Civil War Washington

As the subject of reflex paralysis is one of great interest in the study of spinal injuries, and has been thoroughly and exhaustively treated in Circular 6, S. G. 0., March 10, 1864, it is deemed proper to reproduce the Circular [MITCHELL, MOREHOUSE, and KEEN, Gunshot Wounds and Other Injuries of Nerves, Philadelphia, 1864, p. 22 et seq.] at this point:

"We have seen that in all probability the state of shock from gunshot injuries is a state of general paralysis. We have also seen that in the great mass of cases it is temporary. We have now to show that in rare instances the paralysis continues as a more or less permanent evil after the general depression has passed away. When, therefore, a wound occurs, and the patient surviving the first effect is found to have paralysis of a distant limb or limbs, it is impossible to deny to such cases the title of reflex paralysis. . . . [T]he following instances seem to us to have fulfilled every condition which would entitle them to be so considered:

"CASE II.—Flesh Wound of Right Thigh, without wound of any large nerve; complete paralysis of all four limbs; speedy recovery of the left arm, tardy recovery of the other limbs, subsequent analgesia of the right side.

"Jacob Demmuth, aged 21, Swiss, enlisted July, 1861, company 'D,' 108th New York Vols., a man somewhat below the average standard of height, of lymphatic temperament and moderate intelligence. Reports himself as healthy up to the date of his wound, which took place at Fredericksburg, December 13, 1862. He was marching at double-quick, when a fragment of shell as large as a musket ball struck his right thigh at the junction of the upper and middle thirds, directly over the femoral artery. The fragment did not enter deeply, but merely lodged in the leg, and was removed a day later without injury to the vessel. Effect of wound.—He fell half conscious, and although aware that he was wounded, he could not fix on the site of the injury until he had examined the limb. He felt instantly a burning pain in both feet, in front of the right chest and in the right arm, and in the right thigh about the wound. At first he was entirely powerless, but after a few minutes the power of the left arm returned, leaving him paralyzed as to motion in the right arm and in both legs. He lay on the field twenty-four hours, the weather being very cold. Sensation was defective in all the parts paralyzed as to motion. He had no pain in the back, but the burning pains alluded to above continued for a long time, and were always eased by cold applied to the wound. While the wound was healing he had headache and difficult, painful micturition. The wound closed in four weeks. During this period he regained the power to move the right arm, feebly and slowly, although perfectly as to extent. The pain in the side and feet also diminished, and the former disappeared altogether at a later period. He could not stand, however, or lift his legs from the bed at the time the wound healed, but there was then no headache or difficulty with the bladder or rectum. January 28, 1863, he was sent to Washington, where he improved so as to be able to walk with the help of a cane. His subsequent transfer to West Philadelphia caused a relapse; the pains returned, the paralysis increased, and he walked with difficulty on crutches. June 4, entered Christian Street Hospital. Present state: Movement.—The patient is partially paraplegic. He has some power to move the thighs when lying down, but cannot lift the legs from the bed. Below the knee all motion is lost, except a slight power of flexing the smaller toes in both feet. Pressure upon the cicatrix causes feeble twitching of the anterior muscles of the right thigh; both legs are subject to cramp and twitchings, which increase at night. The left arm is strong, the right arm has all the normal movements, but all are slowly and feebly executed. Sensation.—He has shooting pains, which start from the seat of the wound and dart down the thigh to the knee. No other pain exists at present, but there is still a good deal of burning sensation in both feet alike. Localizing sensibility perfect everywhere. Tactile sensation normal, or very nearly so, in all parts of his body; no loss of sense of pain in the skin. Pressure or pinching of the muscles gives him more than the usual pain, so the muscles (of both legs, especially below the knees) may be regarded as affected with hyperæsthesia of common sensation. The left arm is in all respects normal; the right arm is also free from lesions of sensibility. Nutrition.—There is no special atrophy of individual groups of muscles, but both legs are slightly wasted, the right arm not at all so. The legs below the knees are relaxed and cold; the feet are congested, but not swollen to any marked extent. Along the edges of both soles there are singular purple and blue mottled spots, which he says existed from the time his boots were first taken off, twenty-four hours after he was wounded. It is possible that these marks are due to frostbite. The muscles of the legs are about equally irritable to induced electric currents. Unfortunately, no very perfect electric examination of their condition was made at this period. Treatment.