Shell-explosion in confined space; paraplegia after fifteen minutes; slight hemorrhage and LYMPHOCYTOSIS of spinal fluid; Hematomyelia.
Case 203. (Froment, July, 1915.)
A Sergeant lying down in a small dugout space, 2 × 1 m. high, had a 77 shell burst behind his head and between his head and the back of the dugout. The patient was not moved by the explosion, but was buried in a small amount of earth and stones to a depth of about 20 cm. He was not wounded and showed no ecchymoses either then or later. Aided by stretcher bearers, he was able to walk to the relief post about 400 meters from the trench. He did not lose consciousness, and got to the relief post about a quarter of an hour after the shell burst. Thereafter, however, he was unable to move his legs. The accident happened February 6 at 4 o’clock. He was examined 24 hours after the trauma. The accompanying diagrams show the variations in sensory disorder at intervals during six months.
A lumbar puncture, February 8, 1915, showed hypertensive clear fluid without macroscopic clot on centrifuging, but showing a number of red blood cells and lymphocytes—3 or 4 to the microscopic field. There was a slight hyperalbuminosis. The development of the muscular atrophy and hypo-excitability of the left lower extremity, the exaggeration of the left knee-jerk, together with the spinal fluid appearances, seemed to prove the organic nature of the paraplegia. There was an intense rhachialgia, with radiation along the sciatic nerve. This outlasted all other symptoms. Thermo-analgesia was the most prominent sensory disorder. There were no sphincter disorders.
During the first days, the anesthesia was of a pure segmentary type, with nothing about it to suggest that it was later to be supplanted by a radicular type of disorder. Hematomyelia was, years ago, thought—according to Froment—to tend to yield sensory disorders of a segmentary nature. At the outset this anesthesia was total, though there was a vague, poorly localized feeling on intense painful excitations,—as with energetic pricking or burning. Thus the protopathic sensibility of Head had remained, whereas the epicritic sensibility had disappeared.
Detailed examination of this case showed extreme errors in the position sense. For example, pricking the foot might be localized as pinching above the knee. The cremaster reflex was extremely marked and would appear upon even slight excitation of any part of the lower extremity, even at times when the patient declared he felt nothing. These phenomena at the beginning early gave place to a syringomyelic type of anesthesia.
At the time of report, July 29, 1915, Froment regarded this case as analogous to hematomyelias of divers, although there is not such a degree of decompression; the suddenness of the decompression is more marked in these Shell-shock cases than in divers.