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VOL. II.

ORIGINAL ARTICLES.

REPORT OF THREE CASES OF MULTIPLE NEURITIS.

BY W. H. RILEY, M. D.

Sanitarium, Battle Creek, Mich.

IT has only been during the past few years that the symptoms of the abovenamed disease have been correctly recognized and diagnosticated, even by neurologists. The symptoms presented had been for many years classified under the heads of "Alcoholic Paralysis,' "General Spinal Paralysis," "Locomotor Ataxia," and others; and at the present time in general practice, multiple neuritis is frequently mistaken for some form of spinal trouble, or a very vague and indefinite idea is entertained as to the real nature of the disease, and the correct methods of its treatment. The following three cases are reported,

1. For the purpose of briefly directing attention to some of the prominent symptoms and the course of the above disease. 2. To illustrate successful methods of treatment.

CASE I.

Mr. A., aged 33 years, an American by birth, a laborer by occupation, came to the Sanitarium for treatment of "paralysis of the upper and lower extremities," and gave the following history:

With the exception of slight ailments, the patient had always enjoyed good health up to the beginning of the present trouble. The disease with which he is now suffering began about ten weeks ago, by persistent vomiting, attended with nausea, which continued at short intervals for twenty-four hours. At this time he had a very sore throat, and was obliged to take his bed for one week, with a temperature of 100° to 101° F. While in bed,

NO. 6.

his throat continued sore. At the end of one week he was able to be up, but in attempting to walk, noticed a "weakness in the knees." He would tire on the slightest exertion, and walking was an effort. He had a sensation as though the cords and muscles of the legs were getting too short. At times he suffered from a numbness, and burning and aching pains in the feet, which later traveled up the legs. Simultaneously with these symptoms in the feet and legs, were similar manifestations of the disease in the upper extremities. There was a numbness and soreness in the fingers and hands.. The fingers felt thick and clumsy, and a weakness, which showed itself most prominently in performing some delicate moveclothing, was present. ment, such as writing or buttoning the These symptoms continued and grew worse. The patient became weaker, and tired more easily on the slightest exertion. Walking was difficult, and his movements were all weak, incoördinated, and ataxic. At the end of a month the weakness was so great that he could walk no longer, and was obliged once more to take his bed. The pain continued, and increased in severity. The patient remained helpless in bed for several weeks, part of which time he could not move toes or feet. Finally he came to the Sanitarium for treatment, about ten weeks from the beginning of his trouble, and his condition on entrance is indicated in the report of

EXAMINATION.

The patient is a man of medium stature; height, five feet and seven inches; weight, 125 lbs.; thin in flesh; digestion somewhat impaired, bowels constipated; action of the heart somewhat weak; pulse 100, sitting; temperature normal. Other organs of the body are normal, except as indicated below.

Motor Symptoms. By the aid of support he can barely take a few steps at a

time. In attempting to walk, he broadens his base, staggers in his path, and keeps his eyes closely fixed on his movements. All his movements are weak and slow. He can only flex the ankles and extend the toes to the slightest degree in both feet. The paralysis of the muscles of the front of the leg, allow the foot to drop and the toes to scrape on the floor in an attempt to walk. He partially overcomes this difficulty by increased flexion of the thighs, which raises the foot and frees the toes from the floor.

Paralysis of the small muscles of the foot, especially the interossei, and the extreme weakness of the flexors of the ankles, together with the unopposed action of antagonistic muscles, has developed a deformed shape in the foot, which

Fig. 1. Shape of Foot in Case 1, of Multiple Neuritis. Paralysis of flexors of ankle and interossei muscles of foot, adductor and short flexors of great toe.

is illustrated in Fig. 1. In this figure it will be noticed that the foot is extended at the ankle, the arch of the foot is increased above, and the hollow of the sole of the foot is increased below. The four smaller toes are extended at the first joint, and flexed at the others. The adductor and short flexor of the great toe are also paralyzed, which allows it to take a somewhat different position than the other

they are done with the greatest difficulty. A careful test of the strength of the muscles in the upper and lower extremities with a mercurial dynamometer, shows their weakness even more conspicuously than in the ordinary movements. Such a test develops the fact that the weakness is greater in the muscles below the knee in the lower limbs, and below the elbow in the upper limbs. The symptoms are all most prominent in the extreme distal end of the upper and lower extremities. There is present in the limbs a twitching and jerking of muscular fibers, and sometimes of a bundle of muscular fibers. The knee jerk is absent in both legs. The plantar skin reflex is absent. Cremasteric and abdominal skin reflexes are present. The patient can stand but for a moment with his eyes open; he cannot stand or walk at all with his eyes closed. The electrical reaction of the muscles of the legs is decidedly diminished to both faradic and galvanic currents.

