MULTII'U: NEURITIS, WITH I Hi; DEVELOP 
MI NI OF UNILATERAL FACIAL PARALYSIS 
LATE IN THE COURSE OF THE DISEASE. 
BY 
J. T. ESKRIDGE, M.D., 
OP DENVBK, COL , 
PROPESSOR OP NHHVOUS AND MKNTAL DISEASES IN THE MEDICAL DEPARTMENT OP 
THB UNIVERSITY OP COLORADO; NEUROLOGIST TO THE ARAPAHOE 
COUNTY AND THE ST. LUKE’S HOSPITAL. 
FROM 
THE MEDICAL NEWS, 
December 22, 1894. [Reprinted from The MEDICAL News, December 22, 1894.] 
MULTIPLE NEURITIS, WITH THE DEVELOP- 
MENT OF UNILATERAL FACIAL PARALY- 
SIS LATE IN THE COURSE 
OF THE DISEASE. 
By J. T. ESKRIDGE, M.D., 
OP DENVER, COL., 
PROFESSOR OP NERVOUS AND MENTAL DISEASES IN THE MEDICAL DEPART- 
MENT OP THE UNIVERSITY OP COLORADO; NEUROLOGIST TO 
THE ARAPAHOE COUNTY AND THE ST. LUKE’S HOSPITAL. 
We shall study to-day the case of D. F., fifty years of 
age, colored, single, a male laborer, born in Kentucky, 
but who has been living in Colorado since 1872. As a 
child he was well and strong, and thinks he did not suffer 
from any of the diseases incident to early life. When 
two years old he had an attack of smallpox, and was ill 
about four months. At his thirtieth year he contracted 
a chancre. He has never indulged in alcohol to excess. 
During the last twelve years he has worked in damp 
places, and frequently contracted colds. Ten years ago 
the glands of his neck suppurated, and about that time 
he experienced numb and tingling sensations in the feet 
and legs below the knees. These sensations would pass 
away on exercising, but when at rest his legs would be- 
come stiff and painful. After suffering with these symp- 
toms, which increased for some weeks, he had to quit 
work a week ; he was then able to resume work, although 
for some months he was not entirely free from uncom- 
fortable sensations in the legs and feet. Subsequently 
to this trouble he remained in good health until Decem- 
ber, 1893, when, after working in a damp and cold place, 
he first felt numb and tingling sensations in his toes and 2 
in the anterior portions of the soles of the feet. In a 
few days these sensations had spread all over the feet, 
and extended up the legs nearly to the knees. About 
this time his ankles seemed weak, so that he could 
not stand without some support. As he expresses it, he 
‘‘ rocked on his feet.” Within two weeks from the time 
the numb and tingling sensations were first experienced 
in the feet he found his legs were paralyzed from the 
knees downward. About the time the legs were first 
paralyzed he felt a burning sensation in his hands, especi- 
ally in the palms, and a numbness in the fingers, and a 
week or ten days later his arms were paralyzed from the 
elbows downward. A few weeks after the paralysis be- 
came manifest he was troubled less from burning and 
numb sensations. From December, 1893, to March, 
1894, he was treated for rheumatism. About the latter 
date a disagreeable tingling sensation, which later 
assumed a distressing burning character, appeared in the 
feet, and was worse at night and during cloudy and in- 
clement weather. Similar sensory disturbances soon 
afterward manifested themselves in the hands, but to a less 
intense degree. He was admitted into the nervous wards 
of the Arapahoe County Hospital, August 11, 1894. 
Examination.—He lies in bed with all muscles below 
the knees completely paralyzed. Foot-drop is well 
marked, with extreme plantar contraction, and toes flexed, 
the great toes being flexed to the greatest possible degree. 
