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 Breslau, 1876), 1; case by Schultze (Virchow's Archiv, Bd. lxviii.; also Bd. lxxiii.),
autopsy, 1; case by Bernhardt (Archiv für Psych., Bd. ix., 1879); case by Sinkler
(Amer. Journ. Med. Sci., Oct., 1878), 5; case by Althaus (ibid., April, 1878), 2; case by
Ross (Dis. Nerv. Syst., vol. ii. p. 139), 1—total, 57 cases.

Morton (St. Bartholomew's Hospital Reports).

Others have doubtless been published since this date, but, as they do not
immediately concern our subject, need no further citation.

3 Vulpian, Leçons sur les Myelitis, 1880.

SUMMARY OF CLINICAL HISTORY.—The clinical features of an acute

attack of infantile paralysis are well known. The children affected are
usually between eighteen months and four years of age (Henoch).
The attack is more likely to occur in summer than in winter, as
Sinkler4 found that 47 out of 57 cases began between May and
September, and Barlow noted 27 out of 53 in July and August.5
4 Amer. Journ. Med. Sci., April, 1875.

5 Loc. cit., p. 75. Among Sinkler's 57 cases, only 6 furnish autopsies, thus:

Case by Cornil and Lepine and case by Webber (quoted and accepted by Erb in
Ziemssen's Handbuch, Bd. xi.); case by Gombault (rejected by Erb and Westphal);
case by Schultze; cases by Dejerine and Lucas Championnière (quoted by
Hallopeau).

The influence of heat is perhaps shown in the case related by Dyce-Duckworth in the
Lancet of 1877: a child two and a half years, after exposure to great heat on a
steamboat-landing, became paralyzed in all four limbs, but the paralysis was
subsequently confined to the lower extremities. Coincidently, the patient became
delirious; suffered from anæsthesia and temporary paralysis of the sphincters. The
paralyzed muscles wasted rapidly and lost faradic contractility. Treatment by
faradization was begun in a month from the date of the attack, and recovery was
complete three months later.
The onset of the paralysis is either really sudden, occurring in the
daytime, while the child is under competent observation, or
apparently sudden, being discovered in the morning after a quiet
night, the child having gone to bed in health (West); or is preceded
by some hours or days of fever or of nervous symptoms, especially
convulsions, or both. The paralysis is almost always at its maximum
of extent and intensity when first discovered, and from this maximum
begins, within a few hours or days, to retrocede. The improvement
may, however, be delayed much longer. A variable number of
muscles remain permanently paralyzed, and in these, within a week
(thirty-six hours, according to some observers), faradic contractility is
first diminished, then abolished; galvanic reaction is exaggerated,
ultimately is characterized by the degeneration signs (entartungs
reaction). The temperature of the paralyzed limbs falls; the muscles
waste; the atrophy may rapidly become extreme. The paralysis and
loss of faradic contractility are complete, however, while the atrophy
is only incipient and progressing. The absence of lesions of
sensibility, of visceral disturbance, of trophic lesions of the skin, or of
sphincter paralysis is as characteristic of the disease as are the
positive symptoms above enumerated.

In the third or chronic stage the paralyzed limbs often become

contracted and deformed. At other times, and with more complete
paralysis, the growth of the bones is arrested, the muscles remain
flaccid, the entire limb shrivels, and dangles so loosely from its
articulations that it may be dislocated by slight effort (membre de
Polichinelle). The general health of the patient remains remarkably
good, the intelligence clear, the disposition lively. The duration of life
seems to be in nowise shortened by the paralysis. Thus,
suddenness of development, intimate association of trophic, motor,
and electrical disturbance, absence of cerebral or sensory lesion,
peculiar localization and grouping of the permanent paralyses,—
such are the salient characteristics of this remarkable disease.

SYMPTOMS IN DETAIL.—Three well-defined stages exist—the initial, the

paralytic, and the chronic.
Initial Stage.—Seeligmüller6 signalizes three principal varieties in this
stage. The first is characterized by fever; the second by nervous
symptoms, principally convulsions, sometimes delirium or coma; in
the third no symptoms either precede or accompany the local
disease—"la paralysie est toute la maladie.”7
6 Gerhardt's Handbuch der Kinderkrankheiten, 1880 (separat Abdruck).

