A CASE OF RAPID AND WIDESPREAD MUSCU- 
LAR WASTING WITHOUT DISEASE 
OF THE SPINAL CORD. 
By J. J. PUTNAM, M. D., 
BOSTON. 
THE patient whose history is the subject of this paper 
entered the Massachusetts General Hospital in 
May, 1879, under the care of Dr. S. L. Abbot, who very 
kindly allowed me to see and investigate the case, and sub- 
sequently to examine the spinal cord, and now permits me 
to make full use of his clinical notes. My thanks are due 
both to him and to his then clinical assistant, Dr. W. P. 
Gannett. 
The essential features of the patient’s last illness were as 
follows: It was an acute febrile attack, ending fatally in 
about one month, and characterized by severe pain, diminu- 
tion of sensibility, rapid muscular wasting, and diminution 
of electrical irritability in all four extremities, mainly con- 
fined to the parts below the elbows and the knees, also by 
alteration of the mental condition, and delirium. 
After death, spots of softening were found in the great 
ganglia of the brain and in the centrum semiovale. The 
spinal cord was essentially healthy. The peripheral nerves 
Reprinted from the Journal of Nervous and Mental Disease, Vol. 
viii, No 2, April, 1881. 2 
y y. putnam. 
were not examined, but the inference is drawn that the case 
was one of disseminated neuritis. 
The following are the details of the case: 
Margaret C., married, 50 years old, was admitted to the Massa- 
chusetts General Hospital May 22, 1879, and gave the following 
history : 
She had always been well, as she thought, until three weeks be- 
fore entrance. At that time she became chilly and feverish, and 
supposed herself to have taken cold. She was attacked at the 
same time with severe pain, which began in the toes of both feet, 
but extended over the entire body. The use of the legs became 
progressively impaired, and the hands also grew so weak that in 
the course of two weeks she became unable to hold anything in 
her grasp. She had been obliged to keep her bed from the first of 
the attack, and her sleep had been much disturbed by pain. No 
nourishment could be retained except milk. 
On examination there was found to be no swelling of the joints ; 
a good deal of general tenderness on pressure, not sharply local- 
ized ; motion at the wrist and ankle and phalangeal joints was 
found to be greatly impaired, and the cutaneous sensibility of the 
skin over the feet and ankle joints diminished. Auscultation of 
the heart revealed nothing abnormal. No reflex movement could 
be excited by tickling the soles of the feet. The temperature 
was 100.10 (F.) ; pulse, 1x0; respiration, 30. Milk was ordered 
in small quantities, and salicyl. soda, grs. x, every hour, p. r. n. 
The subsequent history of the case is as follows: 
May 23d.—Much pain during night. Was given Dover’s pow- 
der, grs. x. The catamenia appeared during the night. 
May 24th.—Was somewhat delirious and quite restless through 
the night, and is still slightly so. Complains of pain and burning 
in the feet, but they are not swollen or tender. 
May 25th.—Delirious during night ; nearly free from pain and 
delirium this morning. Tongue dry in centre, furred on both sides. 
May 26th to 31st.—No marked change. 
The report of the examination of the urine (Prof. E. S, 
Wood) is as follows : 
Urine.—Acid; yellow; sp. grav. 1017; urophain slightly di- 
minished ; indican and urea normal ; uric acid in excess. A CASE OF MUSCULAR WASTING. 
3 
Earthy phosphates normal. Alkaline phosphates slightly in- 
creased. A slight trace of albumen. Considerable sediment 
containing numerous hyaline and granular casts, considerable uric 
acid, excess of mucus, a little blood, clumps of pus, much bladder 
and vaginal epithelium. Some of the casts have highly refracting 
granules on them. 
May 31st to June 2d.—Complains of no pain except in feet. 
No tenderness or other abnormal sign about vertebral column. A 
subcutaneous injection of pilocarpine (gr. Jd) yesterday caused a 
profuse sweat. 
Her present condition is as follows: 
All movements of the arms at the shoulder and elbow, and of 
the legs at the thigh and knee, are possible, though but slowly 
and feebly performed. There is no voluntary or reflex move- 
ment of the fingers and hands, nor of the feet and toes. The 
movements of the head are apparently free. 
There is well-marked loss of sensibility of the skin of all four 
extremities, especially of the arms below the elbows, and of the 
legs below the knees, the intensity of the anaesthesia increasing 
the nearer the feet are approached. 
Within these areas neither contact of the finger nor moderately 
strong applications of electricity excite any sensation. Applied 
to other parts of the arms or legs, such currents cause manifesta- 
tions of pain. 
