in the paralysed limb. The whole of the limb is not necessarily paralysed, often it is only a group of muscles, and even if the paralysis affects both legs or the arm and leg on one side, it generally fails in the uniform distribution of the previously described paraplegia or hemiplegia. The affected muscles rapidly waste and become flaccid, the electrical reactions change, and finally the muscles may cease to respond to electrical stimulation whether of the continuous or interrupted current. In the less severe cases (and they are the most common) only a group of muscles undergo complete paralysis and atrophy, and there is always hope of some return of power in a paralysed limb. Associated with the withered condition of the limb due to the muscular atrophy is an enfeebled circulation, rendering the limb cold, blue and livid; the nutrition of the bones and other parts is involved, so that a limb paralysed in early infancy does not grow and is shorter than its fellow. Deformities arise, some the result of simply failing muscular support; others due to permanent changes in the position of the limbs, for example clubfoot. There is absence of bladder and bowel troubles, and bedsores do not occur; the disease itself is rarely, if ever, fatal. About a month after the onset of the disease local treatment of the atrophied muscles should be commenced, and every effort should be made by massage, by suitable positions and passive movements to promote the circulation and prevent deformities in the affected limbs. Should these measures fail, surgical aid should be sought.
Sub-acute and chronic forms of atrophic and spinal paralysis have been described, but some of them were undoubtedly cases of peripheral neuritis.
Wasting Palsy. Progressive Muscular Atrophy.—This is a chronic disease characterized by slow and insidious weakness and wasting of groups of muscles due to disease of the anterior spinal grey matter. It begins mostly in adult life between 25 and 45 years of age, and affects males more than females. In the majority of cases it commences in the upper extremities, and the small muscles of the hand are especially liable to be affected. The palmar eminences of the thumb and little finger, owing to the wasting of the muscles, gradually disappear, and a flat ape-like hand is the result; in extreme cases all the small muscles of the hand are atrophied, and a claw-like hand is the result. The muscles which are next most liable to atrophy are those of the shoulder and upper arm, and the atrophy may thence spread to the muscles of the neck and trunk, and the intercostals and even the diaphragm may be affected, causing serious difficulties of respiration. The lower extremities are less often and later affected by wasting. This disease generally runs a slow and progressive course; it may however be years before it spreads from the hand to the arm, and a, period of arrest may occur before other muscles become involved. A characteristic feature of the disease is fibrillary twitching of the wasting muscles. The electrical excitability of the muscles is diminished rather than changed, except where the wasting is very extreme, when a partial reaction of degeneration may be obtained. Sensation is unaffected, as the disease is limited to the motor cells of the anterior grey matter (see Neuropathology). There is no affection of the bowel or bladder. Death usually occurs from intercurrent diseases, e.g. bronchitis, pneumonia, or broncho-pneumonia. Some patients die owing to failure of the respiratory muscles; others from the disease spreading to the medulla oblongata (the bulb of the brain) and causing bulbar paralysis. The chronic morbid process leading to decay and destruction of the spinal motor cells which is the essential pathological feature of this disease is generally accompanied, and sometimes preceded, by degeneration of the path of voluntary impulses from the brain. It is then called amyotrophic lateral sclerosis, a rapid form of progressive muscular atrophy.
Bulbar Paralysis.—A number of different morbid conditions may give rise to a group of symptoms, the principal features of which are paralysis of the muscles concerned in speech, swallowing, phonation and mastication. These symptoms may arise suddenly from vascular lesions or inflammatory processes, which involve the nuclei of origin of the cranial nerves supplying the muscles of the tongue, lips, pharynx and larynx. But there is also a slow degenerative insidious progressive bulbar paralysis affecting both sexes pretty equally; it came on between 40 to 60 years of age, and the cause is unknown. Slight indistinctness of speech, especially in the utterance of consonants requiring the elevation of the tip of the tongue to the dental arch and palate, is usually the first symptom. Later the explosive lip sounds are indistinctly uttered; simultaneously, owing to paralysis of the soft palate, the speech becomes nasal in character and sooner or later, associated with this difficulty of speech, there is a difficulty of swallowing, partly because the tongue is unable to convey the food to the back of the mouth, and it accumulates between the cheeks and gums. Moreover the pharyngeal muscles are unable to seize the food and start the process of swallowing on account of the paralysis of the soft palate; liquids are apt to regurgitate through the nostrils, the patient must therefore be nourished with soft semi-solid food. As the disease proceeds, the difficulty of speech and swallowing is increased by the affection of the laryngeal muscles; the pitch of the voice is lowered and the glottis is imperfectly closed during deglutition; there is consequently a tendency for liquids and food to pass into the larynx and set up fits of coughing, which, however, are ineffectual. Later the muscles of mastication are affected and the disease may extend to the respiratory centre, giving rise to attacks of dyspnoea. The intellectual faculties are as a rule unimpaired, although the facial expression and the curious emotional mobility of the countenance, with a tendency of the patient to burst into tears or laughter, would suggest weak-mindedness. Whilst the lower half of the face is strikingly affected, the upper half retains its normal expression and power of movement. This disease is usually rapidly fatal, since it affects the vital centres, and liability to bronchopneumonia excited by the entrance of food into the air passages is also a constant danger in the later stages.
Bulbar Paralysis without Anatomical Change.—This condition is also termed “myasthenia gravis”; it differs from acute and chronic bulbar disease by the absence of muscular atrophy, by normal electrical excitability of the muscles, by a marked development of the paralysis by fatigue, and by considerable remissions of the symptoms. The bulbar symptoms are the most prominent, but all voluntary muscles are more or less affected, especially the eye-muscles. It is a rare disease affecting both sexes equally at almost any age, the causes and pathology of which are unknown.
3. Paralysis resulting from disease or injury of the motor path to the muscles in the peripheral nervous system.
Neuritis.—Paralysis may arise in a muscle, a group of muscles, a whole limb, the lower extremities, or there may be a generalized paralysis of voluntary muscles as a result of neuritis. A typical example of neuritis giving rise to paralysis owing to inflammatory swelling and compression is afforded by the facial nerve; this purely motor nerve as it passes out of the skull through a narrow bony passage is easily compressed and its function interfered with, causing a paralysis of the whole of one side of the face and Bell’s Palsy. Exposure to a cold draught in a person with rheumatic diathesis is a frequent cause. As an example of simple mechanical compression producing paralysis, crutch palsy may be cited; it is the result of continuous compression of the musculo-spiral nerve as it winds round the bone of the upper arm.
Lead poisoning may give rise to a localized neuritis affecting the posterior inter-osseous nerve, especially in painters and in those whose occupations necessitate excessive use of the extensors of the forearm; the result is wrist drop or lead palsy.
Sciatica is a painful inflammatory condition of the sciatic nerve, in which there may be weakness of the muscles; but inability to move the limb is more on account of the pain it causes than on account of paralysis of the muscles. Exposure to cold and wet, e.g. sitting on a damp seat, may lead to sciatica in a gouty or rheumatic person.
Multiple neuritis is a painful generalized inflammation of the peripheral nervous system and arises in many toxic conditions