7 Rilliet et Barthez, Traité des Maladies des Enfants, ii. p. 551.

Mode of Invasion.—I have elsewhere8 described eight different

modes of invasion: absolutely sudden, coming on in the daytime;
morning paralysis (West), discovered after a quiet night, preceded by
fever or by vomiting alone (?), or by another typical disease,
especially one of the exanthemata, or, finally, by a traumatism,
generally slight. An interval of time almost always elapses between
the occurrence of the traumatism and the development of the
paralysis—a fact which already indicates that a definitely-evolved
morbid process must intervene between the two occurrences. An
exception is related by Duchenne fils;9 and some apparent
exceptions, in which recovery occurred rapidly, seem to belong to
the temporary paralysis of Kennedy,10 more recently described again
by Frey.11
8 Am. Journ. Obstet., May, 1874.

9 Archives gén., 1864. A father pulled his child from a table by the right arm, and set it
rather roughly on the ground. Immediate pain, almost immediate paralysis of arm,
which persisted, and was followed by atrophy of its muscles.

10 Dublin Quarterly, 1850.

11 Berlin. klin. Wochens., 1874. Frey considers these cases to be identical in nature
with, though differing in severity from, anterior poliomyelitis.

PRODROMATA.—There is rarely any lengthened period of prodromata.

Seeligmüller has noticed in some cases an indisposition on the part
of the child to stand or walk during several weeks before the
occurrence of the paralysis. He does not say whether such children
were rachitical. In marked contrast with cases of cerebral paralysis is
the habitual absence of generalized nervous symptoms. Thus in only
1 case of Seeligmüller's (total of 75) did the child suffer, and that
during six months preceding the paralysis, from intermittent muscular
contractions, and also from attacks of laryngismus stridulus.

The fever is usually of moderate severity (Seeligmüller), but

sometimes extremely high (Erb)12—as much as 41° C. (Henoch),13 or
104° F. (Barlow).14 Duchenne fils observed 7 cases alleged to be
entirely without fever, and Laborde counts 10 cases out of 50 as
apyretic.15
12 Ziemssen's Handbuch, Bd. xi. Abh. 12.

13 Vorlesung. über Kinderkrank., 2d Aufl., 1881. Seeligmüller (Jahrb. für Kinderheilk.,

1878, p. 345) quotes another case from Henoch's clinic where the fever lasted thirty-
six hours, the temperature on the first evening being 39.2°, the following morning
39.0°, the second evening 39.5°; the second morning, at which date the paralysis was
discovered, it was normal. The author states this to be the only case known to him in
which thermometric measurements were taken.

14 Loc. cit.

15 De la Paralysie de l'Enfance.

The duration of the fever usually varies from a single night to forty-
eight hours; much more rarely does it last six, eight, twelve, or
fourteen days, or even, but quite exceptionally, three or four weeks.
According to Duchenne, its intensity and duration increase with the
age of the child, perhaps indicating greater resistance on the part of
the nerve-tissues which are the seat of the morbid process of which
it is symptomatic. Rarely does it last after the paralysis has once
occurred, but ceases then with an abruptness which recalls the
defervescence of pneumonia when the exudation process is once
completed.16
 16 See p. 1144 for pathogenic inferences to be drawn from this fact. Seguin (New
York Med. Record, Jan. 15, 1874) seems to throw some doubt on the existence of
apyretic cases; but, as Seeligmüller remarks, there is too much testimony to this
possibility to render it really doubtful.

There is no proportion between the intensity of the fever and the

extent of the subsequent paralysis; nor is there any marked contrast
between the fever in children and that in adults in those rare cases in
which the disease, instead of being subacute, is sudden as in
children.

Erb considers the fever to be purely symptomatic of an inflammatory

process in the spinal cord.17 But Vogt regards it rather as an
essential factor in the development of a spinal lesion, and thus
explains the occurrence of this in the course of febrile diseases
which at the outset have no special relation to the cord.
17 Loc. cit., p. 279.

Convulsions, usually accompanied by fever, were observed in 11 of

Seeligmüller's cases out of 67; Duchenne had 13 out of 70; Heine, 9
out of 86;18 thus a total of 33 cases of convulsions in 223 cases of
infantile paralysis—nearly 15 per cent. The paralysis may set in after
a single brief convulsion, or this may be repeated several times at
variable intervals before the paralysis is definitely declared (Ross).19
The convulsive movements are apt to be particularly intense in the
limbs destined to become paralyzed (Vogt).
18 Die Spinale Kinderlahmung.

