Paraplegia

“ But in bilateral paralysis the predilection is still more remarkable, paraplegia of the lower extremities being among the most frequent, paraplegia cervicalis the rarest, form of paralysis. This is not because a lesion situated in the cervical spinal cord must interfere with the motor tract going toward the lumbar, and hence nearly always paralyze all four extremities, if any. Because when this does happen the upper extremities alone exhibit the atrophic changes characteristic of anterior poliomyelitis: the lower, though paralyzed, do not atrophy and retain their faradic contractility. ”

“ One of the commoner forms of the grave phase of hysteria is paraplegia.153 Often muscular atrophy—which ensues from disuse—exaggeration of the deep reflexes, and retention of urine are added to the paraplegia and heighten the resemblance to an organic affection. Its development, though sometimes sudden, often occupies weeks or months, and may be preceded, exactly as in chronic myelitis, by weakness in the legs, and not infrequently by combined ataxia and weakness. It is much more difficult to discriminate here than is generally held or than is enunciated in textbooks. ”

“ It gives an account of the existing knowledge of hemiplegia, paraplegia, paralysis of separate nerves, epilepsy, apoplexy, lethargy, and hydrocephalus internus. It shows considerable clinical acquaintance with the subject and a careful study of old writers, but the imperfect state of knowledge of this part of medicine is illustrated by the fact that apoplexy and hemiplegia are treated as subjects having no relation to one another. ”

“ 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. ”

“ Clinical Features.—This affection is almost always met with in adults, and the earliest symptoms are pain and weakness in the legs, and sometimes a slight kyphotic projection of the spinous processes. The loss of power, which is sometimes attended with spasticity, usually manifests itself in one leg first, and later affects the other; it is progressive, and ultimately ends in complete paraplegia. The pain is not confined to the region supplied by any one nerve root, but affects a diffuse area, and the patient complains also of a sensation of tightness in the limbs. ”

“ The cutaneous plantar reflex is impaired in hysterical paraplegia; bed-sores are usually absent, as are also acute trophic eschars and the nail-markings present both in generalized subacute myelitis and diffused myelitis. True muscular atrophy is also wanting in hysterical paraplegia, although the limbs may be lean and wasted from the original [p. 266] thinness of the patient or from disuse. The temperature of the limbs is usually good. There is no blueness nor redness of the limbs, nor are the bowels or bladder uncomfortably affected. ”

“ But even with this source of fallacy it holds good that in men suffering from cobra-poisoning, paraplegia is a most characteristic symptom; whereas it is exceptional in dogs. Why, then, as a rule should paraplegia occur in men, and not in dogs? Standing and walking are to a very great extent reflex acts. A man when walking places one foot on the ground, and the sensation of contact with the ground, serves as a stimulus to a centre in the cord by which the motor impulse to move the other leg is excited, and paralysis of these few lower centres would at once impair the action. ”

“ Hysterical paraplegia is one of the most important forms of hysterical paralysis, and is sometimes the most difficult of diagnosis. It occurs usually, but not exclusively, in women. It comes on, particularly in young women, between puberty and the climacteric period, commonly between the twentieth and thirtieth years. Such a patient is found in bed almost helpless, possibly able to move from side to side, but even by the strongest efforts seemingly incapable of flexing or extending the leg or thigh or of performing any general movements of the foot. ”

“ The debility, numbness, retraction, and paralysis of the limbs, appeared long before the pain in the back, after which the curve in the back began to appear; and then these limbs regained their sensibility, force, and motion, while the gibbosity remained always the same. This curve, then, could not be the cause of the paraplegia, because the latter appeared first, and the spine remained curved after the paralysis was removed. The development of symptoms apparently scrofulous, in a man more than twenty years old, who had hitherto presented nothing analogous, and whose parents were healthy ”

“ Some such cases are restless and in continual movement while others are dull, apathetic and indisposed to move. The precise seat of the paresis or paralysis will be determined by the seat of the lesion as in the larger animals. Thus paraplegia is most common, less frequently hemiplegia, palsy of the fore limb, palsy of a single limb, and monoplegias, about in the order named. Palsy of the tail and sphincters implies a lesion of the lumbar section of the cord and is very offensive in the incontinence of urine and fæces especially in long-haired subjects. ”

“ Thus we have the alternating paralyses from tumors of the crus cerebri or of the lower part of the pons, and paraplegia, or perhaps what might be better called double hemiplegia, from multiple tumors which affect both sides of the brain. In rare cases paralysis of all four extremities has resulted from a growth in the middle line of the base of the brain. ”

“ The term acute with reference to inflammation of the spinal cord refers only to the active period of the disease. Just as an embolic softening of the brain is an acute affection, but may be followed by a chronic paralysis or aphasia, so the acute myelitic process may be followed by a chronic paraplegia. ”

“ Spondylitis, or caries of the vertebræ, is sometimes difficult to distinguish from hysterical paraplegia or hysterical paraplegia from it, or both may be present in the same case. Likewise, painful paraplegia from cancer or sarcoma of the vertebræ may offer some difficulties. A woman aged forty-four when two years old had a fall, which was followed by disease of the spine, and has resulted in the characteristic deformity of Pott's disease. ”

“ Congenital cerebral disease, due to intra-uterine lesion, causes imperfect walking, and even contraction of the calf-muscles, which may simulate the analogous symptoms of pseudo-hypertrophic paralysis. But the trunk is bent straight forward, and not bent in lordosis; the lower extremities tend to cross in spastic paraplegia; there is no lateral oscillation of the trunk, and the faradic contractility is always preserved. The progress of the diseases suffices to decide all doubts. ”

