Frederick Walker Mott

“ It is characteristic, however, of the disease that there is no loss of sensation in the paralysed limb. The whole of the limb is not necessarily paralysed, often it is only a group of muscles, and even if the paralysis affects both legs or the arm and leg on one side, it generally fails in the uniform distribution of the previously described paraplegia or hemiplegia. The affected muscles rapidly waste and become flaccid, the electrical reactions change, and finally the muscles may cease to respond to electrical stimulation whether of the continuous or interrupted current. ”

“ Occasionally the face is paralysed on one side and the arm and leg on the other side; this condition is termed alternate hemiplegia, which is due to the fact that the disease has damaged the motor path from the brain to the leg and arm before it has crossed over to the opposite side, whereas the path to the face muscles is damaged after it has crossed. In rare cases both leg, arm and face on one side may be paralysed—triplegia ”

“ As regards the respiratory function, one of the dangers of paralysis is an intercurrent pneumonia - sometimes unavoidable, often due, however, to attempts to give nourishment to a patient in an insensible state, with the result that some of the fluid enters the bronchial tubes, when either the reflex protective coughing is not excited or is ineffectual. Attention to the bowels and bladder is most important. A purge at the onset of paralysis is indicated when the pulse is full and of high tension, and the regular action of the bowels is necessary in all conditions. ”

“ Disease or destruction of the lower spinal segment causes not only loss of voluntary power but an atrophy of the muscles themselves. Paralysis may therefore be divided into three great groups: (i) loss of voluntary power without muscular wasting except from disuse, and without electrical changes in the muscles due to injury or disease of the upper cerebral segment of the motor path of volition ”

“ Convulsions are common, and the child is unable to sit up or walk long after the age at which it should do so.
Paraplegia is a term applied to paralysis of the lower extremities; there are many causes, but in the great majority of instances it arises from a local or general disease or injury of the spinal cord. A localized transverse myelitis will interrupt the motor and sensory paths which connect the brain with the spinal grey matter below the lesion, and when the destruction is complete, motor and sensory paralysis in all the structures below the injury results ”

“ The muscles do not waste except from disuse, nor undergo electrical changes unless the disease affects extensively the spinal grey matter or roots as well as the cerebral path. When it does so, as in the case of acute spreading myelitis, the symptoms are usually more severe and the outlook is more grave. ”

“ A progressive atrophy of muscles associated with progressive weakness and various disabilities of movement is soon recognized in the relation of cause and effect; but the parents whose first child looks like an infant Hercules, with abnormally large calves and buttocks, cannot for some time appreciate any connexion of this condition with a muscular weakness which is manifested in various ways. The child stands with its feet widely separated; it waddles along rather than walks; it falls easily and rises with difficulty, having to use the hands to push against the floor ”

“ When the passive movements are being made the patient should be instructed by the operator to will the movement which he is performing, and thus try to re-establish the connexion of the brain with the muscles through the point of interruption or by a new path if that is not possible. ”

“ Some muscles are completely paralysed, others are merely weakened, while others, e.g. the trunk muscles, are apparently unaffected. In many cases of even complete hemiplegia, improvement, especially in children, takes place after a few weeks or months, and is generally first indicated by return of movement in the muscles which are habitually associated in their action with those of the opposite unparalysed side; thus, movement of the leg returns first at the hip and knee joints, and of the arm at the shoulder and elbow, although the hand may remain motionless. ”

“ Multiple neuritis is a painful generalized inflammation of the peripheral nervous system and arises in many toxic conditions of the blood; among the most important are lead, arsenic and chronic alcohol poisoning. ”

“ Sciatica is a painful inflammatory condition of the sciatic nerve, in which there may be weakness of the muscles; but inability to move the limb is more on account of the pain it causes than on account of paralysis of the muscles. ”

“ A characteristic feature of the disease is fibrillary twitching of the wasting muscles. The electrical excitability of the muscles is diminished rather than changed, except where the wasting is very extreme, when a partial reaction of degeneration may be obtained. Sensation is unaffected, as the disease is limited to the motor cells of the anterior grey matter (see Neuropathology) . There is no affection of the bowel or bladder. Death usually occurs from intercurrent diseases, e.g. bronchitis, pneumonia, or broncho-pneumonia. Some patients die owing to failure of the respiratory muscles ”

“ The patient in walking leans to the sound side and swings round the affected leg from the hip, the inner side of the toe of the boot scraping the ground as it is raised and advanced. The arm is adducted at the shoulder, flexed at the elbow, wrist and fingers, and resists all attempts at extension. According to the part of the brain damaged variations of paralytic symptoms may arise; thus occasionally the paralysis may be limited more or less to the face, the arm or the leg. ”

“ As soon as the acute symptoms have passed off passive movement and massage may be employed with advantage; in some cases electrical treatment is indicated; but as a rule, especially in children, electrical treatment offers the disadvantage of being painful and not accomplishing more than can be effected by massage and passive movements. ”

“ There is wasting of the muscles, and electrical changes in them; frequently there is anaesthesia and analgesia of the skin, which takes a stocking-like distribution. In severe cases the upper limbs may be affected, and all the muscles of the body are more or less liable to be paralysed - even the heart may suffer. The mental condition in such a severe case is usually quite characteristic; there is delirium, the patient is the subject of hallucinations and delusions; there is loss of knowledge of time and place, and illusions of personal identity. ”

“ Moreover the pharyngeal muscles are unable to seize the food and start the process of swallowing on account of the paralysis of the soft palate; liquids are apt to regurgitate through the nostrils, the patient must therefore be nourished with soft semi-solid food. As the disease proceeds, the difficulty of speech and swallowing is increased by the affection of the laryngeal muscles ”

“ Later the muscles of mastication are affected and the disease may extend to the respiratory centre, giving rise to attacks of dyspnoea. The intellectual faculties are as a rule unimpaired, although the facial expression and the curious emotional mobility of the countenance, with a tendency of the patient to burst into tears or laughter, would suggest weak-mindedness. Whilst the lower half of the face is strikingly affected, the upper half retains its normal expression and power of movement. ”

“ There is absence of bladder and bowel troubles, and bedsores do not occur; the disease itself is rarely, if ever, fatal. About a month after the onset of the disease local treatment of the atrophied muscles should be commenced, and every effort should be made by massage, by suitable positions and passive movements to promote the circulation and prevent deformities in the affected limbs. ”

“ In cases of paraplegia the legs should be covered with warm woollen hand-knitted stockings, and a cradle employed to protect the feet from the continuous, weight of the bed-clothes, a fruitful source of foot drop. ”

“ Daily inspection of the back should be made of all paralysed patients, and precautions taken to keep the skin of all parts exposed to pressure clean; the back should be laved with eau-de-Cologne or spirit to harden the skin. ”

“ Lead poisoning may give rise to a localized neuritis affecting the posterior inter-osseous nerve, especially in painters and in those whose occupations necessitate excessive use of the extensors of the forearm ”