19 Loc. cit., p. 107. The author is quoting Laborde.

The convulsion may be very slight—an isolated spasm of a limb or

even a single group of muscles. Whether, on the other hand, it can
ever be so intense that the child succumbs to it before the
development of paralysis, is a question which could only be decided
by repeatedly examining the cord in the cases of convulsion which
have terminated fatally. In a case of Seeligmüller's the child was
affected for eight days preceding the paralysis by tremblings
generalized through all his muscles.

The convulsion is usually followed by a soporous or even comatose

condition, or this may replace the convulsion. Delirium may take the
place of either.

Special interest attaches to those cases where the paralysis

develops in the course of an acute specific disease; for then
becomes most plausible the suggestion of Vogt, that a fever excited
by some cause remote from the spinal cord may itself become a
cause of lesion in this centre. In Roger's first and most celebrated
case, paraplegia developed suddenly during the course of a fatal
scarlatina in a child already suffering from paralysis of the left deltoid
of two months' standing.20 The scarlatina was hemorrhagic, and, as
will be shown farther on, the autopsy showed traces of a
hemorrhagic extravasation in the cord. Thus a double influence was
presumably exerted by the scarlatina, while, moreover, the previous
and recent occurrence of a deltoid paralysis indicated a morbid
predisposition in the spinal cord. Of Seeligmüller's 75 cases, 1
occurred during scarlet fever, 1 with measles, 1 in the course of an
erysipelas, and 1 of pneumonia.
20 Gaz. méd., 1871.

Apyretic diseases, especially of the gastro-intestinal tract (Brown-

Séquard), also seem to have an influence on the development of
infantile paralysis. Two of my own cases occurred during an attack of
cholera infantum; another in a child who had been for several weeks
in bed with a purulent conjunctivitis. Study of these varied
antecedents is of interest in connection with the obscure question of
the etiology of infantile paralysis. In this latter connection we will
refer to them again.

Vomiting, or even the entire symptom-complex of gastric fever, not

infrequently ushers in the paralysis. Fever is then usually present,
but I have recorded one case of vomiting where, according to the
mother's assurance, no fever at all existed.
At the moment that the symptoms of the invasion subside, and the
child seems to enter upon convalescence, the terrifying discovery is
made that an arm or a leg or all four limbs, or even they and the
muscles of the trunk, are paralyzed.

In the severest form the child lies motionless, unable to stir hand or
foot, or even a finger or toe. Yet, singularly enough, this extensive
paralysis is sometimes overlooked, especially in very young children,
as the immobility of the patient is attributed merely to weakness
caused by previous illness. General paralysis, during at least the first
few hours of the paralytic stage, is probably more common than
appears from our present statistics. Not only, as has just been noted,
may this condition be overlooked, but it may exist during the hours of
sleep which precede the cases of morning paralysis. Seguin21
speaks as if the paralysis were at first always generalized, but this
statement seems to me somewhat exaggerated. Referring merely to
the statements of the parents, a considerable number of paralyses
would be found limited from the beginning. Heine's third table of
partial paralysis is entirely composed of cases so limited. In 16 out of
the 19 cases of hemiplegia (monoplegia) the original limitation of the
paralysis is also specified; similarly with 7 out of the 20 cases of
paraplegia contained in the first table.
21 Loc. cit.

Paralysis of one or both lower extremities is often first detected when

the child gets out of bed and attempts to walk; or in children too
young to walk the flaccid immobility of the limb attracts attention as
soon as they are again carried on the mother's arm. Paralysis of the
upper extremities is discovered early in proportion to the liveliness
recovered by the child, leading him to occupy himself with his toys as
usual. In unilateral paralysis of the trunk the child will fall over to one
side when placed in the sitting position; in bilateral paralysis it cannot
be made to sit up at all.

From lack of competent observation during the initial stage it is really

not quite certain whether any degree of paresis precedes the
paralysis; but from the testimony at present accumulated the
paralysis is nearly always complete when first observed. This is in
striking contrast with adult spinal paralysis. In some few cases the
paralysis has been observed to creep on slowly, and not reach its
maximum for several days (Ross). Laborde relates a case where
recovery from a first attack of paralysis was followed by two relapses
in the same limbs at intervals, each ushered in by fever. After the
second relapse the paralysis remained permanent.

Significance of Original Extent of Paralysis.—The question of the

original distribution of the paralysis is of special interest in
connection with that of the original distribution of the morbid process
in the spinal cord. The real effect of the latter cannot be adequately
measured by the permanent paralyses; for, as will be seen, it is not
unusual to find traces of an extensively diffused process in the cord
in cases of quite partial paralysis.

