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BATTLE CREEK, MICH., U. S. A., JULY, 1893.
REPORT OF THREE CASES OF MULTIPLE NEURITIS.
BY W. H. RILEY, M. D. Sanitarium, Battle Creek, Mich.
(Concluded.) CASE II. Mr. B., aged —, American by birth, a grocery and saloon keeper by occupation, came to the Sanitarium for treatment for "paralysis," and gave the following history: -
The patient had been addicted to the use of alcoholic liquors for some years; but during the last two or three years, had been drinking whisky rather excessively, being in the habit of drinking daily, but was seldom intoxicated. For some time previous to his present trouble, he had been working out of doors in the sun, and was exposed a great deal. About four months before coming under my observation, he noticed a numbness and sometimes a burning and prickling sensation in his hands and feet. These sensory symptoms continued for several weeks before the disease manifested itself by more decided symptoms. About twelve weeks ago, after overwork and exposure to heat and sun, he was taken sick with dizziness and vomiting, and could not see well. At times, things appeared black before his eyes. He also suffered from
mental weakness and confusion and loss of memory. The numbness, burning, and prickling sensations, which had appeared several weeks previously in his hands and feet, had continued to this time, and were now even more prominently present than before. The muscles soon became very sore. Muscular weakness increased. He was soon unable to stand on his feet or use his hands, and was obliged to take his bed. He remained in bed ten weeks previous to his arrival
at the Sanitarium, with no improvement. His condition on entrance is indicated in the following report of
1. Motor Symptoms.- The patient is totally helpless; cannot stand at all on his feet; is unable to move his hands; cannot feed himself; remains in bed all the time; unable to get out of bed even to evacuate the bowels and bladder. The paralysis of certain muscles in the arms and legs, the contraction of unopposed antagonistic muscles, the severe pains and soreness of muscles, have all contributed to cause the patient to occupy a certain position while lying, illustrated in the accompanying cut taken from a photograph. (See Fig. 6, frontispiece.) The patient maintains this position constantly. He cannot straighten his legs himself, nor can they be straightened by applied force; he holds his hands in the position shown in the photograph, on account of the paralysis and soreness of the muscles. He can do nothing for himself. The flexors of the legs are contractured, which keeps the limbs in the position shown in Fig. 6. The weakness of the muscles in the extremities is greatest below the elbows and below the knees. The kneejerk is absent in both legs; the abdominal and cremasteric reflexes are present. The faradic irritability of the muscles is very much decreased, no contractions at all being produced in some of the muscles with a very strong current. The galvanic irritability of the nerve is also decreased, and the galvanic irritability of the muscles in front of the leg and the smaller muscles of the hand and forearm is increased. It requires a weaker galvanic current to produce contractions in these muscles than in health. With the galvanic current, the anodal closure contraction approaches the cathodal closure contraction in these muscles. The reaction of degeneration is present.
upper and lower extremities. The area and extent of the anesthesia is indicated by the shading in Figs. 7 and 8. In that part of the figures where the shading is deepest, the anesthesia is complete. The lighter portion of the shading indicates a partial loss to the sensation of touch and temperature. (This case differs from the foregoing in that all the nerves of the skin in the periphery of the extremities are the seat of marked sensory disturbance, as is shown in Figs. 7 and 8. In Case I, the disease selected some nerves and left others.) The muscles are extremely tender and sore. The limbs cannot be manipulated without producing severe pain, and any movement of the limbs has to be done with the greatest care in order to avoid severe pain.
Trophic and Vasomotor Symptoms.The muscles of the upper and lower extremities are wasted and flabby, and have lost their natural tone. The wasting of the muscles is greatest in the hands and
feet. Hands and feet are clammy, and perspire freely. The fingers are pointed, and the finger nails glossy. Vasomotor symptoms are prominently present in this case. The hands and arms below the elbows, and the feet and legs below the knees, have a decided cyanotic appearance, and the extent to which the disease has affected the vasomotor nerves can be clearly seen on the limbs by the discoloration of the skin. There is also a slight eruption over the anesthetic area.
