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Gray's 'Descriptive Anatomy.' And in appealing to these and other gentlemen to do their best to raise the subject to the rank ot a science, we feel assured we are only uttering the wishes of the best-informed of educated society.
Pathologie und Therapie der Muskellahmung. Von Dr. Hermann Friedrerg, Dirigenten einer chirurgischen und aogenilrztlichen Privatklinik, Docenten an der Friedrich-Wilhelm's Universitat in Berlin. Mit 4 Tafeln Abbildungen.— Weimar, 1858. pp. 349.
Tlie Pathology and Therapeutics of Muscular Paralysis. By Dr. Hermann Friedrerg. With Plates.
Morrid anatomists often resemble the engineer, who, in determining the causes of an accident on a railroad, would seek for them only in the construction of the steam-engine, in the safety-valve, the boiler, or some part of the moving power of the whole apparatus, while he neglected the axletrees of the carriages or their wheels, or some other extraneous part of the structure, which might no less have been faulty, and have thus given rise to a fatal accident. Similarly have medical men been disposed to look to the viscera too exclusively for the interpretation of morbid phenomena, forgetting or overlooking the important bearing of the external organs upon disease and its manifestations. There can be little difference of opinion as to the relative importance of the various organs of the body; their necessity to the preservation of physical and mental life and individuality at once enables us to fix their rank; but while we willingly concede to the nervous centres, the organs of circulation and respiration, the organs of assimilation, a higher position in the scale than to the organs of locomotion and protection, yet we fail in taking a comprehensive view of the physiology and pathology of these parts if we deny to the latter the undoubted prerogative that they possess of initiating processes which may re-act upon the former. We do not claim absolute mathematical stringency for any classification of morbid processes; we know that it ia scarcely ever possible that in man one organ should suffer without consensual suffering of the entire system; yet, unless we are to lose ourselves in vague generalities which lead to nothing, we cannot but see that, physiologically and pathologically, certain functions and derangements of function take place in one or more organs antecedently to changes that are effected in other organs, and that these two series of changes bear to one another the relation of cause and effect.
The more profound our knowledge of the changes that accompany functional derangement of the body, the more completely we disprove the evidence of ancient sluggishness, that life could be arrested without material change in the organs necessary to life. Every autopsy in which we fail to discover those changes proves merely that our knowledge of life and death is defective, not that the changes do not exist. How many sudden deaths for which formerly no apparent cause could be assigned, are now readily traceable to plugging of the arteries, or to fatty degeneration of the heart. Every advance made by aid of the scalpel, the microscope, or the test tube, towards the determination of organic change, diminishes those opprobria medidnai the cases of disease and death for which no adequate cause can be assigned. Nervous pathology has been in medicine the scapegoat upon which more professional sins have been heaped than any other; and hysteria, neuralgia, nervous apoplexy, hyperesthesia and anaesthesia, spinal irritation, are a few of the many terms with which we seek to cloak our ignorance of the real nature of many disorders, the intimate nature of which is beyond our ken. But there are many and able workers in the field. Every now and then a stride is made in advance which opens out a new vista, while it shows the value of steady perseverance even where no immediate result promises to accrue from our researches. At the present moment the organs of locomotion engage the attention of inquirers more than they have done before, and the muscles are made responsible for derangements seriously affecting the health of the individual and involving his prospects of life, which have long been regarded as depending upon disease of the nervous centres. The interesting work of Dr. Inman has recently drawn our attention forcibly to the fact, that overworked muscles may cause pain in their tendinous insertions, simulating inflammation of vital viscera or neuralgia of nervous cords ; he has shown the close relation between amentia and exhaustion, and tendon-pain and muscular spasm, from which important corollaries follow regarding the treatment of the disorders in question. Dr. Inman's researches and observations have materially narrowed the field of hysteria and spinal irritation. Dr. Roberts has successfully collected the evidence we possess regarding the existence of fatty degeneration of the external muscles, giving rise to a disease which, until a recent date, was confounded with paralysis arising from lesion of the brain or spinal cord. Dr. Friedberg, the author of the work heading this article, has still further extended the pathology of this disease, and investigated the question of muscular degeneration in connexion with various disorders which have not hitherto been regarded as being primarily seated in the muscles. While we believe that Dr. Friedberg has by no means exhausted the topic, and while it appears to us that he somewhat confuses the subject by mixing up primary and secondary morbid conditions as essentially identical, we owe him thanks for enlarging our field of view, and trying to combine into one chain numerous detached links which by themselves lacked meaning or have been erroneously interpreted.