The arms are usually, though not invariably, somewhat flexed, 
and the biceps rigid. 
Under these circumstances the biceps can be excited to con- 
traction by sudden, passive stretching. 
The results of the electrical examination at this date 
were as follows: 
Left arm j faradic current j the reaction of the ulnar and 
musculo-spiral nerves, and of the muscles supplied by them, is 
preserved but greatly diminished. The biceps and triceps react 
better, though hardly as well as normal. 
The reaction of the median nerve, and of all the muscles sup- 
plied by it, as well as that of the interosseous muscles, is entirely 
wanting. 
Galvanic current. The typical degenerative reaction is no- 
where present. Strong currents, however, elicit feeble contractions 4 
y. y. putnam. 
from most or all of the muscles, if applied directly ; not, however, 
through the medium of their nerves, except in the case of the 
median. However excited, the contractions are quick and short 
in character. 
The condition of the right arm is essentially the same with that 
of the left. 
Left (and right) leg; faradic current. The reaction of the 
quadriceps ext. cruris group and of the hamstring muscles is 
preserved, though only the feeblest contractions can be excited. 
When applied to the peroneal nerve even the strongest currents 
fail to excite any contraction in the corresponding muscles. 
A strong galvanic current, on the other hand, applied to the 
same nerve, excites marked though feeble contractions in all the 
muscles supplied by it. These contractions appear and disappear 
more slowly than normal. 
Strong galvanic currents applied directly also excite contractions 
in these same muscles. These contractions likewise are slower 
than normal, and if repeatedly excited their intensity becomes 
rapidly less (reaction of exhaustibility). 
The muscles of the back and of the neck react apparently well. 
All the muscles of the body, but especially those which have 
lost their faradic reaction, are extremely feeble. The interosseous 
muscles, as well as the long flexors of the fingers, are noticeably 
atrophied. 
All the reflexes (except that of the biceps above alluded to), 
including also the reflex of the abdominal muscles, and the con- 
junctival reflex, are wanting. The corners of the mouth are drawn 
down, giving the face a haggard expression ; but this may be 
partly due to the fact that the patient is drowsy and but semi- 
conscious. 
The fundus of the right eye, examined with the ophthalmoscope, 
shows no abnormal appearance. 
Passive movements of the arms and legs cause decided ex- 
pressions of pain. 
The patient lies groaning without interruption, though she can 
be aroused by the sound of her name, etc., when her face often 
breaks into a senseless smile. 
The pupils are equal and about normal in size ; they respond 
slightly, though promptly enough to light. 
June 4th. Condition the same. Patient lies in a stupefied con- 
dition, but can be aroused without much difficulty, and says she 
has no pain. A CASE OF MUSCULAR WASTING. 
5 
June 6th. Since the last report the patient has failed very rap- 
idly. Cannot now be aroused. Swallows a little brandy and 
water with much choking. Passes urine involuntarily, as she has 
for several days. 
The patient sank rapidly during the following night, and died 
quietly at 4.15 a.m. of the 7th, the temperature having risen 
through the past two days, reaching 107° an hour before death. 
The temp, (axillary) chart of the greater part of the sickness 
was as follows : 
Date. 
Temp. (F.). 
A.M. P.M. 
Pulse. 
A.M. P.M. 
Resp. 
A.M. P.M. 
May 22d 
100.4° 
no 
— 
30 
“ 23d 
IOO° 
99° 
no 
100 
21 
24 
“ 24th . 
98.7° 
98.7° 
no 
102 
20 
25 
“ 25th 
98.6° 
99° 
100 
108 
20 
25 
“ 26th . 
98° 
104° 
106 
104 
20 
30 
“ 30th 
IOO° 
102° 
no 
140 
17 
30 
“ 31st . 
IOO° 
102° 
108 
120 
30 
34 
June 2d 
IOI° 
102.4° 
no 
128 
28 
32 
Noon. 
Midnight. 
Noon. 
Midnight. 
Noon. 
Midnight. 
“ 6th . 
105.2° 
106.4° 
no 
140 
34 
39 
3 a.m 
“ 7th 
107° 
Death at 4.15 A.M. 
The treatment employed (salicylic acid at first, subse- 
quently brom. pot. and other palliatives, moderate alco- 
holic stimulation, milk) had the effect of keeping excite- 
ment, pain and fever down to a moderate point, and in 
view of the acute softening in the brain, discovered post 
mortem, it is improbable that death was directly hastened 
by any of these conditions. 
