. There was at least a strong suspicion of there existed a condition of total blindness, and psychic trauma. The patient has a paralysed sister, why there has been recovery. - and there was an anxiety-neurosis that the burden of was wounded on Feb. 20th, CASE I.-Private .n additional cripple should not be laid to his charge. being struck in the occipital region by a bullet at a range On April 30th the patient was anaesthetised with of about 700 yards. Immediately he lost his sight com.nitrous oxide. During the slight temporary rigidity pletely, but was not unconscious. Twenty-four hours later which occurred the lower limbs were seen to parti- he was trephined; and on recovering from the anassthetic his sight began at once to improve, so that he could just cipate in the change. Before consciousness returned see objects moving in the room. the legs were flexed and placed in a position in On admission to the 4th London General Hospital the which the change could readily be seen by the patient presented a horizontal scalp wound 1 inch long, patient, who, upon the return of complete con- crossing the middle line 1 inch above the external occipital sciousness, was persuaded that the legs had moved protuberance. There was a large, healed, irregular operaduring the anaesthesia and commanded to replace tion wound at the back of the head and extending along them in a more convenient position. Slight volun- the right side, the original flap of which included the A large gap in the skull could be felt, tary movement of the thighs immediately took bullet weund. to the right of the middle line, with its long axig mainly place, and suggestion was continued throughout running horizontally. He was intelligent, and speech and the day, movements being encouraged against articulation were normal-as was the whole of his central resistance which the patient did not realise. On nervous system, including optic discs, pupils, and cranial the following day he was gradually raised to the nerves. But vision was markedly impaired, and he could vertical position and supported upright. At this only count fingers at a few feet. Examination of the - stage his mental condition was one of resistance visual field revealed a condition of quadrantic hemianopsia. The patient improved rapidly, and a month after admis.and resentment and reluctance to admit that any sion (two months after the date of his original wound) his movement was the possible. During day voluntary the upright position was resumed at intervals and field of vision was quite normal except in the direction of the left lower quadrant. As he put it himself, he was the patient made to walk between two attendants. "afraid of into on the left, especially On the following day he walked alone. By this chairs and walkingand he things had some difficulty in finding dogs," time his attitude of resistance had broken down, the beginning of a line while reading the newspaper. his movements were now made without any CASE 2.-Between 12th and 16th Private demonstration of the great exhaustion which received a bullet woundMay of the mid-occipital region. He characterised his first efforts, and he began to was unconscious for, he believes, 24 hours. On recovering consciousness he found himself totally blind, and was - express interest and pleasure in his recovery. Henceforth improvement was steadily progres- forced to lie where he was until found by stretcher-bearers. sive. His coordination and strength increased so He was trephined the same night, and immediately he -that he was soon able to walk 100 yards with a began to be conscious of the difference between day and and later of people moving about him. When he =stick, and then unsupported. A pronounced night, reached us on June lst, about a fortnight after being hysterical element persisted, encouraged by the he had a circular, rather septic wound about almost perpetual attention he received from visitors wounded, 1 inch above the external occipital protuberance, nearly .and other patients. When he left for an auxiliary in the middle line but inclined slightly to the right. hospital on May 25th there was sharply defined Beneath this the edges of the trephined wound could be 4iemianaBsthesia on the right side throughout the felt. Like the patient in Case 1, he also was normal in every body to light tactile sensation (cotton-wool) and to way except for a similar restriction of the visual field. Incidentally, about a week after admission, he became .slight painful sensation. On the left side sensation was perfect, with the exception of a doubtful drowsy and irritable, and his temperature (which, owing to local sepsis around the wound, was always somewhat patch of aneasthesia on the dorsum of the foot, the raised) reached a level of 101° and 102° F. on successive sole, and the plantar surface of the heel. In the absence of localising neurological evenings. I am greatly indebted to Lieutenant-Colonel W. symptoms a diffuse meningitis was suspected, lumbar ’Turner, commanding officer to the Connaughtj puncture was performed, and the fluid examined. But the evidence of a sterile culture and a normal cell-count Hospital, for permission to publish these notes. -
-
,
, ’
,