The main difference between neural and muscular paralysis, in regard to the nutrition of the muscle, consists in this, that in the former the nutrition of the muscle is secondarily affected, whereas in the latter it is the primary disturbance which attracts the attention of the patient and his physician: in order to define the disease as originating in the muscle itself and depending upon a lesion of its proper texture without involving himself in any pathological theory as to the nature of the changes that are effected, Dr. Friedberg coins the word myojxithia, with its derivative myopathic. Myopathia is a disease of the muscles, and as movement is the main function of these organs, it is scarcely conceivable that disease should settle in them without proportionately impairing this property. Loss of motor power is one form of paralysis, hence myopathic paralysis is almost necessarily a term at once required to designate the site and chief expression of muscular disease. The main objection that we see to this new term is, that it multiplies the designations of a disease already known as progressive muscular atrophy, fatty degeneration of the muscles, progressive muscular paralysis, and wasting palsy. In itself it is good, because it involves no hypothesis, but simply expresses a fact. Having in our last number* dwelt upon the symptomatology and anatomical changes that take place in the muscles in this disease, we need not again recur to them, but shall only draw attention to the features peculiar to Dr. Friedberg's work.
After passing in review the doctrines advocated by Romberg, Cruveilhier, Valentin, and Leubuscher regarding the disease under consideration, Dr. Friedberg sums up his arguments in favour of muscular atrophy occurring independently of lesion of the nervous centres and the nerves, thus:—
"1. The grey matter of the cord may be extensively diseased, without the occurrence of progressive atrophy and paralysis of the muscles.
"2. Other parts of the spinal cord may be diseased in progressive atrophy of the muscles without the grey matter being involved.
"3. Even when the entire muscular system is involved in the atrophy and paralysis, both the spinal cord and the nerves proceeding from it have been found perfectly healthy.
"4. The assumption that degeneration of the roots of the spinal nerves is the cause of the paralysis connected with muscular atrophy, is opposed to scientific data." (p. 118.)
Dr. Meryon's well-known cases,* with others that have been examined with equal care, are brought forward in support of the above doctrines. The change itself which takes place in the muscular fibre may be derived from various causes, which the author classifies under six heads, and accordingly he establishes six varieties of myopathia.
"The derangement of nutrition of the muscles inducing paralysis may arise— "1. From propagation of a similar morbid process from adjoining organs (myopathia propagata sive communicate).
"2. From mechanical injury (myopathia traumatica).
"3. From sudden change of temperature (myopathia rheumatica).
"4. From diseased conditions of the blood (myopathia dyscrasica).
"5. From diminished supply of blood and diminished exercise (myopathia marasmodes).
"6. From causes which are beyond our reach (myopathia simplex)." (p. 136.)