Sensory Symptoms. — The sensory symptoms are quite as prominent as the motor symptoms. The patient suffers from dull, aching pains in the legs and arms, sometimes has sharp, shooting pains in the legs, resembling somewhat the pain of locomotor ataxia. The muscles of the legs, thighs, and forearms are sore and tender to pressure, and there is tenderness along the course of the affected nerves. He also complains of numbness, "deadness," and burning in the hands and feet.

In standing, or attempting to walk, he cannot tell from any sensation in his feet whether he is on a bare floor or a carpet. Anæsthesia is more or less complete in certain parts of the upper and lower extremities.

The disease has in this case selected certain branches of the nerves distributed to the skin of the extremities, so that by careful examination, areas where there is more or less complete anesthesia can be readily outlined on the limbs. These areas are represented by the shaded parts of Figs. 2 and 3. In the upper extremities in front, branches of the musculocutaneous nerve, which supply the skin on the outer or radial side of the forearm; branches of the median nerve, which are distributed to the palm of the hand, the thumb, and the palmar surface of the first two and one half fingers; and branches of the ulnar nerve, supplying the little finger, and half of the ring

finger adjacent to the little finger, are the seat of the anesthesia. Behind, the anesthesia confines itself to the branches

external popliteal and the musculo-cutaneous; and behind, the external saphenus and the posterior tibial. The loss of sensation is greatest in the feet, and especially in the bottom of the feet. (See Figs. 2 and 3.)

The disturbance of sensations over the shaded areas in the figures may be briefly stated as follows:

1. Tactile Anæsthesia. The patient is unable to tell when objects touch the skin; cannot recognize objects, or tell one object from another when in contact with the skin; is unable to localize place touched on surface of limb by an object; cannot tell whether one, two, or more points touch the skin at any single contact; sensibility of skin to the faradic current much diminished.

2. Thermo-Anesthesia, or a loss, partial or complete, of the cold-sense and heat-sense. He cannot readily tell when an object is hot or cold when applied to the skin. This loss of sensation is more marked in the feet and hands.

Fig. 2. Shaded areas representing anesthesia in front of upper and lower extremities. Degree of anesthesia indicated by shading

of the musculo-cutaneous nerve in the forearm, and the radial and ulnar branches in the hand.

The degree of anesthesia is indicated by the lightness or deepness of the shading. For instance, in the hand in front, the median nerve being more affected than the ulnar, the area to which it is distributed is more deeply shaded, and the distribution and border line of the two nerves in the hand can be very clearly distinguished, as is shown in the difference in shading in Fig. 4. Fig. 5 illustrates different degrees of anesthesia in the distribution of the radial and ulnar nerves in the back of the hand. Where the shading is deep, the anesthesia is complete, the light shade representing slight loss of sensation.

In the lower extremities, the anesthesia confines itself to the feet, except their inner surface, and to the outer and back part of the leg, below the knee. The nerves affected by this anesthesia in front of the leg and the top of the foot are the

Fig. 3. Shaded areas representing anæsthesia in back of upper and lower extremities. Degree of anesthesia indicated by shading.

3. Hyperalgesia, or an increased sensibility to painful sensations. Lightly drawing a blunted instrument across the

bottom of the feet causes a painful sensation to travel up the legs. Slightly pinching or pricking the limbs causes

feet, and legs is dry, harsh, wrinkled, has lost its natural softness, and is beginning to peel off. The nails are glossy, and have a white band across them trans

versely in the center. (See Fig. 5.) This peculiar marking of the nails, I believe, is a rather rare symptom of this disease, as I have seen only one other case reported (by Dr. Bielschowsky, in the Neurologisches Cantralblatt) in which it was present. The blood vessels of the feet and hands are relaxed and distended; the skin in the hands and feet is reddish in appearance, due to vasomotor disturbance. There is also some oedema of the feet.

Mental Symptoms.-The mental symptoms in this case are not prominent. The patient, however, is given to despondency; has fits of mental depression in which he fears that he will never recover his health.

