Читать книгу Shell-Shock and Other Neuropsychiatric Problems - Elmer Ernest Southard - Страница 115

Brain abscess in a syphilitic: Matutinal loss of knee-jerks.

Case 110. (Dumolard, Rebierre, Quellien, 1916.)

An unmarried subaltern officer, 30, entered an army neuropsychiatric center, April 8, 1915, looking exhausted and bearing a ticket “nervous asthenia, evacuated for neurological examination.” He said he had had scarlet fever at ten; strongly denied syphilis, of which he presented no trace; had not been excessively alcoholic and had had no nervous seizures. Detailed information showed that he had been a normal child. He left his two years’ military service with promotion and was a man of above the ordinary intelligence.

He was wounded in the right buttock with a shrapnel bullet about the end of September, 1914. He went back to his regiment two months later and had shared in a number of actions up to the time of his evacuation. He said he had been very tired for several weeks, and had finally been sent to the physician. There were pains in the kidney region and in the head, especially on the right side. The head felt empty. He could not sleep, but did not dream. Ideas were not distinct. Memory had become impaired. He could not keep his accounts right, and was afraid something might go wrong.

There was no pain or nervous or reflex disorder of any sort except for the knee-jerks and Achilles jerks (see below). A special examination proved complete normality of eyes. There was a slight hesitation in words, but no dysarthria. There was a slight tremor of the tongue and fingers.

As to the tendon reflexes, April 9, on waking, the knee-jerks were absent, but later in the day gradually came in evidence again. The Achilles jerks were also absent at first, but could be obtained after a prolonged examination and after percussion of the calf. In the afternoon, after exercise, the knee-jerks and Achilles jerks were easily demonstrable. The left Achilles jerk was always a little weaker than the right. Massage brought these jerks out to virtual normality. April 10 and thereafter, similar findings; percussion of the muscular masses of the thighs and calves always brought out the reflexes.

Lumbar puncture yielded a clear fluid with hyperalbuminosis, 20 cells per c.mm. (lymphocytes and mononuclear cells 95 per cent) and a positive W. R. Iodide of mercury treatment was given April 18.

April 23, the patient went into a coma, with trismus, stiff neck, Kernig’s sign, sluggish pupils, incontinence. He was transferred to a special hospital, showed on lumbar puncture, April 23, 85 per cent polynuclear leucocytes, and died April 27. The autopsy showed a yellowish, quasidiffluent softening of the size of a small egg in the first occipital gyrus on the right side. The authors comment on the fact that the only objective sign in this case was the variable tendon reflexes of the lower extremities, “l’unique cri de souffrance des centres nerveux.”