Why we should term that disease simplex of which we know least, we are puzzled to determine; but we are acquainted with the difficulty of inventing a nomenclature, so let that pass. We have, however, a much more serious objection to raise to the pathological doctrines taught by our author in the ensuing section of his work, doctrines for which we and our readers would be the less prepared after learning that the author lays so much stress upon the derangement of nutrition accompanying the muscular atrophy, and after perusing the list of circumstances to which that derangement is attributable. Dr. Friedberg enunciates that inflammation of the muscle induces the changes which characterize muscular paralysis, and that muscular atrophy can only be the consequence of a disorder which alters the nutrition of the muscle 'in the same way as inflammation;' in other words, that in the six varieties of muscular paralysis enumerated above, inflammation is equally the causa proximo, in all. With all respect for the learned author, we cannot but think that his desire to generalize has here led him into a serious error, for the time has passed when degenerative processes and inflammation were regarded as identical. Traumatic influences, sudden changes of temperature, and the propagation of inflammation from adjoining textures, may undoubtedly cause muscular paralysis by exciting inflammation in the muscle, but we are unable to understand how Dr. Friedberg's fourth and fifth varieties can be regarded as dependent upon inflammatory action. Under those forms which depend upon diseased blood he enumerates typhus and lead poisoning as causes; these can, as little as arrest of the supply of blood or diminished exercise, be regarded as in anyway suggestive of inflammation. While, then, we will not deny that primary inflammation of the muscles may be the immediate cause of muscular paralysis, we think that it is essentially a degenerative process that leads to these results, without at any time showing symptoms that are of an inflammatory character. Moreover, we would suggest that the majority, if not all, of the cases in which inflammation is the cause, may be classed together as second to, or symptomatic of, some other affection; at all events there is, even according to the author's Bhowing, a wide difference between those which may be regarded as inflammatory and those in which inflammation manifestly has no part. We have at this moment a case of well-marked muscular paralysis under our care, in which it is impossible to trace any symptoms indicating in its history, inflammation; it has been from the first degenerative; a gradual wasting, dependent doubtless upon an impaired state of nutrition, in which color, rubor, tumor, dolor, at no time or in any combination, formed an item. But even if in one or other of the varieties of muscular atrophy, inflammation is the first step in the morbid process, it generally comes under the notice of the practitioner only when all trace of inflammatory action has subsided,
* Medlco-Cbirurglcal Transactions, vol. zxxy.
when he has to deal only with a condition demanding the most active and persistent stimuli that we are able to apply. Nor does it appear that there is any material difference between our views and those of the author upon the question of tre<- ment. His theory does not interfere with the practical tact which directs him to avoid all antiphlogistic remedies for the cure of muscular paralysis. Of thk Avc will speak again. For the present a brief analysis of the features and circumstances characterizing and surrounding the various forms of muscular paralysis spoken of by the author, may be the subject more immediately interesting to our readers.
1. Myopathia Propagata.—A muscle that is in contact with inflamed tissue may cease to contract, either because movement of the adjoining parts is painful, or because the inflammation is communicated to the muscle itself. In peritonitis and in pleuritis, the abdominal muscles and intercostals may be respectively involved in this way; the right half of the diaphragm may thus be paralysed in inflammation of the liver, and the muscular tissue cease to respond to the stimulus of the blood in pericarditis. Neuropathologists are apt to treat all these and analogous cases as the result of reflex nervous paralysis, overlooking the most immediate effects of influence by mere contact. Again, conjunctivitis may in a similar manner induce paralysis of the levator palpebral superioris and of the orbicularis palpebrarum, so as to give rise to ptosis and ectropium. Inflammation of the lumbar muscles may result from nephritis; the muscles surrounding the shoulder and other joints are attacked by inflammation, and its degenerative sequelae, as a consequence of inflammation of the parts immediately involved in the structure of the articulation. All these are clearly not primary affections of the respective muscles, and therefore differ essentially from Cruveilhier's disease.
2. Myopathia Traumatica.—A change in the nutrition of the muscles may be induced by an external injury, which need not necessarily be very severe to give rise to the effect spoken of; there may be comparatively little pain or other evidence of a serious lesiou, where subsequently the degenerative process is developed.
"Traumatic myopathia not unfrequently occurs in children who, for instance, have been suddenly caught up by the arm when they were on the point of falling, or were roughly pulled by the leg while they were undressing. Some hours, or at the latest some days after the injury, one finds, generally when the child is taken out of bed, that one arm or leg is motionless and very painful to the touch. I have seen cases of this kind, in which a partial dislocation or an affection of the nervous centres had been erroneously diagnosed."
Here, as in regard to the other varieties, the author gives detailed cases that have fallen under his own observation, confirmative of his views, and analyses critically the accounts found in various authors of affections which, as he avers, have hitherto been falsely interpreted. Thus he considers that the debility and emaciation of fractured extremities after the consolidation of the fracture is attributable rather to inflammation set up in the muscles contiguous to the injured bone, than to mere inactivity, because the loss of power and substance bear no ratio to the period during which the limb has been inactive. Again, after amputation, we meet with a traumatic myopathia in the muscles of the stump, as evidenced by the twitchings, the fatty degeneration, the atrophy of the muscles, and by the bad position of the stump.