By using considerable force I am able to dorsally flex 
the feet at right angles with the legs. The legs lie 
straight at the knees, and he can flex and extend the legs 
at these joints, but the muscular power is slight. Flexion 
and extension at the hips are fairly good, but the muscles 
that make these movements are rather weak. Moving 
the legs and thighs at the knees and hips causes some 
pain, or a drawing sensation in the calf and posterior 
thigh-muscles. Extreme wasting has taken place in all 
the muscles below the knees, and to some extent in the 3 
thigh-muscles. The greatest amount of muscular atrophy 
is found in the interossei of the feet and in the anterior tibial 
and peroneal groups. The trunk-muscles are nearly nor- 
mal. Wrist-drop is present, with flexor contraction of the 
muscles of the hands and wrists. Both hands ordinarily 
lie in the wrist drop position, yet with considerable effort 
he is able to extend the left wrist on a line with the fore- 
arm, but he cannot extend it beyond this point. Marked 
atrophy is present in the muscles of the hands, most pro- 
nounced in the interossei and in those forming the thenar 
eminences. The muscles of the forearms are wasted, 
but to a much less degree than the muscles of the legs 
below the knees. The muscles of the upper arms are 
fairly strong, and present but slight wasting ; the muscles 
of the shoulders appear normal; none of the muscles 
below the knees or elbows responds to the strongest fara- 
dic current from a large-sized Flemming battery. All 
these muscles show reaction of degeneration. The mus- 
cles of the neck, face, and larynx are not involved. 
Sensory phenomena. Tactile sense, when tested by 
the contact of a feather, is lost on the feet and legs from 
a point about midway between the ankle joints and knee- 
joints downward ; the sense of touch is present down to a 
point about six inches above the ankle-joints ; in the right 
hand and arm the feather in contact is not felt from a 
point four inches above the wrist joint downward, and 
in the left, from a point about six inches above the wrist- 
joint downward, while a feather in motion can be felt over 
the greater portion of the backs of the hands and wrists, 
but is not perceived on the dorsal surfaces of the fingers, 
the palmar surfaces of the fingers and hands, and the 
anterior surfaces of the wrists, and the anterior surfaces 
of the arms from a point about two inches above the 
wrist-joints downward. Tactile sense is present and 
nearly normal over all other portions of the body. 
Pain-sense is present throughout the body, but is not 
normally acute in the areas of tactile anesthesia until 4 
the skin is pierced. Temperature-sense is lost all over 
the feet, delayed, uncertain, and lessened over the ankles 
and areas of tactile anesthesia of the legs, and much per- 
verted over the hands, but not lost as in the feet. Localiza- 
tion-sense is greatly disturbed, especially over the feet, 
as a sensation produced on the leg is referred to the foot, 
and sometimes to the foot of the opposite side. Pressure- 
sense is disturbed more in the hands than in the feet. 
Joint-sense and posture-sense are present and about 
normal. Muscular sense is absent. 
The knee-jerks, the plantar, cremaster, and forearm 
reflexes are absent; abdominal and iritic reflexes are 
present. Taste, smell, hearing, and vision are about 
normal. The internal and external ocular muscles, and 
an ophthalmoscpic examination show no abnormalities. 
During the five weeks he has been in the hospital there 
has been a steady but rather slow improvement of his 
condition. The contractures of the flexor muscles of the 
feet, the legs below the knees, the hands and the arms 
below the elbows, were so great that we were compelled 
to give the patient an anesthetic before the deformities 
could be overcome. After this procedure the hands and 
arms were put on padded splints, and by means of ad- 
hesive plaster the feet have been kept forcibly dorsally 
flexed. The apparatus was removed every second day, 
allowed to remain off several hours, and the parts thor- 
oughly massed. By the end of two weeks we had pretty 
well overcome the contractures in the flexors of the feet 
and ankles, and since then sand-bags laid at the soles 
of the feet have been sufficient to keep the feet in proper 
position. We have not been so successful in getting rid 
of the contractures of the hands and wrists, but these 
are much less than when the patient entered the hospital. 
The splints are now kept on the hands and arms about 
half the time. The muscles will not respond to the 
faradic current, and in consequence this is at present 
valueless in the treatment. The continuous and inter- 5 
rupted galvanic current is the most useful form of elec- 
tricity for nerves and muscles in this stage of the disease. 