It is interesting to notice that certain muscles are always exempt

from paralysis. With the exception of a single case of paralysis of
one temporal muscle, cited by Seguin,22 the muscles of the head,
eyeballs, ears, larynx, and pharynx are always exempt, as are also
the diaphragm and intercostals. The arrest of the spinal lesion below
the medulla explains the immunity of muscles supplied by the vagus
and spinal accessory nerves. But since the cervical plexus is often
involved, the constant escape of the diaphragm, innervated by the
phrenic nerve which comes from this plexus, is remarkable. Still
more so the immunity of the intercostal muscles, whose nerves arise
in the dorsal region—a position of the cord frequently affected. This
fact tends to confirm Ross's hypothesis, that the nuclei of the
intercostal nerves lie in the vesicular columns of Clarke—columns
confined to the dorsal region of the cord, and which are invariably
found intact at autopsies of atrophic paralysis.
22 Loc. cit.

The immunity of these respiratory nerves explains the absence of

the dyspnœa which is so marked in Landry's ascending paralysis. In
the adult case described by Schultze and Erb23 dyspnœa was
present for a short time. The disease terminated fatally twenty
months from the time of invasion. In this case traces of myelitis were
found extending through the dorsal region of the cord, and including
not only the anterior nerves, but, to a less degree, the columns of
Clarke.
23 Arch. Virch., Bd. lxviii.

The facial nerve (itself a respiratory nerve) shares the immunity of

the phrenic and intercostals. In the cases in which facial paralysis
has been noted the limb paralysis has been hemiplegic, as in
Seeligmüller's twentieth case. A cerebral origin is then always to be
at least suspected.

Barlow24 has seen 6 cases of paralysis of the facial, but the histories
render a cerebral paralysis more probable in 4 out of those 6.
Henoch25 gives a case of paralysis of left arm, accompanied by
paralysis of corresponding facial nerve. The latter rapidly recovered,
but the paralysis of the arm persisted and was followed by atrophy.
Ross26 implies that the sides of the neck, face, and tongue are
always at first implicated in spinal hemiplegic paralysis, but do not
remain permanently affected.
24 Loc. cit.

25 Loc. cit., p. 205.

26 Loc. cit., p. 108.

That the facial should be affected while the other medullary nerves
escape probably depends on the more anterior position of its
nucleus.

The regression of the original paralysis is characteristic, indeed

almost pathognomonic, of the disease. It is on this account that
Barlow has proposed the name regressive paralysis.27 This author
quotes the case of a boy who at five months was affected with a
universal paralysis, even affecting the neck, but entirely recovered
except in the extensor longus digitorum of the foot. This
improvement constitutes a second apparent convalescence, as
deceptive as that which immediately succeeds the pyrexia. Only in
rare cases do all the muscles at first paralyzed remain so
permanently (Seeligmüller); nor, on the other hand, do all entirely
recover (temporary paralysis of Kennedy and Frey). Even when an
entire limb appears to be paralyzed, careful examination will usually
detect certain muscles that retain their faradic contractility. Thus the
order of frequency of paralysis in the different limbs must be
distinguished from that observed for different muscles.
27 Brit. Med. Journ., 1882.

Duchenne fils28 and Seeligmüller29 have tabulated, for lists of 62 and

75 cases respectively, the general locality of the permanent
paralyses in their order of frequency. The cases of monoplegia are
by far the most numerous. Thus in the table quoted below there are
97; in Heine's tables (86 cases), 47; in Sinkler's tables (86 cases), 29
—total, 173 from a total of 309, or nearly one-half:

Duchenne. Seeligmüller. Total.

Left lower extremity 7 27 34
Right lower extremity 25 15 40
Right upper extremity 9
10 13 23
Left upper extremity 4
All four extremities 5 2 7
Both upper extremities 2 1 3
Both lower extremities 9 14 23
Left over and under extremity 1 1 2
Right over and under extremity 0 1 1
Right over and left under extremity 2 1 3
Muscles of trunk and abdomen 1 0 1
62 75 137

This limitation is all the more noteworthy when compared with the
frequency of general paralysis at the outset.
28 Archives gén., 1864.
 29 Jahrbuch der Kinderheilkunde, N. H. xii. pp. 338-343.

The next peculiarity is the great preponderance of paralysis of the

lower over that of the upper extremities. This is noticeable even in
the monoplegias. In Sinkler's cases only two of these affected an
arm. 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. Heine
denied the existence of paraplegia cervicalis. But in the table of
Duchenne-Seeligmüller 3 cases are recorded; Rosenthal30 relates 1;
Lockhart Clarke, 1.31 This is the somewhat famous case, described
by Clarke as a progressive muscular atrophy, which contributed one
of the earlier autopsies.
30 Klinik der Nervenkrankheiten, 2 Aufl. p. 413.