"The twitchings are at first to be attributed to the altered pressure of the blood, but subsequently to the deranged nutrition of the muscles, resulting from the lesion and leading to atrophy and paralysis. This does not exclude the possibility of the muscular twitchings originating in the lesion of the nerves, nor of the muscular atrophy resulting from loss of movement. Here we also see the paralysis affecting chiefly the extensors; hence the stump assumes the flexed position."
Dr. Friedberg points out that excessive fatigue and other lesions of certain muscles may induce traumatic myopathia in -them, and refers to cases reported by Darwall, Aran, himself, and other writers, in evidence of bis observations.
3. Myopathia Rheumatica.—Dr. Friedberg avoids a discussion as to the intimate nature of rheumatism, by defining rheumatic myopathia to be that variety of the affection in which degeneration of the muscles results from exposure to sudden changes of temperature. It may be acute or chronic, and lead to universal degenerative atrophy and pals)7 of the muscles. The author describes rheumatic inflammation of the muscles as proceeding either from the fascial arjd subfascial areolar tissue, or attacking ab initio the interstitial areolar tissue of the muscles. The continuity of the different layers of areolar tissue leads to infiltration of the deeper and superficial parts coincidently; this infiltration has been termed by Proriep the rheumatic callosity (rheumatische Schwiele), and he asserts that it invariably occurs in the skin and the subcutaneous areolar tissue as an accompaniment of rheumatic pains. Among the various instances brought forward by Dr. Friedberg, we may briefly quote the main features of one detailed by Cruveilhier. A rope dancer, named Lecomte, spent a night, in 1848, on damp ground in the open air; on waking up he felt a numbness pervading the right side of the body. Three weeks later he perceived so great a weakness in the right hand that he found it very difficult to grasp anything. This remained the only symptom for about a year; he then again passed a night in the open air, in cold damp weather, followed by considerable weakness in the lower extremities. From this time the disease made rapid strides, and when the man came under the care of Professor Cruveilhier, the paralysis and atrophy, which were accompanied by the characteristic fibrillary tremors, had already involved numerous muscles. The special senses, the intellect and sensibility, throughout remained unaffected. The upper extremities, the muscles of deglutition, those of the larynx, the thorax, and the face, were affected, though they still contracted under the galvanic stimulus. The patient could only swallow with great difficulty after forcing the mouthful into the pharynx. The paralysis and emaciation of the muscles continued to increase, and the patient died in January, 1853, of influenza.
It is manifest that rheumatic myopathia may, as the author points out, be complicated with an affection of the cord, and it will often be a matter of some difficulty to establish the diagnosis; on the one hand, we have in idiopathic muscular paralysis atrophy of the muscles disproportioned to the duration of the disease, and affecting prominently certain groups of muscles in which fibrillary twitchings or tremors are perceived, sensibility remaining unimpaired and the affection spreading consecutively from one group of muscles and one extremity to another; in pure spinal paralysis, both sides of the body are commonly affected at the same time, motion and sensation are generally both more or less impaired, there is tenderness and pain in some portion of the spinal column, the wasting is more uniform and more gradual, and the sphincter muscles are more liable to become paralysed than in muscular palsy. The galvanic test may also be of assistance in cases of doubt, inasmuch as the reaction to the galvanic current will in muscular palsy be exactly proportionate to the amount of degeneration which has taken place. Whereas, in spinal paralysis dependent upon disease of the cord, the galvanic stimulus will from the first cease to produce a reaction, and all the muscles of an extremity will equally show the same amount of impairment.
4. Myopathia Dyscrasica.—We have already expressed the objections that wc feel to the author's mode of viewing idiopathic muscular palsy, and should be disposed in all cases to assume the presence of a dyscrasia, without which the change of nutrition characteristic of the disease could not be excited. If any affection could, in our opinion, be cited as peculiarly representing a dyscrasic disease, it is fatty degeneration of the voluntary muscles. Dr. Friedberg, however, limits the term to certain forms of the malady accompanying or following diseases that impair the nutritive functions. Cholera, dysentery, typhus, gastric fever, the exanthematic fevers, are successively reviewed in their bearings upon the disease in question, and cases are addueed to show that muscular degeneration may occur as one of their sequelae. With regard to the paralytic affection sometimes occurring during pregnancy and after confinement, the author remarks, that although