Mental Symptoms. The mental symptoms in this case are very prominent, and form an important part of the picture of the disease. The patient is very talkative; his mind is wandering and weak; he talks incoherently; is extremely forgetful, especially of things that have hap-. pened recently. He forgets that his physician has seen him five minutes after the physician has left the room. At times he is irritable and delirious; is constantly asking his nurse to remove something from his feet and hands when
Fig. 8. Areas of Anesthesia Behind in Case II. Degree of anesthesia indicated by the degree of shading.
there is nothing on them. He often thinks he has socks on his feet and
gloves on his hands. (These delusions of sensation and forgetfulness of mind are usually prominent mental symptoms in cases of multiple neuritis due to alcohol. The fact should also be emphasized that these mental symptoms have been present from the beginning of the disease, and were not due simply to acute intoxication.) The disease has in this case affected the pneumogastric nerve, which is the cause of an irritable heart and a rapid, weak pulse; the pulse is 100, and sometimes IIO. The temperature is slightly above normal, 99.5°. The patient was put on the following treat
Treatment. A very important part of the treatment of this case is a removal once and forever of the cause - alcohol. The patient was put in the care of a welltrained nurse, and brought under proper mental and moral influences. Hot blanket packs to the legs, hands, and arms, one hour, twice daily; galvanism applied to arms and legs twenty minutes twice daily; passive extension of limbs daily; and cotton packs on hands and arms, below the elbows, and legs and feet below the knees, to be worn all night, constituted his treatment. This treatment was continued for one month. By this time he was able to sit up alone, and an electric light bath was ordered once a week in addition to the above treatment. Instead of giving galvanism to his arms and legs daily, it was reduced to three times a week, and on alternate days the faradic current was applied. was applied. The severe pain and much of the soreness of the muscles had by this time disappeared. The patient was able to move his hands and fingers slightly, and straighten his legs in bed. His mind was stronger, and his mental wanderings and forgetfulness were less noticeable.
Two weeks later the treatment was changed as follows: Hot water bath to hands and arms, feet and legs, for one hour daily; a light massage to arms and legs, with passive extension of the limbs daily. The wet cotton packs were continued at night. The galvanic current was applied to the muscles of the legs and arms, that were wasted and that would not respond to the faradic current. Where contractions could be developed with the faradic current, in the muscles of the extremities, it was used. The galvanic and faradic currents were used
daily. At this time, also, light exercise in the gymnasium was ordered, and the patient took outdoor rides daily.
At the end of two months the patient was able to use his hands and fingers, and did some writing. By the aid of a walking machine, which partially supported the weight of the body at the shoulders, he was able to make a circuit of the gymnasium. His temperature was now normal; pulse, 80. Two weeks later he was able to bear the weight of his body on his legs without support, and take a few steps alone. There was still some soreness and tenderness of the muscles of the calves of the legs, the feet, and the hands, but the severe pains had disappeared. Another two weeks passed, and the patient was able to walk five rods alone. His legs were now entirely straight. tirely straight. The "blueness" of the legs and hands, which was due to vasomotor disturbance, was all gone.
Especial attention was now directed to proper and sufficient exercise to develop the weaker muscles. The improvement of all the symptoms continued. He remained under treatment about five months, at the end of which time he was able to walk two hours daily, but was obliged to rest at intervals. There was still a weakness of the smaller muscles of the hands and feet, which was greater than in the other muscles of the limbs. With the exception of slight soreness in the hands and feet, the sensory symptoms were absent. The mental symptoms of forgetfulness, delusions of sensation, weakness of mind, etc., which had been so prominent at first, and which had continued for some months, were now entirely absent. The patient was entirely relieved of the general prostration and exhaustion. He had gained several pounds in weight. His pulse was regular, and beat 72 times per minute, sitting.
The natural position of the body while standing is shown in Fig. 9, taken from a photograph. (See frontispiece.) This, when compared with condition of the patient at the beginning of treatment, shown in Fig. 6, presents a decided
Mr. C., a merchant, aged 35 years, on entrance for treatment, gave the following history:
The patient has always enjoyed good health up to the beginning of the present
trouble, which was three months ago. His disease developed suddenly with fever, temperature 103° F., vertigo, and digestive disturbances. He was obliged to use a catheter at the beginning of the trouble, for a day or two only. The fever, with accompanying symptoms, lasted a week or two, and then disappeared. In a few days from the onset of the disease, he noticed a numbness in his feet and hands, which traveled upward in both the upper and the lower extremities. Along with the numbness was also developed a weakness in the upper and lower extremities, and a general feeling of prostration. These motor and sensory symptoms increased, reaching their height at the end of two weeks, and continuing with little or no improvement until the patient came under my care.
Motor Symptoms. The patient goes about in a wheel-chair; cannot bear the weight of his body on his legs without support. In attempting to walk, his movements are ataxic and incoördinated. He cannot stand still with his eyes open, much less with them closed. Knee-jerk is absent in both legs. There is also considerable weakness in the upper extremities, especially in movements of the hands and fingers. Faradic and galvanic irritability of muscles but little if at all diminished.
Sensory Symptoms. Partial loss of sensation in the upper and lower extremities; various paræsthesia in the upper and lower extremities; muscular sense much diminished; has a feeling of general weakness and prostration; dull, aching pains in the muscles of the legs; muscles tender and somewhat sore; also sharp, shooting pains at times in the limbs.
