25 Loc. cit., p. 32.
26 Med.-Chir. Trans., 1874, 1877.
Reflex excitability is maintained, not only in this, but in the second stage of the disease, except in the patellar tendon, where it is abolished after the quadriceps extensor has been invaded. This fact may be of importance in diagnosticating paresis depending on incipient pseudo-hypertrophy from that which would be caused by a mild anterior poliomyelitis.
No symptoms of the third kind (deformity) appear in the first period of the disease. The second is ushered in either by the first perceptible degree of hypertrophy in the calves (Duchenne) or by increase of the hypertrophy, which may have already begun during the first period of paresis, and by extension of this to other muscles.
This extension of the lesion is indicated by further derangement in the functions of station and locomotion. To steady himself the child instinctively widens his base of support by placing the feet far apart, and thus straddles while walking in a manner that is highly characteristic. A second peculiarity is an oscillating movement of the trunk from side to side. The trunk is carried over to the side of the foot planted on the ground, the so-called active limb, and while the passive limb is being swung forward. A third peculiarity of attitude, already exhibited in station, but exaggerated by the act of walking, is lordosis. The lumbar portion of the spine, with the abdomen, is carried forward; the shoulders are carried backward, so that a plumb-line dropped from them falls behind the sacrum. Thus, the walk of the patient becomes highly characteristic—the feet planted so far apart; the lumbar portion of the trunk projecting forward; the body oscillating at each step from side to side.
At this stage the act of rising from a sitting or recumbent position becomes more difficult than walking. If near a support, the child always tries to draw himself up by his arms; if a fixed support be lacking, he first gets on his hands and knees, and then, grasping each thigh alternately with one hand, is enabled to get first one foot and then the other on the floor. He then seizes the thighs by successive grasps, each higher than the other, pressing back the flexed hip- and knee-joint as he does so. By this method of apparently climbing up his own thighs the patient is finally enabled to extend his body and arrive at an upright position.
This attitude of the hands, on the knees, and subsequently on the thighs, during the act of rising, is pathognomonic of pseudo-hypertrophy, for it is observed in no other disease.
Corresponding with this increased disturbance in function is the increased visible alteration in the muscles of the lower extremities. The muscles on the anterior part of the legs are not always attacked, but often become hypertrophied and paretic contemporaneously with the gastrocnemii. After these, hypertrophy of the glutæi comes next in frequency. The quadriceps extensor of the thighs may become paretic, and even perfectly paralyzed, without showing any sign of enlargement. In many cases, however, hypertrophy proceeds regularly up the limbs, and invades the thighs simultaneously with the buttocks.27 The exact proportion of cases is difficult to ascertain, because the history is often imperfect, and at the time of observation the quadriceps extensor is frequently atrophied, even when it has been hypertrophied at an earlier date. The thinness of the thighs is then all the more conspicuous from the hypertrophy of the calves below and of the buttocks above. The sacro-lumbales and quadratus lumborum muscles are also frequently enlarged, next in order to the quadriceps extensor femoris, which, as seen, is rather less often hypertrophied than are the gluteal muscles.
27 Cases in which the calves and thighs are alone described as hypertrophied: those by Kaulich, Griesinger, Sigmund, Wagner, Wernich (2d), Lutz (1st and 2d), Foster, Stoffella, Eulenburg (2d).
Cases of hypertrophy of calves with atrophy of thighs: those by Eulenburg (1st), Lutz (3d), Adams, Barth (2d), Knoll, Friedreich, Gowers (1st, 4th, 5th, 9th, 10th, 11th, 12th, 14th). In Rakowac's case, as also Barth's, the glutæi were also hypertrophied.