31 Med.-Chir. Trans., li. p. 219.

Seeligmüller's case32 is remarkable in several respects. The

paralysis, occurring after a brief fever in a child seventeen months
old, exclusively attacked the two arms at the moment of invasion,
and never retreated from them, thus offering a double exception to
the usual rule. At four rears of age the arms were much atrophied,
and faradic contractility was lost in their muscles, the legs being
sturdily developed. Nevertheless, the child constantly fell in walking,
because, observes Seeligmüller, he was unable to balance himself
with his arms, as is habitual with little children learning to walk.
32 Jahrbuch, loc. cit., p. 349.

The hemiplegic variety of paralysis is again very rare. The

Duchenne-Seeligmüller table contains (out of 137) 3 cases; Sinkler
records (out of 86) 4; West, 5; Heine (out of 86), 1; Leyden, 1;
Duchenne, 1. West's 5 cases all present certain peculiarities, at least
unusual in spinal paralysis. In 2 the paralysis came out gradually; in
1 succeeded to remittent fever (pigmentary embolism?); in 1 was
preceded by heaviness of the head for several days; and in 1 the leg
was paralyzed fourteen days after the arm.33 It is probable that in
almost all, if not in all cases, hemiplegic spinal paralysis is the
residue of a paralysis originally generalized to all four limbs, if only
for a few hours.34
33 In three cases of hemiplegia observed by myself, and previously diagnosed as
spinal paralysis by other physicians, I doubted the diagnosis from the coincidence of
unusual cerebral symptoms. In the first case the hemiplegia appeared after coma,
during cerebro-spinal meningitis; in the second, after a violent convulsion the face
was drawn to the opposite side, and the patient, a child of seven, remained for a
month in a state of intense maniacal excitement. In a third case, developed during
convalescence from scarlet fever, the hemiplegia was preceded during two days by
hemiparesis, and accompanied for a year by complete aphasia. Finally, in these
cases faradic contractility persisted in the paralyzed limbs (Am. Journ. Obstet., May,
1874).

34 Seeligmüller relates one case where hemiplegia, including the facial nerve, was
observed in two days from the beginning of the fever.

The question of hemiplegia is closely connected with that of

paralysis of the facial nerve, inasmuch as the existence of the latter
often serves to suggest a cerebral paralysis—a suggestion
confirmed later by the absence of atrophy and of characteristic
electrical reactions. However, in some cases of undoubted spinal
paralysis the facial does really seem to have become involved. Thus
in the case just quoted from Seeligmüller (Case 20 of his table)
Henoch35 relates a case of paralysis of the left facial coinciding with
paralysis of the left arm. Rapid recovery from facial paralysis: arm
atrophied. Barlow36 records temporary facial paralysis in six cases,
but only two of these seem to be really spinal. Such temporary
paralysis is not altogether infrequent in the poliomyelitis anterior of
adults (Sinkler, Seguin). Ross37 implies that the sides of the neck,
face, and tongue are always implicated at first in hemiplegic spinal
paralysis, but do not remain so.
35 Loc. cit., p. 203.

36 Loc. cit., p. 76.

37 Loc. cit., p. 108.

Crossed paralysis is extremely rare. There are 3 cases in the

Duchenne-Seeligmüller table; Leyden38 has one. But paraplegia of
the lower extremities, coinciding with paralysis of one upper
extremity, is by no means so rare, especially as a residual paralysis.
38 Archiv Psychiatrie, Bd. vi.

Finally, as in cerebral paralysis, the muscles of the trunk, though

often paralyzed at the outset, rarely remain so in children—much
more often in adults. Eulenburg39 relates one interesting case of
complete paralysis and atrophy of the extensors of the back. Even
the interspinous muscles were involved, as shown by the divergence
of the spinous processes. The paralysis was observed in a girl of
fifteen affected since the age of three, and was completely cured in
five months by daily faradizations of ten minutes each, and two
gymnastic séances, each lasting two hours.
39 Arch. Virch., Bd. xvii., 1859.

Birdsall40 has described one case of unilateral paralysis of the

abdominal muscles.
40 Journal of Nervous Diseases.