His food has been as nutritious as the hospital affords, 
with abundance of soups, meats, and eggs. In the way 
of medicine, iron, arsenic, and strychnin have seemed 
most appropriate. To-day he is able to slightly flex and 
extend the right foot. No movements of the left foot have 
been regained. He is now able to extend both wrists. 
Tactile anesthesia is slightly less than when he entered 
the hospital. Peripheral paralysis of the left side of the 
face developed after the patient had been in the hospital 
two weeks. 
Let us consider the nature of our patient’s trouble. In 
the first place, I wish to call your attention to the marked 
symmetry of the disease, limited as it is mainly to the 
distal portions of the extremities ; the failure of the mus- 
cles to respond to the faradic current, and changed re- 
action to the galvanic ; the pronounced muscular atrophy 
with motor paralysis ; loss of and disturbed sensory func- 
tion. There are many diseases with which a case of 
this kind may be mistaken by the casual and superficial 
observer. The least likely is rheumatism, yet the 
patient tells us that he was treated during all of last 
winter for this affection. In the present instance only 
gross ignorance or criminal negligence would permit 
such a mistake. In rheumatism there sometimes occurs 
paralysis early in the disease, either of an inhibitory or 
hysterical origin; but this is rare, and it only lasts for a 
few days. I have seen one such case. The man was 
apparently unable to move a hand or foot, but the ankle- 
joints and knee-joints, not the nerves, were very tender, 
and were the seat of severe pain. Suspecting the charac- 
ter of the trouble, large doses of sodium salicylate were 
given, and within two days the patient began to move 
the hands and feet. Late in rheumatism there may be 
partial paralysis and well-marked wasting of the mus- 
cles below the affected joint in which adhesions have 6 
occurred, producing a condition known as arthritic 
muscular atrophy ; but there is no loss of sensation, the 
affected muscles respond to the faradic current almost 
normally, the disease is not symmetrical nor limited to 
the distal portion of the extremities. The temporary 
paralysis in the early stage of acute rheumatism, and 
the arthritic muscular paralysis usually affecting one 
limb, apparently from rheumatic inflammation of a 
large joint, are about the only points of similarity be- 
tween rheumatism and the symptoms presented by the 
patient before us, while the symmetry of his disease, the 
distal portions of the limbs being as a rule alone affected, 
the electric changes, the sensory phenomena, and the 
nerves, instead of the joints, being involved, are abun- 
dantly sufficient to prevent a mistake in the diagnosis if 
care and judgment are used in the examination and 
summing up of the case. 
In poliomyelitis the absence of objective sensory 
phenomena and the symmetry of the paralytic symp- 
toms serve to distinguish this disease from the one before 
us. Spinal pachymeningitis is attended with radiating 
pains from the spine, with involvement of the trunk- 
muscles and those of the upper portions of the limbs, 
with severe pain on moving the muscles of the back, 
and with incomplete paralysis and sensory loss, distrib- 
uted irregularly, symptoms very unlike those present in 
our patient. In acute ascending paralysis the feet, legs, 
thighs, trunk, and arms become affected in the order 
named The ataxic symptoms manifested by the man 
before us, with loss of the knee-jerk, has more than once 
misled careless observers to mistake the disease for 
locomotor ataxia, but the latter disease has shooting 
pains, prominent eye-symptoms, anal and vesical dis- 
turbances, absence of paralysis until very late, when it 
is incomplete, and wrist-drop and foot-drop are never 
present. There are many other points of difference, but 
these are the most prominent. Myelitis affects the anal 7 
and vesical sphincters, the muscles of the trunk up to 
the level of the spinal lesion, and when the lower por- 
tion of the cord is the seat of inflammation, anesthesia 
of the external genitalia and the parts around the 
anus is present. We can then exclude myelitis in this 
patient. 
