Wound of calf; operations: hysterical contracture with “physiopathic” features. “Brutally conquered” by reëducation.
Case 567. (Ferrand, March, 1917.)
A French infantryman, class of 1912, was wounded, May 12, 1915, in the upper third of the right calf. His posterior tibial artery had to be ligated. In a few weeks the wound was healed, but he began to walk badly, presenting a contracture of the calf with retraction of the tendo Achillis.
Toward the last of 1915 a surgeon under the impression that the disease was organic cut the tendo Achillis but the soldier could not walk any better. As he could not take the position of equinism, he semiflexed his knee and walked upon a crutch.
Another surgeon was now found to perform a tenotomy on the flexors of the leg and put the patient in a plaster cast to correct the flexion and immobilize in extension. This second operation was in July, 1916. The patient now walked without a crutch.
He was then sent to a neurological center, Dec. 8, 1916, walking on two canes, right leg in forced extension on thigh, in permanent and absolute contracture. All movements except leg flexion could be executed, though slowly and weakly; but positive movements were impossible, except flexion of the knees. There was no sensory disorder. Reflexes were normal save that the leg reflexes were a little stronger on the affected side, and the patellar reflex on that side was nullified by the contracture. Electrical reactions proved normal. There were marked trophic disturbances of the right foot and of the lower third of the lower leg. There was a certain amount of edema, cyanosis, coldness and thickening of skin; marked muscular over-excitability of the distal extremity of the leg. In short, Ferrand was here dealing with a case of Babinski’s group of the so-called physiopathic cases. The man was somewhat feeble-minded, and anxious and a trembling suppliant for cure.
He was put, December 15, in a reëducation room and by means of fatigue, induced by violent physical exercises, was (Ferrand states) “brutally conquered.” The contracture after a half hour of physical movement of flexion and extension of the leg ceased. The patient was shown how he could himself both flex and extend the limb himself; he was then caused to do this spontaneously. These active movements were aided and at times provoked by somewhat painful galvanic discharges. The patient then walked slowly, and flexed both knees to the maximum. He was cured after a treatment of 2½ hours. There were, of course, some (surgical) intra-articular adhesions in the knee and it was necessary for the patient to break these adhesions. An X-ray had shown the bone to be intact. A slight hydrarthrosis developed the next day, but a few days later he was able to walk as well as anyone. For five weeks he followed a training platoon in the reëducation work and was evacuated, January 23, 1917, to his station, though he had entered the neurological center with the idea that he was to be invalided with a pension.
He had a few relics of physiomotor disorder when he left, including the abnormal delicacy of skin and muscular over-excitability above mentioned. On the basis of this and similar cases Ferrand believes that, although the physiopathic group of Babinski exists, it does not signify a separate clinical syndrome and the occurrence of physiopathic symptoms does not contraindicate psychotherapy.
Re this controversy, see remarks under Case 530.