Study of the precise combinations of the muscles paralyzed has

recently acquired peculiar interest in connection with the localization
in the spinal cord of the motor or trophic nuclei of their nerves.41
Several facts have been ascertained: 1st, that, in notable contrast
with progressive muscular atrophy, atrophic paralysis tends to
involve definite groups of muscles; 2d, that this grouping is not
effected in accordance with the proximity to each other of the
muscles on the limb, but with their functional association. Remak
affirms that Charles Bell had already called attention to the fact that
in cases of local muscular paralysis of the extremities the paralysis
does not spread by muscular continuity, but in accordance with the
functional association of muscles. Thus, paralysis of the thumb is
more often associated with that of the forearm than with paralysis of
the other muscles of the hand. 3d. From such grouping may often be
inferred a different localization of certain nerve-nuclei than would be
supposed from the position of the muscles alone. 4th. That the fibres
contained in a single nerve-trunk, but distributed to different muscles,
probably separate from each other within the cord, to be there
distributed to variously-situated nuclei.42
41 Ernst Remak, “Localis. der Atroph. lahmung,” Archiv f. Psych., ix., 1879; Ferrier,
Brain, vol. iv. No. 3; also, Proceedings Royal Society, No. 212, p. 12.

42 The theory of course assumes the truth of the demonstration by which atrophic
paralysis is rendered symptomatic of disease of the spinal cord, and the nutrition of a
muscle dependent on the integrity of the muscles of origin of its nerves.

In the arm two mutually correlative cases are observed: (a) Immunity
of the supinator longus during paralysis of the forearm muscles; (b)
paralysis of the supinator in association with paralysis of the deltoid,
biceps, and brachialis anticus. The latter constitutes Remak's upper-
arm type of localization, and is exhibited in his first case.43
43 Loc. cit.; also, cases 1st and 2d by Ferrier, in which, however, other shoulder-
muscles were involved.

Ferrier has experimentally confirmed this muscular association by

means of isolated irritation of the fourth cervical nerve, which threw
into contraction the supinator longus, together with the deltoid,
biceps, and brachialis internus. At the same time, in the experiment
the flexors and extensors of the wrist were excited, while in the
special form of paralysis noted they were exempt. This electrical
method is a less precise mode of analysis than the pathological, for
the double reason that (a) fibres whose nuclei are dissociated may
pass together in the same root; (b) because the same muscles
receive fibres from more than one root: thus the flexors and
extensors of the wrist from the fifth as well as the fourth cervical.
Thus when the nucleus of the latter was destroyed paralysis would
be averted by means of the fibres coming from the fifth root.

The experiment and the pathological observation, however, concur in

indicating that the fibres innervating the supinator longus, though
passing to it in the path afforded by the radial nerve, afterward
ascend in the cord to a ganglionic nucleus in close proximity to those
of the upper-arm muscles specified—liable, therefore, to be affected
with them. The purpose effected by such association is the
supination of the arm.

It is excitation of the fourth root in Ferrier's experiment which gives

results most closely corresponding to Remak's observations.
Excitations of the fifth and sixth root reveal other combinations,
which Ferrier has found realized in adult's spinal paralysis. Thus in
his second case, in addition to the group of muscles already
mentioned, the rhomboid, infraspinatus, and serratus magnus were
paralyzed, the last muscle indicating complication with the fifth root.
In the third and fourth cases muscles supplied from the sixth root
were joined to those innervated by the fourth and fifth—namely, the
pectoralis major and latissimus dorsi.

In this upper-arm type the muscles affected are supplied by three

different nerve-stems—the axillary, musculo-cutaneous, and the
radial. In the forearm type the most common variety consists in
paralysis of the extensors of the wrist, thus exactly imitating lead
palsy.44 The supinator remains intact, the intrinsic muscles of the
hand are sometimes intact, sometimes paralyzed. Sometimes,
however, the extensors are relatively intact; the interossei are
atrophied, and a clawed hand, resembling that characteristic of
cervical hypertrophic pachymeningitis, is developed.45
44 It is on this fact, indeed, that Remak has been led to argue the spinal nature of
saturnine paralysis (“Zur Pathogenie der Blei lahmung,” Archiv für Psych., Bd. vi.,
 1876).

45 The march of this disease, together with that of tabes dorsalis, furnishes data for
localizing the nervous nucleus for the wrist extensors. In both diseases the lesion is
ascending: in tabes disturbance of sensibility occurs first in the distribution of the
sensory fibres of the ulnar nerve; in cervical pachymeningitis the flexors and intrinsic
muscles of the hand are first paralyzed. Hence it is to be inferred that the central
nucleus for the latter muscles lies in the lower, that for the extensor muscles in the
middle, segment of the cervical enlargement of the cord.