The character of the paralysis, the distribution of the 
anesthetic areas, the extreme muscular wasting and the 
well-marked electric changes which have taken place 
in the muscles, enable us at once to dismiss the sugges- 
tion of hysteria, an affection which should always be 
allowed to obtrude itself in the mind of every one when 
engaged in arriving at a diagnosis by exclusion in cases 
attended with paralysis and loss of tactile sense. We 
have left but one other affection, multiple neuritis, which 
will likely account for the condition of this man. The 
symptoms that this patient presents are typical of mul- 
tiple neuritis. The symmetry of the parts affected is 
almost complete; the parts invaded are the extremities, 
in the arms below the elbows, and in the legs, princi- 
pally the regions below the knees, although motor 
weakness is found in the muscles of the thighs, and to 
a slight extent in those of the hips, but no loss of sen- 
sation is found above the knees; the feet and hands are 
affected more than the forearms ; wrist-drop and foot- 
drop, profound muscular wasting, with electric changes 
and absence of the deep reflexes—all go to make up a 
clinical picture the like of which is found only in multi- 
ple neuritis. When we call to mind that the vesical 
and anal sphincters have not been affected, and that 
the nerves were at one time tender and the seat of pain 
and distressing sensations, there seems to be no room 
to doubt the correctness of the diagnosis. 
As the management of individual cases of multiple 
neuritis depends somewhat upon the cause of the inflam- 
mation, it will be well for us to inquire into the etiology 
of this man’s attack. This man suffered from syphilis 8 
twenty years ago, but syphilis in its tertiary stages at- 
tacks mainly fibrous and connective-tissue elements. I 
have not observed, or seen the report of a case of typi- 
cal parenchymatous multiple neuritis caused by syphilis. 
It seems to me that we may dismiss the consideration of 
the syphilitic poison as a causative factor in this man’s 
case. The principal causes for us to consider in the 
present instance are diphtheria, alcohol, malaria, ex- 
haustion, insufficient nourishment, gout, rheumatism, 
and exposure to wet and cold. In the absence of the 
history of diphtheria or involvement of the muscles of 
the iris and palate, and the long duration of the 
disease (diphtheric multiple neuritis running its course 
in two or three months), we are justified in excluding 
the effects of diphtheric poison. The patient has never 
been addicted to the steady or excessive use of alcohol; 
he has not been exposed to malaria for more than 
twenty years; his work has not been exhausting; he has 
been able to obtain plenty of nutritious food, and he has 
never suffered from gout, so that we may as well dismiss 
all causes first enumerated except rheumatism and ex- 
posure to wet and cold. His occupation during the last 
twelve years has necessitated his being more or less ex- 
posed to damp and cold, and undoubtedly the slight 
attack of nervous disturbance from which he suffered 
some ten years ago was of the same character as the 
present one (though much lighter). He tells us that 
he has never suffered from attacks of acute rheuma- 
tism, and that he enjoyed good health from the time 
of his attack, ten years ago, until the beginning of his 
present illness, in December, 1893. It is probable, 
then, that to exposure we must attribute the cause of his 
trouble. 
The duration of the disease is variable. The diph- 
theric form, as a rule, runs the shortest course, conva- 
lescence in the majority of instances being pretty well 
established, so that the patient is able to walk about, by 9 
the end of the second or third month from the time the 
neuritis first became manifest. The alcoholic form is 
not infrequently slow in reaching its height. I have 
under my care at present a patient who suffered from 
neuritic pains, with absent knee-jerks, for eight months 
before the paralysis became so great that he was com- 
pelled to remain in bed. During the last two or three 
months of this period he was decidedly ataxic in the 
legs. In the majority of cases of multiple neuritis not 
due to diphtheria the disease is one or two months in 
reaching its acme; then it remains stationary for one, 
two, or three weeks, after which apparent recovery takes 
place in from a few to several months. It must be 
remembered that the muscular strength is not regained 
for several months after the patient is able to resume his 
duties. The parts that are first affected are usually the 
most seriously involved, and are the last to resume a 
normal condition. The legs, as a rule, improve before 
the hands and arms, although occasionally this order is 
reversed. The feet, and sometimes the hands, especi- 
ally around the nails, remain hyperesthetic long after 
all spontaneous pain has subsided. Relapses greatly 
lengthen the course of the disease. 