—Regarding the case as one of reflex paralysis chiefly, he was ordered to have rough frictions, with cold to the spine, and to take the twentieth of a grain of strychnia three times a day. Under this treatment the cramps and twitchings increased, so that after three weeks the strychnia was abandoned. Every future attempt to repeat its employment caused the same increase of annoyance, without correspondent benefit, so that it was finally laid aside as useless or worse. About the middle of August a blister was placed on the cicatrix, with the effect of greatly relieving the burning in both feet. At the same time he was ordered to use the hot and cold douche to the spine alternately, and faradized daily. The electricity was persistently employed during two months, and a month later he was also treated with iron and quinine, porter and liberal diet. The electric treatment caused a rapid amelioration of his case, so that he soon left his bed and began to walk on crutches. Early in November he ceased to improve, and the treatment was abandoned. At this time he could use his right arm well and quickly, and walked unaided, although with a little unsteadiness of gait. No close examination was made as to his sensibility until December 3, 1863, because during this time he had been able to give aid in the wards, and made no complaint, except of more or less constant aching in the dorsal and lumbar regions of the spine. About December 3d he was closely inspected for discharge, when the following notes were taken: Motion.—Good in left arm; not so perfect in right arm. Both legs somewhat weak, so that he shuffles a little in walking, the worst movement being that of extension in the toes of the right foot. Sensation.—Tactile sensibility feeble in the right leg and right arm, but nowhere entirely lost; it is normal in the left leg and left arm. The sense of touch is first found to be feeble below the navel on the right side. It lessens in perfection to the knee, and is better below that part, especially on the inside of the calf, being worse in the foot. Tickling the sole causes no sensation of tickling on either side. Pain.—There is absolute loss of sense of pain in the right leg, belly, chest and arm, with somewhat lessened sensibility to pain on the left side also. In many localities he was able instantly to tell by the altered sensibility when the needle point crossed the median line; in others, this was more difficult. So complete was this analgesia that the most intense faradization of the nails of the right hand or of the right nipple caused not the least sensation. The penis remained sensitive, but all over the right side he could be cut or stuck full of needles without evincing the least consciousness of anything but a touch. The sense of temperature was good in the left leg, confused and uncertain at the upper third of the right thigh, and lost below the knee, where a heat of 110° Fahrenheit was felt as a touch only when the sponge wetted with hot water was applied. On the foot of the right side this degree of heat was unfelt in any form. Higher heat caused reflex movements, which did not tend to remove the limb from the irritant, but were merely convulsive in their character. Intense cold also gave rise to these irregular movements. Electric examination.—There was some difficulty in determining the state of the muscles as to their electric sensibility, owing chiefly to the want of intelligence in the patient and to the fact that he spoke an impure German patois, which made it no easy task to obtain from him a clear statement of his feelings. The electro-muscular contractility is slightly diminished in the right leg and arm; it is much impaired in the extensors of the toes on both sides; everywhere the muscles respond slowly. The patient was discharged December 14, 1863.

". . . CASE II. Fragment of shell; wound of muscles over and external to the right femoral artery. The injury may have caused concussion of the crural nerves, and thus much of traumatic paralysis. Result: Reflected paralysis of the right arm and leg and the left leg.

". . . In CASE II, the permanent lesions were chiefly of secondary character, and were at all events additions to those which were first observed. In no other case were similar phenomena noticed. In two of the seven cases there were lesions of sensation and motion; in three, motion alone was lost; and in two the sense of tact and of pain were affected without other loss of function. The extent and duration of the induced paralysis have already been considered.

"Demmuth, CASE II, came under our care seven months after he was wounded; as to his previous treatment we know nothing. In our hands strychnia not only failed to aid him, but did harm. He was rapidly relieved by faradization, active and passive movement, and the douche, with iron, quinine, and liberal diet.

"S. WEIR MITCHELL,

"GEO. R. MOREHOUSE,

"W. W. KEEN, jr.​,

"Act. Ass't Surgeons, U. S. Army."