159 Am. Journ. Med. Sci., Oct., 1878.
160 Orthopædic Surgery.
In a case observed by myself, which had been previously diagnosed as coxitis, the mistake was all the more interesting as the paralysis which really existed seemed to have been caused by a meningitis rather than primary myelitis of the cornua.161 It thus corresponded to the meningo-myelitic case related by Leyden.
161 The details of this case are as follows: C. P——, aged 11, ten months previous to consultation suffered from febrile attack, accompanied by retraction of head, severe pains diffused through body and intense at nape of neck; unconsciousness for thirty-six hours; vomiting; no convulsions. Case diagnosed as cerebro-spinal meningitis by attendant physician. Convalescence in a week, but with pain in lumbar region of back, predominating on right side, so aggravated by standing or walking that both acts impossible. Coincidently, pain in right calf; exquisite tenderness to pressure even from stocking. No complaint in recumbent position. Child could not get from floor to bed, nor raise right leg from ground. As pain subsided walking became possible, but right leg dragged. Chronic twitchings on left side, face, arm, leg. These symptoms lasted ten or twelve weeks, but at end of nine weeks patient could walk up stairs. In ten months power of walking almost recovered, but there remained a certain amount of lordosis and oscillation of pelvis, which is jarred on the left side while the right leg is swung forward. Recumbent, all movements executed equally well on both sides and passive motion of the hip-joint perfectly free. Circumference of right thigh and leg diminished from one-half to one inch as compared with the left. Faradic contractility diminished on the right side in the gluteal muscles, vastus externus, and rectus, and in the gastrocnemii. The sacro-lumbalis muscle was, unfortunately, not examined, but from the lordosis was probably affected. The remaining muscles were intact. Pain on pressure persisted over right side of second, third, and fourth lumbar vertebræ. Diagnosis was made of a limited meningeal exudation, with compression of anterior part of cord or of a portion of the lumbar and of the sacral plexus.
Scoliosis, which may be caused by the relatively rare unilateral paralysis of some of the muscles of the trunk, may also be simulated by paralysis with shortening of one lower extremity. To compensate the shortening, the trunk is bent over on the paralyzed side; hence a lateral curvature, easily reducible, but easily leading into error.
It would seem easy to distinguish traumatic cases of subluxation of the humerus from those due to paralysis of the deltoid. Yet sometimes only the history will serve to establish, and that somewhat doubtfully, the diagnosis.162
162 A child of four was brought to me with a stiffness and rigidity of the shoulder-joint which could only very partially be overcome by passive motion, and not at all by voluntary effort. The mother stated that several months previously the child had, without apparent cause, become suddenly unable to move the arm. After two months' delay it was taken to a dispensary, and told that the arm was out of joint, and had it reset under ether. From this date the stiffness had gradually developed. The deltoid was atrophied, with marked diminution of the faradic contractility. Question: Were these signs merely symptomatic of an arthritis consequent on a dislocation, or was the latter the result of a spinal paralysis of the deltoid?
THERAPEUTICS.—The treatment of anterior poliomyelitis embraces two stages. In the first it is directed against inflammation of the spinal cord and the paralysis of the muscles; in the second period the spinal lesion has run its course and the paralysis is considered incurable. Treatment is then directed to the prevention or palliation of deformities or toward facilitating the functions of the limb in spite of them.
These two periods are not, however, rigidly separated from each other in chronological order. From the very outset it is important to take certain precautions to prevent deformities, and while palliating these with orthopædic apparatus it is important for years to continue treatment of the paralyzed muscles in the hope that at least a remnant of them may be saved. To abandon the case to the orthopædic instrument-maker, or to neglect the problem of dynamic mechanics while applying electricity and studying the progress of fatty degeneration, are errors greatly to be condemned.
The treatment of the initial stage is necessarily purely symptomatic for the fever and convulsions, since the diagnosis cannot be made out until these have subsided.