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MEDICAL SCIENCES, »iSiM(i Read before the Associntiun uf American Physicians, Washington, 18S8. ROSS, PARALYSIS AFTER TYPHOID FEVER. It is not to be wondered at that the nervous system suffers in many ways after the prolonged disturbance to which it is subjected during a siege of typhoid fever. Indeed, it would be remarkable if derangements of the nervous functions were not often witnessed under these circum- stances. In a certain proportion of all cases of this fever, the incidence of the poison seems to be upon the nervous system, as is evidenced by the occurrence of cephalalgia, insomnia, delirium, tremors, and debility. As a sequel of these profound and prolonged disturbances in the nervous system all patients who have thus suffered are left in a condition of very marked asthenia, and it is a lo.ig time before they are in a condition to bear any, even moderate, amount of either bodily or mental fatigue. These signs of exhaustion of the nervous system are constant, and generally in proportion to the severity of the fever, and the degree to which its violence has fallen upon that portion of the mechanism. But, apart from such general functional diminution, there are, in exceptional cases, signs that certain isolated, and often strictly localized, portions of the nervous system have suffered out of all proportion to the rest, and in them the impairment of function may reach a high degree. Thus, the cerebral cortex may be the part chiefly affected, and we olxserve, even after full convalescence has set in, that the mental functions remain imperfect and hallucinations and delusions may persist for a very con- siderable time — or, as concerns us most at present, some part of the spinal cord, or some one or more of the spinal nerves, exhibits altered function. It is, however, a fact that, although these sequential paralyses are more frequently observed after somewhat severe attacks of typhoid, yet they do not specially occur when the fever has been marked by an excess of nervous disturbance. Nor can any such predisposing cause as the in- fluence of country or of a neurotic temperament be shown to play any part. The nervous phenomena, almost invariably, are both motor and sensory, presenting paraly^s with either pain or anesthesia. This has always been observed in spinal nerves, and has not been seen in any of the mixed (motor and sensory) central nerves. According to Nothnagel (Deutsch. Archiv fur klin. Med., 1872), from an examination of recorded cases, the following is the order of frequency of these affections : 1. The parts supplied by one nerve or branch of a nerve, with special pre- dilection for the ulnar and the peroneal. 2. Paraplegia, generally con- fined to the lower extremities, but not very infrequently involving an upper extremity — sometimes both arms and legs — sometimes one side more than the other. 3. Less frequently, one extremity, either upper or lower, or two extremities in crossed order. 4. Simple alterations of sensibility; if looked for, these will be found very frequently, though not so striking as the cases with combined paralysis and anaesthesia. They are observed chiefly in the lower extremities and especially in the feet. From a consideration of many cases of paralysis after this fever, it )' ROSS, PARALYSIS AFTER TYPHOID FEVER. 8 may be inferred that the mode in which it is produced is by no means always the same ; that, indeed, the effect of the poison is exerted some- times upon some of the great nervous centres, especially of the spinal cord, and at other times upon the structures of some special and indi- vidual nerve or nerves. Jaccoud, e. r/., speaks of paraplegia being due to cedemafous injiUndlon of the parts in the vertebral canal, and is of opinion that even prolonged exhaustion of these centres without organic lesion may be the cause of a motor loss enduring even for a considerable time. Prof Biermer relates an important case, in which he finds difficulty in deciding between acute poliomyelitis anterior and multiple degenerative neuritis, there having been pain, motor paralysis, good sensation, dimin- ished electrical reaction, atrophy, and bedsores, a tedious illness of several months, and, finally, complete recovery. As the tendency in all these cases is toward recovery their pathology is necessarily scanty and founded upon what is better known about recognized lesions whose symptoma- tology is somewhat analogous. The commonest variety of post-typhoid paralysis is that which is confined to the district supplied by one nerve, e. g., the ulnar, peroneal, or the circumflex. Here, it is extremely probable that two distinct patho- logical conditions may exist. There may be a true interstitial neuritis or there may be an acute parenchymatous change in the nerve elements. The two varieties are separated from each other mainly by the presence or absence of pain — this symptom being a marked feature in the former, owing to the pressure exerted upon nerve-filaments, and being absent in the latter where tliis condition does not exist ; the main feature, however, the loss of power in the supplied muscle.