At the autopsy, which was made by Dr. R. H. Fitz, the 
organs of the chest and abdomen were found to present no 
abnormal appearance. The kidneys were not further exam- 
ined, but the condition of the urine, together with the fact 
that the arteries throughout the spinal cord were subse- 
quently found notably thickened, suggest that, nevertheless, 
some degree of disease may have been present in them. 6 
J. y. PUTNAM. 
Examination of the brain revealed the presence of a num- 
ber of spots of softening, of yellowish color, varying in size 
from that of a marble to that of a pea. The largest of 
these spots lay in the upper portion of the white substance 
of the left parietal lobe, and the tissue round it was red- 
deped. 
In the right optic thalmus and left corpus striatum were 
similar spots of rather smaller size, and the posterior third 
of the outer division of the nucleus lenticularis on both 
sides showed evident microscopic, though but slight macro- 
scopic signs of a somewhat ill-defined process of the same 
kind, in the presence of numerous granular corpuscles such 
as the larger spots also contained. 
The internal capsule was but little if at all involved, and 
that in its posterior part. 
The spinal cord was not removed until the following 
morning, and, owing no doubt to that cause, the subse- 
quent processes of hardening (by Muller’s fluid) and color- 
ing were not so satisfactory as could have been wished, and 
there was difficulty in making as thin sections as were de- 
sired. Still, with the aid of Rutherford’s freezing micro- 
tome and the methods of hardening in mucilage, specimens 
were obtained which permitted of careful microscopic study. 
Before hardening, cuts were made into the cord at short 
intervals, but no departure from the normal appearances 
could be discovered. The membranes seemed everywhere 
healthy. After the specimen had lain for a day in Muller’s 
fluid, the surface of several of the cuts, both in the cervical 
and lumbar enlargement, was scraped, and fine specimens 
of ganglion cells obtained. Of these almost all contained 
more, sometimes much more, pigment than is usually met 
with, but they presented no appearance that was distinctly 
pathological. Neither was any abnormal condition of the 
nerve fibres to be made out. A CASE OF MUSCULAR WASTING. 
7 
On examination of the hardened cord one pathological 
change was everywhere visible, namely, thickening of the 
walls of the arteries, and there was also, in the cervical re- 
gion, a very slight increase in the connective tissue of one 
of the lateral columns, giving rise to a slightly heightened 
blush in the carmine-stained sections. This change did not 
extend through the whole length even of the cervical cord, 
most of the sections showing no trace of it. As it was 
thought to be of but little significance no attempt was 
made to define its limits. 
The ganglion cells of the anterior cornua were normal 
botji in number and outline. They contained, as stated, 
more pigment than usual, failed to take up the carmine 
readily, and in a few of them small vacuoles were found. 
No great importance could be attached to the loss of re- 
action to the carmine in the absence of other signs of dis- 
ease, since this may well have been due to the same putre- 
factive changes that prevented hardening, the more so that 
the other cellular elements of the cord were in the same con- 
dition in this respect. 
The formation of the small vacuoles may have been due 
to disease, but it also may have been due to putrefactive 
changes, and at any rate the number of the cells affected in 
this way was too small to account for the widespread mus- 
cular atrophy. 
Of the condition of the peripheral nerves and of the mus- 
cles I am, unfortunately, unable to speak. A portion of 
the peroneal nerve and of one of the diseased muscles was 
reserved for examination, but was accidentally thrown away. 
To the naked eye the nerve seemed to have undergone no 
change whatever, either in size, consistency or color. 
The symptom which presents the most interest in this 
unusual case, and for which we might have expected the 
most readily to find an explanation through the post-mor- 8 
y. y. putnam. 
tem examination, is the rapid muscular atrophy, associated, 
as it was, with great diminution or entire loss of electrical 
reaction of the affected nerves and muscles. Only so far 
as the pathological changes that were actually discovered 
may be taken as a guide, the lesion which brought about 
this result must have had its seat either in the muscles 
themselves or in the peripheral nerves, and, as a matter of 
fact, the clinical picture was closely like those presented by 
most of the cases quoted and reported by Leyden in his 
recent admirable paper,* or others given in the thesis of 
Dr. J. Gros,f and, indeed, in the case given at greatest 
length by Leyden (p. 40), and in one or two of those 
quoted from others, just such slight changes in the 
spinal cord were found (formation of small vacuoles, in- 
crease of pigmentation) as in this case, and good reasons 
are offered for thinking that they were secondary and of 
little moment. ' 
The diagnosis by exclusion speaks likewise with great 
positiveness either for disseminated neuritis or for a myositis 
with secondary involvement of the mixed nerves. The 
idea could not be entertained that the lesions in the cere- 
bral ganglia might account for the pain and the rapid atro- 
phy; the cord was essentially healthy ; there remains only 
the nerves and the muscles themselves to consider. That 
all the symptoms, even including the pain, might be due to 
an acute myositis is not to be denied on a priori grounds; 
but we are, perhaps, bound to exhaust, first, the better ac- 
cepted hypothesis, which favors the neurotic origin of such 
cases as this. It remains, at the same time, to be said that 
since, in all the cases quoted, the muscles as well as their 
nerves were found diseased, it is somewhat a begging of the 
question to say that the nerves were certainly primarily at 
fault. 