Fig. 4. Different degrees of anesthesia in the distribution of median and ulnar nerves in front of hand; also an atrophy of muscles of hand.

pain. The increase of the pain-sense is not confined to the areas of anesthesia. 4. Delayed Sensations to Touch and Temperature.- Impressions of touch and temperature that are recognized require a longer time than normal to reach the brain.

5. A Loss of the Muscular Sense, as manifested in ataxic and incoördinated movements. This also affects a larger part of the limbs than is covered by the shaded areas in the figures.

Trophic and Vasomotor Symptoms.-The muscles in the upper and lower extremities, especially those below the elbows and knees, are soft, flabby, and wasted, and have lost their natural elasticity and firmness. In the smaller muscles of the hand and feet the atrophy is most marked. The thenar eminence is flattened in both hands. Figs. 4 and 5 show a wasted condition of the muscles of the ball of the thumb and the smaller muscles of the hands. The skin on the hands, arms,

Fig. 5. Different degrees of anesthesia in the distribution of radial and ulnar nerves in back of hand; also peculiar transverse marking of nails.

entirely, and all attempts at muscular exercise were interdicted. Three or four hours out-of-doors, lying on a cot or in a

wheel chair, was part of his daily program. Hot blanket packs were applied to the arms and legs continuously for an hour twice daily. During the night, wet cotton packs were applied to the legs below the knees, and to the arms below the elbows, and worn all night. The packs were applied as follows: Wet cotton cloths wrung out of tepid water were applied directly to the limbs, these covered by dry cotton batting, and over this a layer of oiled muslin, and all bound firmly to the limb, the object being to retain heat and moisture during the night.

The patient's nutrition received proper attention. He was placed on a wholesome and nutritious diet, and ordered to drink freely of water, the bowels being regulated by diet and massage.

Almost immediately, as the result of this treatment, the severe pains from which the patient had been suffering for some weeks previously, were relieved to the extent of making the patient comfortable, and the numbness and anæsthesia soon became much less. His strength began to improve rapidly, as was shown. by repeated tests with the mercurial dynamometer, and the natural firmness and elasticity of the paralyzed muscles began to return.

At the end of one month, in addition to the above treatment, a galvanic current of electricity was applied daily by placing a large electrode attached to the negative pole of the battery at the base of the spine, and making a labile application with the positive electrode over the upper and lower extremities, each treatment occupying about twenty minutes. A general massage three times a week was also added to his regular treatment. At this time, the patient was ordered to his feet and directed to begin a course of exercise, which was carefully outlined. There was continued improvement. The numbness, burning, pain, and other sensory symptoms were fast fading away. He continually increased in strength, and his out-of-door walks grew longer. After being under treatment seven weeks, he was able to walk two miles without a cane, and had increased several pounds in weight. At the end of two months, the soreness and pain having almost entirely disappeared, the faradic current was applied to the muscles three times weekly, and the applications of the galvanic current were reduced from daily applications

to three times weekly. At this stage of the disease, still more importance was attached to sufficient and proper exercise; and careful measurement of the strength of the different muscles was again made, and an exercise prescription consisting of work in the gymnasium adapted to developing the weaker muscles, and exercise out of doors was carefully and fully followed out.

The above course of treatment was followed for another month. At the end of that time, or about three months from the beginning of treatment, the patient discontinued treatment, and began manual labor on a farm. The severe, dull aching, and sharp, shooting pains in the limbs had disappeared some time before quitting treatment. The "numbness" and "deadness" and anæthesia in the extremities had also disappeared, with the exception of some lingering numbness in parts of the hands and feet where the anesthesia was most marked at the beginning of the disease. The patient's gait was quite natural. The ataxic symptoms, so prominent at first, were now present only in the slightest degree, and could only be detected by the closest observation. He could stand and walk well with his eyes closed. The muscles had regained their natural firmness and elasticity. Those muscles which had been badly wasted by disease, were very much increased in size. The electrical reactions had returned to the normal. The patient had gained twenty pounds in weight, and was able to do a full day's work at manual labor on a farm. (To be continued.)

FACTS AND DOUBTS ABOUT CHOLERA.

BY L. BREMER, M. D.,

St. Louis, Mo.

(See frontispiece in April number.)

ONE would think that the etiology of cholera being settled beyond cavil, and the unity and specificity of its organized virus being firmly established, it would not be difficult to arrive at harmonious conclusions as to the manner in which it spreads and the means best calculated to prevent it from becoming epidemic.

The cholera vibrion is, indeed, to-day the best known of all bacteria, and its