«, being ecpially present in them both. It has been suggested by a recent writer (Thomson) that a similar acute parencliyniatous degeneration is to be looked upon as explaining that common post-fubrile paralysis, the diphtheritic, and the view has much to commend it. It is not unusual after typhoid fever of considerable severity to find a definitely enfeebled condition of the lower extremities persisting for some time, and sometimes a person never entirely recovers his capacity for walking long distances. Such paretic cases have never been spe- cially studied, but it is probable they would, if any should, fall under the head of defective innervation from prolonged exhaustion of the nervous centres. The most important, however, of cases of post-typhoid ])aralysis are those of paraplegia, confined sometimes to the lower extremities and sometimes involving these together with some other parts. Well-marked cases of this kind are sufficiently unusual, and one may see several hundreds of cases of typhoid fever without meeting with a single exam- ple. Not much has been written upon it, and in some articles very dissimilar conditions are probably included under the same description. BOSS, PARALYSIS AFTER TYPHOID FEVER. The following case is a striking instance of a very severe fiirm of paraplegia directly resulting from typhoid fever and still ending in com- plete recovery. Julia L. was brought by the airbulance to the Montreal General Hos- pital on the 8th November, 1887. The following account of her illness wag obtained from her attending physician. She complained on the Ist September of headache, feverishness, pains in the linibs, and a short hacking cough. After Oiie week took to her bed. Was first seen by her physician on 12th September. At this time she had a severe cough with whitish expectoration. Moderate distenticm of abdomen, and gurg- ling in right iliac fossa. Temperature 102^ F. The disorder ran the orciinary course of a moderately severe attack of typhoid i'ever without complication. Patient remained in bed until October 2;")th, when she got up, went about the house for three or four days and was apparently convalescent; appetite good, sleeping well, and gaining strength rapidly. On October 29tn temperature rose to 102' F. and she began to suffer from severe pains in the legs. The lower extremities were very sensi- tive, the patient not being able to bear any motion of the bedclothes. The legs were flexed on the thighs and the thighs on the pelvis, any attempt at extension being very painful. At this time had inconti- nence of urine for one day. The skin over the left trochanter and sacrum very soon became red, and in two or three days a large slough, about two inches square, had formed in both these situations. The skii. over the right trochanter also became reddened but did not slough. The temperature soon became normal and remained so. On admission, much emaciated and anaemic ; face pale, eyes brilliant, pupils dilated and equal; expression anxious and haggard; skin dry and harsh, cool ; tongue clean and moist ; abdomen retracted, not tender on pressure. Lies on right side with legs and thighs flexed. Some oedema of left foot. Numerous small purpuric spots on both legs from knees downward. Great wasting of muscles of both lower limbs, thigh and leg ; both knees are rigidly bent ; any movement to relieve the contraction is extremoly painful. Marked paresis in all attempted movements of foot, leg, or thigh. She in unable to hold up either leg from the bed without support. Much tenderness on pressure upon the muscles of the legs or thighs. No antesthesia. The skin over the two malleoli somewhat reddened. Plantar and abdominal reflexes present. There is a large bedsore over the lower part of the sacnini, about two inches square, covered with a hard, black slough and with inflamed edges. There is a similar slough on the left trochanter, and the skin over the right tro- chanter is reddened but unbroken. Pulse feeble and rapid, but regular. Temperature normal. In lungs, many moist sounds heard at both bases, chiefly in the left. Urine contained a small amount of albumin. Com- plains of pain over the bedsores and weakness. Eats well. Sleeps soundly. Urine and feces passed naturally. Is very feeble and resents being moved or stirred. She was put upon a Avater bed and the bedsores poulticed, and was given quinine, good diet, and a small allowance of stimulants. The slough soon separated and the sores were dressed with balsam of Peru and iodoform ; they slowly granulated and finally healed. The contraction of the knees obstinately remained. In February, the legs were grad- ually extended by means of weights and pulleys until they became '1^ '1^ ROSS, I'ARALYSIS AFTER TYPHOID FEVER. 5 quite straight. Duriii;^ this tiino, motor power was 8h)wly returning and jmin (juitc dimippoiireil. After a time, .she (;ouM stand upright, and perform tiie flexion and extension mov(unents of the feet and tiio legrt. Improvement was then rapid, and siie wa.s discharged March 1, 18HJLADeLPHIA. — 70© & 7oe ■Sansom Stseet.-