Harveian Lectures ON SOME FORMS OF PARALYSIS DEPENDENT UPON PERIPHERAL NEURITIS

1885 The Lancet  
PHYSICIAN TO THE NATIONAL HOSPITAL FOR THE PARALYSED AND EPILEPTIC. LECTURE Ill. MR. PRESIDENT AND GENTLEMEN,—It is necessary to bear in mind that peripheral neuritis occasionally occurs in the sequel of some febrile affections. Besides diphtheria, of which 1 shall have to say more presently, other specific febrile disorders are apt to be followed by paralysis, which is sometimes more or less general and at other times strictly localised. Dr. Ross has collected a number of published examples
more » ... blished examples in-which there has been localised paralysis of peripheral origin in the sequel chiefly of enteric and relapsing fevers. I was consulted a few months ago by a gentleman who was suffering from paralysis of the serratus magnus of the right side, which had occurred whilst he was convalescing from an attack of enteric fever, acquired during a tour in Italy. The possibility of paralysis from peripheral neuritis occurring in the sequel of specific febrile affections may give rise to a curious difficulty of diagnosis. A few years ago a gentleman brought me a letter from his medical attendant abroad, which stated that the patient, after a severe attack of pernicious malarious fever, had become paralysed in both legs, sensibility being normal, but the electric excitability much diminished. The memory likewise was weak. Under treatment he had recovered, except as regards the movement of the foot. It was added that the patient was very fond of liquor, and had required great restriction in this respect. When I saw him he had quite recovered. It is evidently difficult to say what share alcohol may have had in the production of the symptoms. In another instance a female patient, who had suffered several times from tropical dysentery, was sent to me from abroad on account of a quasi-paralytic condition of the upper and lower limbs, described in a letter from her medical attendant as resembling locomotor ataxy. In addition, there had been marked loss of memory, and her conversation had at times been incoherent. Irritability of the stomach, flying pains, and numbness of the limbs had characterised her attack. Though she could move her limbs in bed, "and though sensation was but little at fault, she could neither stand on her legs nor walk a step. She complained bitterly of pain and tingling, and numbness in both arms and hands, and the co-ordinate power of the small muscles of the thumb and fingers was greatly impaired." It was a couple of months or so later that I saw her, and although she had recovered to a great extent the knee-reflex was still absent, and there was greatly reduced electrical excitability in the anterior muscles. I could learn nothing of the patient's habits, but her complexion was sallow and the conjunctivas yellow, and her attack had commenced with so-called biliousness." She came from a country where malarious fever is rife, but I could get no evidence of any characteristic intermittent disorder. The symptoms, it is evident, were those of multiple neuritis, but whether this depended on alcohol or malarious fever I am unable to say. One occasionally meets with alcoholic cases in which there is paralysis to a considerable extent which has escaped the notice of the patient's friends. The patient (usually a female) lies in bed in such a muddled condition of mind that she does nothing for herself, and takes sustenance at the hands of others. When moved from side to side in bed, or when her limbs are touched, she cries out with pain. It is not at all uncommon to find this condition referred to rheumatism or gout. In some cases, as an explanation of the mental condition, one is told that the rheumatism or the gout has flown to the brain." Although evidently there is a great probability of persons who indulge to excess in alcohol being affected with gout, yet I am disposed to think that much more often this condition is due to peripheral neuritis from alcohol. The persons who suffer in this way do not drink wine or beer-the liquors which tend so much to induce gout,-but brandy or gin. In such cases as I have described there will often be an amount of muscular wasting of the extremities, not to be explained by mere emaciation. If examination be made, it will very likely be found that the knee-jerks are absent, and the faradaic excitability in the muscles greatly reduced or lost. In a case which I saw in consultation some time ago there was intense pain of a neuralgic character in both lower extremities, with dropping of the feet and absence of kneejerk. A curious question arose in reference to diagnosis. The patient had been operated upon for a carcinomatous tumour unconnected with the spine a year or more previously. The symptoms pointed to secondary growth in the lower part of the spinal column, causing neuritis in some portions of the cauda equina. But there was also a distinct history of long-continued and great alcoholic excess. Examination showed that whilst faradaic excitability of the muscles of the lower extremities was greatly reduced, that of the muscles of the arms was quite normal. This being the case, I came to the conclusion that the paraplegic symptoms were due to malignant disease. It was unlikely that such severe symptoms of neuritis would have been exclusively confined to the legs had alcohol been the cause. At least one would have expected to find some change in the electrical reactions of the upper extremities. The opinion given was in accordance with this observation, and was, I believe, justified by the sequel. Amongst the toxic influences apparently liable to give rise to multiple neuritis, besides alcohol, syphilis, and the essential cause of beriberi, whatever that may be, I have mentioned lead and diphtheria. There are circumstances connected with the question of the pathology of lead poisoning which appear to place it on a somewhat different footing from the other varieties described; and this, together with the narrow limits of my space, renders its discussion on the present occasion impracticable. I will therefore conclude this part of my subject by a few remarks upon diphtheritic paralysis. The symptoms of diphtheritic paralysis are so well known that I need not trouble you with any systematic account of them. My intention is to refer chiefly to those clinical features which show that the disease ought probably to find a place alongside of the other forms of paralysis essentially dependent upon peripheral neuritis which we have been considering. Last year I unfortunately had the opportunity of observing very constantly a case of diphtheria which was followed by paralysis. The patient was a boy nine years of age, who was severely attacked with diphtheria on December 16th. The temperature, which was nearly 105° F. during the first twenty-four hours then declined to a little over 100°, running up to 102° on the sixth day coincidently with the appearance of albuminuria. On the thirteenth day the throat had recovered, the albuminuria continuing till the twentieth day. On the thirteenth day the patient spontaneously complained of much tenderness on the inside and bac4 of each thigh, and on the fifteenth day pressure over the sciatic, posterior, tibial, and median nerves was decidedly painful. Throughout his limbs handling and gently squet-zing the muscles appeared to cause considerable discomfort. The knee-jerks at this time were quite normal. I About the twenty-third day he began to complain of ! difficnlty in reading, and in a few days he could not read at ! nil. Mr. Macnamara, who kindly examined him, found almost absolute inability to accommodate. On the ninetyninth day Mr. Carter found that the left eye had recovered its accommodation, that of the right still remaining ! paralysed. This also recovered later. . On the thirty-eighth day he complained of a peculiar feeling at the "top of the throat," and some water which he drank came for the first time through his nostrils. He spoke with a nasal twang. He fidgetted much and felt as if his legs would give way, and said he could not stand still. At this time he never passed a day without complaining of pain referred to the epigastric region. The pupils were dilated. They responded to light. There was no optic neuritis. : On the fortieth day, in going downstairs, he staggered a B B
doi:10.1016/s0140-6736(02)28966-7 fatcat:5iw66qxtcnfllbgeaathkxkbu4