The much greater frequency of extensor paralysis in the forearm

type of anterior poliomyelitis indicates that the lesion of this disease
begins about the middle of the cervical enlargement (see note).

The foregoing groupings have been made out almost entirely from
cases of adult spinal paralysis or else of lead palsy. In the lower
extremity it is much more difficult to establish such definite muscular
association. Certain laws, however, can be made out: 1st. The
liability to paralysis increases from the thigh toward the foot; thus,
the muscles moving the thigh on the pelvis are the least liable to
paralysis, then those moving the leg on the thigh, while the muscles
moving the foot and leg and thigh are the most frequently paralyzed
of any in the body. 2d. Of the upper thigh-muscles, the glutæi are not
infrequently paralyzed, the ilio-psoas hardly ever, the adductors
rarely except in total paralysis. 3d. Of the muscles moving the leg on
the thigh, the quadriceps extensor is very frequently paralyzed—the
most often, indeed, after the foot-muscles: the sartorius is almost
always exempt; the liability of the hamstring muscles corresponds to
that of the thigh adductors. 4th. At the foot the tibialis anticus often
suffers from isolated paralysis, sharing in this respect the fate of the
deltoid in the upper extremity—a fact already noticed by Duchenne.
On the other hand, (5th) the tibialis anticus often remains intact while
the other muscles supplied by the perineal nerve, the perineus
longus and brevis, are completely paralyzed.46
46 Thus Buzzard relates a case of paralysis involving the quadriceps extensor and
peroneal muscles, while the anterior tibial were intact.
The remarkable contrast in the morbid susceptibility of the
quadriceps on the one hand, and the sartorius on the other, suggests
dissociations of their nuclei. Remak relates one interesting case
(Obs. 13) where the sartorius was paralyzed—coincidently with the
quadriceps, it is true, but also with partial paralysis of the ilio-psoas
muscle, which is as rarely attacked as the sartorius itself. The two
facts, taken together, would indicate that the nucleus of the sartorius
lies high in the lumbar enlargement, in proximity to that of the ileo-
psoas. The inference, continues Remak, is reinforced by functional
considerations, since the sartorius, obliquely flexing the leg on the
thigh, is generally in action at the moment that the psoas flexes the
thigh on the pelvis.

Again: according to Remak the tibialis anticus is generally paralyzed

together with the quadriceps extensor, although supplied by a
different nerve.47 And this should be expected from the necessity of
exciting dorsal flexion of the foot by means of the tibialis anticus at
the moment of extending the leg for the act of walking.48
47 Obs. 14, 15, 16, 17, from Remak's essay.

48 At the moment that the foot is thus flexed, however, to allow the leg to be swung
forward, the thigh and leg are both slightly flexed.

Ferrier, from his experiments on the roots of the lumbar plexus, is

inclined to doubt this association of the tibialis anticus with the
quadriceps, and he adduces Buzzard's case, already quoted, to
show coincident paralysis of the quadriceps and peroneal muscles. It
is not improbable, however, that fibres associated together in nerve-
roots may again diverge in the cord, and thus the discrepancy would
be explained.

DIAGNOSIS OF SPECIAL PARALYSIS.—Paralysis of isolated muscles may

sometimes be concealed by the vicarious action of their synergists:
thus of the extensor communis for the tibialis anticus. Paralysis of
both legs and feet may even be partly concealed by the energy of
the thigh-muscles, which, using the paralyzed segments of the limbs
as inert supports, succeeds in effecting locomotion.49 On the other
hand, in limbs apparently abandoned to total paralysis persevering
search will often discover some muscles or parts of muscles which
respond to faradic electricity: these must be considered as
susceptible of ultimate recovery.
49 Thus in Cornil's famous case, Soc Biol., 1863.

The following table sums up some special diagnostic marks for the
different paralyses50 afforded by the position of the limb and loss of
movements:

Upper Extremity. Deltoid. Absence of deformity, which is averted by weight of arm.

Inability to raise arm. Sometimes subluxation. Frequent association with paralysis,
biceps, brachialis anticus, and supinator longus.

Lower Extremity. Ilio-psoas. Rare except with total paralysis. Associated with
paralysis, sartorius. Loss of flexion of thigh. Limb extended (if glutæi intact).

Glutæi. Thigh adducted. Outward rotation lost. Lordosis on standing. Frequent

association with paralysis of extensors of back.