The vast majority of cases of multiple neuritis result in 
recovery. In a few cases the trunk-muscles, including 
the intercostals, are affected ; then if the diaphragm be- 
comes paralyzed, death takes place from failure of respi- 
ration. These are acute and rapid cases, and not infre- 
quently end in death at the end of from six to ten 
days or two weeks. Cardiac failure in alcoholic and 
diphtheric cases sometimes causes sudden death. In a 
few the patient is worn out by pain, the annoyance of 
bedsores, and the presence of bronchitis. In such cases 
it is probable that the spinal cord is affected. In alco- 
holic cases, cardiac, renal, and hepatic complications may 
lend gravity to the prognosis. Mental failure is a com- 
mon complication of the alcoholic variety of multiple 10 
neuritis, but it usually passes away during convalescence. 
Sometimes there is simple failure of memory for recent 
events, but in typical cases patients become delusional 
and conceive the idea that they go out each day and take 
long walks, although they may be so completely para- 
yzed that they are unable to stand or even flex and ex- 
tend the feet. 
The treatment in the early stage of the acute cases 
consists of rest in bed, protecting the extremities from 
changes in temperature by means of flannels (when there 
is pain the flannels next to the skin should be kept moist 
by frequenly wringing them out in hot water),warm daily 
baths, if they do not inconvenience the patient too much, 
keeping the bowels open, and giving a febrifuge when 
there is a rise of temperature. As soon as the acute stage 
has subsided, massage and electricity and the internal 
administration of strychnin, arsenic, quinin, and iron 
are indicated. The nutrition should be maintained 
throughout the course of the disease by means of good, 
nutritious food, of which animal food should form a large 
proportion during convalescence, and cod-liver oil may 
be added to the list of nutrients. Relapses may be pre- 
vented, as a rule, by protecting the affected parts from 
cold by means of flannels worn next to the skin. Mas- 
sage should not be resorted to while the nerves and 
muscles are sensitive, but gentle rubbing of the limbs 
from the distal portions toward the body is often grateful 
to the patient early in the disease. It is doubtful how 
much the galvanic current hastens resolution of the nerves 
and muscles,but the nutrition may be partially maintained 
and extreme atrophy of muscular tissue prevented, by 
causing gentle contraction of the paralyzed muscles until 
the patient regains voluntary control over them. When 
the muscles readily respond to the faradic current this 
may be used, but the current should be no stronger than is 
necessary to effect gentle contraction of the most affected 
muscles. In the majority of cases the faradic current 11 
will not produce muscular contraction in the extensors 
of the wrist and the anterior tibial and peroneal groups. 
For all muscles that will not respond to the slowly-inter- 
rupted faradic current of moderate strength the inter- 
rupted galvanic must be used, taking care not to exhaust 
the muscles by prolonging the seances to too great a 
length, and effecting too vigorous contractions. From 
three to five minutes is long enough for each of the 
largest groups of muscles, and a slight muscular con- 
traction is less likely to do harm, and is capable of doing 
more good than vigorous movements. Electricity for 
this purpose may be applied daily or every alternate day. 
It is your duty to prevent troublesome contractures of 
the flexor muscles of the legs and arms, with resulting 
deformity of the feet and hands, such as this man pre- 
sents. This may be done by keeping the feet at right 
angles to the legs by meane of sand-bags placed at the 
soles of the feet, and occasionally placing the forearms 
and hands on padded splints. 
I have nearly finished what I had intended to say 
about this case, but have not referred, except in the ex- 
amination, to the unilateral facial paralysis. This has 
come on some nine months after the beginning of the 
attack of multiple neuritis. At my first visit to this 
patient there was no paralysis of the face, but about two 
weeks subsequently I first observed it. He had been 
lying near an open window, and the affected side of the 
face was exposed to a draught of air. In all probability 
it has no connection with his general trouble. It is a 
local neuritis and does not modify the prognosis at all. 
Facial paralysis during the acute stage of multiple neu- 
ritis would, as a rule, excite grave apprehension, as it 
would indicate that the trouble was affecting nerves not 
usually involved in this disease, and fear of cardiac and 
respiratory failure might justly be entertained. The Medical News. 
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