“ When the effusion is in the cervical region—the commonest situation—the arms are more affected than the legs. The paralysis of the arms is of the lower neurone type, and the muscles are flaccid and undergo atrophy; the legs may exhibit a more complete degree of paralysis of the upper neurone type, with exaggeration of the knee-jerks. Blood may trickle down the canal and collect at a level lower than that of the lesion which causes the bleeding, and produce paralysis which slowly spreads from below upwards—gravitation paraplegia (Thorburn) . There is blood in the cerebro-spinal fluid. ”

“ III. Case of paraplegia, could walk after taking the remedy for some time.
IV. Case of paraplegia, no improvement.
V. Rheumatic paralysis, with stiff knees, could walk after use of Lathyrus. (Clark Homœopathic World.)
VI. In a case of a clerk with loss of power of the lower limbs, reflexes exaggerated, knee-jerk violent, locomotion difficult and unsteady, probably a case of transverse myelitis, Lathyrus ʒx, night and morning, gave most satisfactory results. The patient could walk a mile without assistance. ”

“ Symptoms.—The symptoms are largely dependent upon the seat and extent of the hemorrhage, as they are principally owing to the compression of the cord. A large clot may produce sudden paraplegia, accompanied with severe pain along the spine; usually, however, the paralysis of both motion and sensation is not very marked at first; on the second or third day fever is liable to appear, and increased or diminished sensibility along the spine posterior to the seat of the clot. When the bladder and rectum are involved in the symptoms it indicates that the spinal cord is compressed. ”

“ Respiration is of the worst kind when it intermits, or is performed with great exertion. The affection arises suddenly from a cold phlegm obstructing the most important cavities of the brain. Whenever the whole origin of the spinal marrow is affected, all the parts below the face become paralysed, whilst it remains unaffected, because the parts there derive sensibility and motion from the brain; but, if one half only be affected, then is there a paraplegia of these parts, that is to say, a partial paralysis. ”

“ Atrophy of the muscles occurs rather frequently. The palsy and anæsthesia by their localization often give us the opportunity of fixing the upper limit of the lesion. Increase of the reflex acts and marked tendinous reflexions do not occur. Paraplegia, palsy of the bladder, bed-sores, etc. may develop exactly as in tumors occupying a higher seat, [p. 1106] but the symptoms of paralysis do not seem to belong necessarily to the disease, as is shown in my case (just mentioned) , which terminated fatally before paralysis or anæsthesia occurred. ”

“ It occurs in chronic alcoholism and especially in women, and is most frequently due to a combination of a septic absorption from some internal disease and the abuse of alcohol. In a marked case the patient may suffer from paraplegia, but it is distinguished from the paraplegia of spinal disease by the fact that there is loss of control of the sphincters only when there is associated dementia, and that instead of the limbs being insensible they are extremely painful on deep pressure. ”

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“ On the other hand, there may be a complete absence of regression; and this is observed sometimes in cases where the paralysis is originally limited; sometimes where it is extremely extensive, involving nearly all the muscles of the trunk or limbs;138 or muscles or limbs originally spared may become involved in a fresh attack. Laborde relates cases of this kind. In Roger's first case paraplegia occurred under the influence of scarlatina two months after paralysis of one arm. ”

“ From these symptoms it will be seen that the effects of the drug correspond to many spinal symptoms, but more especially to what is known as spastic paraplegia. Indeed, Struempel asserts that it produces a perfect picture of this disease.
It is not so often that such a perfect picture of a disease can be had as in this instance. The disease itself is easily recognized by the stiff, spastic gait; the spasm of the adductors, causing the knees to strike each other, or to become locked, causing the patient to fall; the shuffling of the feet ”

“ A lumbar puncture, February 8, 1915, showed hypertensive clear fluid without macroscopic clot on centrifuging, but showing a number of red blood cells and lymphocytes—3 or 4 to the microscopic field. There was a slight hyperalbuminosis. The development of the muscular atrophy and hypo-excitability of the left lower extremity, the exaggeration of the left knee-jerk, together with the spinal fluid appearances, seemed to prove the organic nature of the paraplegia. There was an intense rhachialgia, with radiation along the sciatic nerve. This outlasted all other symptoms. ”

“ In all alike there are usually a few days of fever, followed by indigestion, colics, anorexia, and a general air of illness. Then appear the lameness, stiffness and swelling of bones and joints. Any joint may suffer, shoulder, elbow, knee, hips, stifle, hock, or fetlock. The lameness may shift as in rheumatism, it may intermit, occurring periodically, or it may advance uninterruptedly to a fatal issue. Paraplegia is common and appears to be due at times to pressure on the spinal nerves by the diseased vertebræ. ”

“ Pressure on brain—pain, spasm, nausea, dullness, blindness, stupor, coma, palsy. Congestion and anæmia synchronous. Lesions of cortex. Encephalic lesions—hemiplegia, with spasms, increased reflexes, spasms follow cranial nerves, vertigo, apoplexy, epilepsy, dementia, coma, little muscular atrophy, or dermal sloughing. Spinal lesions, paraplegia without spasm, reflex reduced or nil, follow spinal nerves, head symptoms less, much muscular atrophy, bed sores. Sensory and motor tracts, in crus cerebri, respiratory centres—inspiratory expiratory, inhibition. ”

“ In rare cases the whole motor area is destroyed—cortical hemiplegia; more generally the lesion affects one or more groups of muscles, and occasionally all the muscles of one limb are paralysed—cortical monoplegia. Lesions are often both irritative and destructive, and lead to paralysis of one or more groups of muscles associated with spasms and convulsions of the muscles governed by neighbouring areas of the cortex. Irritation or destruction of the sensory centres may also exist, giving rise to areas of paræsthesia and anæsthesia. ”