Vasomotor and Trophic Symptoms. The patient complains of cold hands and feet; has a clammy, cold perspiration on his feet and hands; muscles soft, flabby, and wasted. He has lost several pounds in weight since the beginning of the trouble.
ment the patient began immediately to improve, and by the end of one month was able to walk ten rods with a cane. His gait in walking closely resembles that of locomotor ataxia. The treatment was continued two months longer. By this time the patient could walk a mile easily without a cane, or without becoming fatigued. He had gained in weight; the anesthesia and pain in the limbs were all gone. The muscular sense, however, had not returned to the normal condition, as there was still some ataxia in the movements of the lower limbs. The general feeling of weakness and prostration had entirely disappeared. Later the patient returned for treatment, and the ataxia in the legs gradually disappeared.
The three above cases are illustrations of multiple neuritis in its most severe form. Case II is a typical case of multiple neuritis caused by alcoholic poisoning, with motor, sensory, and mental symptoms all prominent. The motor symptoms, however, predominate over the sensory, and for this reason this case, as do most others due to alcoholism, belongs to the motor type of this disease. In Case III the difficulty in walking was not entirely due to weakness of the muscles, but largely to a lack of coordination of movement. This case illustrates another form of the disease, namely, the sensory type. It has received the name of pseudotabes, from the fact that it is often mistaken for tabes dorsalis.
2. Toxæmic, due to some virus in the blood, which may be an organism or the product of an organism. Under this head come the infections of diphtheria, typhoid fever, puerperal fever, and other septic fevers, phthisis, syphilis, and other sources of infection. Under this head may also be mentioned the morbid blood states in rheumatism and diabetes.
Perhaps it is hardly necessary to call attention to the fact that multiple neuritis is an organic disease, a disease in which there is destruction of nerve tissue, the nature of the morbid process being inflammatory and degenerative. Changes are always most marked in the peripheral distribution of the nerve branches which are the farthest removed from the nerve cells, the source of their nutrition, and hence have least resistance to poisons which are usually the cause of this disIt is for this reason that the symptoms of multiple neuritis are most marked in the arms below the elbows, and in the legs below the knees. When this disease is cured, it is only by the growth of new nerve fibers in the place of those degenerated; and any treatment favoring this process is in the right direction. Whether this takes place by the development of new axis cylinders and medulary sheathes from neuclei in the old sheath of Schwann, as held by Neumann, or by a growth of new axis cylinders outward from the undegenerated part of the old fibers, as taught by Ranvier, we are not at present able to state.
The general plan of treatment as usually followed by the writer may be briefly summarized as follows:
Remove the cause as far as possible. Cases that are due to alcoholism need restraint, and need to be brought under proper moral influences. The nutrition of the patient needs to be looked after carefully, and aided by a wholesome and nutritious dietary, plenty of outdoor air and sunshine, and a sufficient amount of sleep. In the early stage of the disease, complete rest should be strenuously enforced. To remove the poisons and the poisons and effete matter that are apt to be in the system, nothing is better than drinking freely of water, which may be taken hot or cold. This also favors nutrition, and helps to regenerate the nervous tissue which has been destroyed by disease. This should be continued throughout the
course of the treatment. In the early stage of the disease, also, the application of heat continuously from one to three hours daily by hot blanket packs, or hot water baths at a temperature from 105° °to 108 F., and not 'carried to the point of exhaustion, should be made to the upper and lower extremities. Moist cotton packs applied to the arms and legs should be worn all night.
Later, in addition to the above, I employ galvanism. Labile uninterrupted applications should be made daily, each application lasting twenty minutes. The positive pole should be applied to the seat of the disease in the limbs, and a large electrode attached to the negative pole should be placed at some indifferent point of the body, as at the lower spine or over the abdomen. When the pain and soreness have left the muscles, massage and the faradic current should be substituted for the hot applications which were used in the earlier stage of the disease. Later, systematic exercise should form an important part of each daily program. The manner of treating patients on "general principles," and prescribing faradic electricity and massage simply because the patient is "paralyzed," in the early stage of multiple neuritis, often does more harm than good.
FACTS AND DOUBTS ABOUT CHOLERA.
BY L. BREMER, M. D.,
THE great obstacle in the way of gaining definite and incontrovertible knowledge on this point is, that there is no animal which either spontaneously or artificially can be said to be attacked with true Asiatic cholera; and that therefore the most important link of the chain of evidence, as formulated by Koch, for the demonstration of specific bacteria, namely, the production at will of an infectious disease by a pure culture of the respective bacterium, is still missing in the study of cholera.
The experiments performed so far have, it must be admitted, yielded results, recalling in a measure choleraic infection in guinea-pigs and dogs, for