* Ueber Poliomyelitis und Neuritis. Zeitschr. fur Klin. Med., Bd. I, Hf. S. 
f Contrib. a l’histoire des nevrites. Paris, 1879. A CASE OF MUSCULAR WASTING. 
9 
At any rate, if the disease begins in the nerves it does so 
usually at their peripheral extremities. Thus, in this case, 
as in very many of those which have been reported, the 
severest symptoms affected not all the muscles or sur- 
faces of skin supplied by one great nerve trunk, but the 
parts furthest removed from the central organs, irrespective 
of the source of the nerve supply,—the legs below the knee, 
the arms below the elbow, and of these the feet and the 
hands more than the forearms and the legs. 
As regards the changes of sensibility, this rule was in our 
case most striking, and the same is true of some of the cases 
reported by others. Thus, in one quoted by Gros* we read : 
“ 24 fevr. Depuis quelques jours, le malade se plaint de 
douleurs trks vives, exclusivements localises aux deux 
pieds,” * * * etc. 
“ 5 mars. Toujours des memes douleurs aux membres 
inferieurs. Diminution de la sensibilite. Tous ces symp- 
t6mes restent limit£s aux pieds et aux regions 
Depuis deux jours, il accuse des douleurs de la meme nature 
dans la paume de la main du cot£ gauche.” * * * 
In another place (p. 51): “ Elle (la sensibility) est abolie 
completement dans les pieds, dans la region externe des 
jambes, c’est-h-dire dans le domaine du nerf externe 
et dans les branches terminates des autres nerfs.” 
It is not, however, always the case that the peripheral 
distribution of several nerves is simultaneously and exclu- 
sively involved, so much so that Gros lays it down as one of 
the diagnostic marks of the affection that the symptoms, 
both sensitive and motor, predominate in the distribution 
of one or more nerves. 
I hope soon to bring further evidence in favor of the 
opinion which I expressed some years ago, that whether we 
are dealing with diseases of muscles, nerves or (motor) 
* Loc. cit., p. 61. 10 
y. J. PUTNAM. 
nerve nuclei, the types of disease are apt to be the same, 
showing a greater vulnerability on the part of certain mus- 
cles, their corresponding nerve fibres and their corresponding 
nerve nuclei, than is shown by their fellows. It is my belief 
that this may hold good of the sensitive tracts as well, 
and that this general law will render clear the recurrence of 
certain types of diseases involving alterations of sensibility 
and muscular nutrition better than any simply topographi- 
cal explanation. 
The admission of disseminated neuritis into our nosolo- 
gies opens a wide field for study, the limits of which are 
well defined in the monographs to which I have referred. 
The differential diagnosis has to take account, not only of the 
so-called ascending spinal paralysis of Landry, of poliomye- 
litis, perhaps progressive muscular atrophy (Leyden) and 
lead paralysis of rapid onset (of which I have recently seen 
a striking illustration), but even of meningitis, as is pointed 
out by Gros (p. 53). 
It is possible that the following case will prove to be an 
illustration of this fact: 
A patient died last summer at the Massachusetts General 
Hospital, under the care of Dr. B. S. Shaw, who kindly al- 
lowed me to examine the case and the specimens, who, 
throughout her sickness, showed marked symptoms of acute 
meningitis, viz., extreme pain in the neck, the back and the 
limbs, greatly increased on even the slightest movement, 
fever and muscular paralysis, which improved after a time 
with marked wasting, especially in certain groups of muscles. 
At the autopsy no sign of meningitis was present. 
The cord has not yet been examined microscopically, but 
seemed to contain minute scattered foci of inflammation. 
The pain, which was the marked feature of the whole 
case, could hardly be explained by the trifling disseminated 
myelitis, if this proves to be present, while the latter could 
well have been secondary to an acute neuritis.