Quadriceps extensor. Flexion and adducting of leg (if hamstrings intact). Loss of
extension of leg. Frequent association with paralysis of tibialis anticus.

Tibialis anticus. Often concealed if extensor communis intact. If both paralyzed, then
fall of point of foot in equinus. Dragging point of foot on ground in walking. Big toe in
dorsal flexion (if extensor pollicis intact). The tendons prominent. Hollow sole of foot
(if perineus longus intact).

Extensor communis. Nearly always associated with that of tibialis anticus. Toes in
forced flexion.

Peroneus longus. Sole of foot flattened. Point turned inward. Internal border elevated.

Sural muscles. Heel depressed. Foot in dorsal flexion (calcaneus). Sole hollowed if
perineus longus intact; flattened if paralyzed. Point turned outward (calcaneo-valgus).

Extensors of back. Lordosis on standing. Projection backward of shoulders. Plumb-

line falls behind sacrum (unilateral). Trunk curved to side. Trunk cannot be moved
 toward paralyzed side.

Abdominal muscles. Lordosis, without projection backward of shoulders.

50 See Duchenne, loc. cit., and also Roth, On Paralysis in Infancy, London, 1869.

After the paralysis the most remarkable symptom of anterior

poliomyelitis is the rapid wasting of the paralyzed muscles. The
atrophy begins within a week after the paralysis, and its progress is
even more rapid than that following the section of a nerve.
Sometimes all the flesh on a limb is shrivelled down to the bone; at
other times the muscular atrophy is concealed by an abnormal
development of fat, constituting a pseudo-hypertrophy. When all the
muscles surrounding a joint are equally paralyzed and atrophied, no
deformity develops,51 unless, indeed, the segment of a limb is used
by means of the non-paralyzed proximate segment. In this case
deformities may be produced by the effect of weight quite
irrespective of muscular action, or in directions opposed to what we
should expect from that.
51 Except talipes equinus.

The weight of the limb or a portion of it, by stretching paralyzed

muscles, often aggravates their atrophy. This is most likely to occur
with the paralyzed deltoid when the arm is unsupported, and with the
anterior tibial muscles when the foot is allowed to drop.

Muscular atrophy occurs in the spinal paralysis of adults as well as in

children; but in the latter alone does the atrophy extend to the bones
and cartilages, tendons, fascia, ligaments, and blood-vessels. The
osseous projections to which the muscles are attached waste; so do
the epiphyses.52 The long bones are thinner and shorter, the foot is
shorter, and the hand is shortened in paralysis of the upper
extremity, even where this is limited to the upper arm, and the
forearm is scarcely affected (Seeligmüller).
52 Seeligmüller, Centralbl. f. Chirug., No. 29, 1879.
In exceptional cases the limb may become even elongated from
passive extension of the ligaments of the articulation. The bones
may become soft and flexible, and break if pressure be applied.53
53 Ch. Salomon, “Des Lesions osseuses et articulaires lieés aux Maladies du
Système nerveux,” Revue mensuelle, No. 8, 1878.

Atrophy of the bones stands in no fixed relation to that of the

muscles, now exceeding, now falling short of that in intensity. This
naturally progresses more slowly; still, within seven or eight months
there may be a centimeter of difference between two limbs.

In marked contrast with this profound trophic disturbance of the

bones is the intact nutrition of the skin. The absence of decubitus is
indeed an important diagnostic mark from ordinary myelitis. The
subcutaneous fat, however, wastes so completely that the skin
seems to be closely adherent to the subjacent tissues, and cannot
be pinched up into folds.

The temperature of the skin always falls; the limb is perceptibly

colder to the touch than its fellow, and is often bluish and cyanotic.
Heine has observed that the temperature diminishes gradually from
the centre to the periphery, and at the coldest point may sink to 14°
R.54 Hammond relates a case where the local temperature was 75°
in an atmosphere of 72°. The author says that exact measurements
of surface temperature should be taken with Lombard's differential
calorimeter, especially when convalescence is expected, as then a
rise of temperature, however slight, is of most favorable augury.
54 Loc. cit., p. 16. This is not a difference of 14 degrees between the sound and
paralyzed limbs, as is erroneously quoted by Seeligmüller (loc. cit., p. 67).

General factors contribute to the fall of temperature: diminished

blood-supply from shrinkage of blood-vessels, or even atrophy of a
certain number among these; loss of nerve-influence upon the
oxidation processes; loss of muscular contractions, which should
attract an afflux of blood. Among these factors the loss of nerve-
supply is probably the most important, since the others exist in