MULTIPLE NEURITIS 
BY 
Irving D. Wiltrout, M. D. 
SUPERINTENDENT AND PHYSICIAN IN CHARGE OF THE OLIVER WENDELL 
HOLMES SANITARIUM FOR NERVOUS DISEASES, 
HUDSON, WISCONSIN. 
REPRINT FROM THE TRANSACTIONS OF THE STATE 
MEDICAL SOCIETY OF WISCONSIN, 1889. 
MILWAUKEE: 
THE CORBITT & SKIDMORE CO., PRINTERS. 
1889. Multiple Neuritis. 
BY IRVING D. WILTROUT. 
Superintendent and Physician in charge of the Oliver Wendell Holmes Sanitarium 
for Nervous Diseases, Hudson, Wis. 
This term applies to a disease in which many nerves are 
simultaneously inflamed. The terms, "disseminated neuritis," 
"polyneuritis," "progressive neuritis" are terms that have 
been used to designate this disease, which in most instances 
pursues a rapid course. Simple neuritis involving one of the 
larger nerves, or its branches, has been recognized by the ear- 
lier neurological writers. Multiple neuritis, in its various 
general forms and its many combinations of symptoms, was 
formerly thought to depend upon a lesion of the spine. 
In 1864, Dumenil, of Rouen, described multiple neuritis and 
showed conclusively that it was a disease not of the spinal 
cord, but of the nerves themselves. That the earlier student 
of neurological study failed to discover a proper seat of lesion 
in this disease in not surprising, when we take into considera- 
tion the fact that our methods of examination and discrimina- 
tion are of so recent origin. Few had confidence in Dumenil's 
observations; it required the conclusive experiments of Jaf- 
fory (1879), Leyden (1880), and Stuart (1881), to settle beyond 
dispute the fact, that the nerves were the diseased structures 
and not the spinal cord. There are various forms of this disease. 
The morbid changes may be interstitial or parenchymatous 
and degenerative or both. Five chief classes are recognized by 
Gowers, as follows: (1) Diphtheritic neuritis, (2) Tabetic neu- 
ritis, (3) Leprous neuritis, (4) Endemic neuritis, (5) Chronic 
neuritis, or that variety so common in this country with inde- 
finite pathological character, running a moderately rapid 4 
course and which will bear many further subdivisions. It 
may involve chiefly the connective tissue between the bundles 
of nerve fibres, and this variety would be called interstitial 
neuritis; or it may involve the sheath of the nerve itself. In 
severe cases, that run a more acute course, the inflammatory 
process necessarily involves the entire nerve, rapidly destroy- 
ing it. In most cases the naked eye changes are very faint if 
at all discernible, but under the microscope the sheath will 
appear to be infiltrated with lymphoid cells and in many old 
cases many spindle cells and fibres increase its bulk. Dark 
spots are seen on sections of the degenerated nerve fibres and 
in some places two or more blend together, and the nerve 
becomes irregular-the white substance is broken up, and 
enlarges the fibres in some places, while at others, it has been 
removed and the sheath left empty. There is no uniformity of 
nerve destruction in a single case. The larger nerves appar- 
ently resist inflammatory action or inflammatory processes, 
more successfully than the smaller ones. In the majority of 
cases the nerves of the limbs suffer most. Corresponding 
nerves on the two sides are usually affected alike. The mus- 
culo-spinal nerve in the arm and the anterior-tibial nerve in 
the leg generally suffers first and in the greatest degree. The 
nerves of the trunk are rarely involved. The pneumogastric, 
phrenic, hypoglossal and laryngeal nerves are rarely involved. 
The spinal cord remains healthy in most instances. Chronic 
myelitis occasionally occurs, but this Gowers concludes is only 
incidental. This disease is found frequently in chronic alco- 
holism and in these cases lesions of the kidneys, heart and 
brain may be found on post-mortem, but they bear no relation 
to this disease. The manifestations of this disease are in most 
instances very striking in spite of the fact that they were, at 
one time, regarded as confusing. The earliest and dominant 
symptoms are those of motor palsy and sensory irritation. 
This disease as it progresses gives great muscular weakness 
and wasting. Gowers, Shultz, Eisenlohr and Stuart believe 5 
that the disease is commonly ushered in by rigors, fever and 
often a temperature of 103° to 105° F. In the nine cases I find 
in my record books, which include some of the most pro- 
nounced types of this disease, I have failed to discover a high 
temperature; even where the exciting cause was presumed to 
exist in exposure, no indication of a chill could be discovered. 
It is my judgment that this disease in many instances occurs 
insidiously. The most striking symptoms and among the first 
to appear, in the cases I have had under observation, are the 
hot, burning prickling pains in the ends of fingers and toes. 
In three of the cases analyzed there were general rheumatic 
pains deep seated, spoken of before the motor symptoms made 
themselves manifest. Sensitiveness is early increased and is 
deep seated. The muscles become sensitive and remain so to 
deep seated pressure. 
In many instances, the loss of power is earliest felt in the 
extensor muscle of the arm, later the power of flexion of the 
ankle and the extension of the toes becomes impaired ; very 
frequently, however, the limbs become useless first and re- 
main so, while the arms maintain throughout a fair degree of 
strength. Most writers confirm a common opinion that rapid 
emaciation and flabbiness of muscle supervenes very soon after 
the initial attack, or at a stage of acute invasion or pyrexia. 
In the cases I have record of, these symptoms in no instance 
came on rapidly, and in three cases came on mildly and tardi- 
ly. The severe pains accompanying this disease-referred to 
by many writers-I think are those in which there is an un- 
questionable rheumatic history. 
Reflex action in the affected limbs is always lost. Knee 
jerk is absent. Trophic changes in the skin, nails and hair. 
Oedema of the limbs is present. The latter symptom is found 
chiefly in the cases of alcoholic origin. An effusion about the 
joints was spoken of by one of my patients, but I attributed 
this to an early attack of rheumatism. Some writers speak 
of incoordinate movements; these cases are evidently of that 6 
variety which have their origin in alcoholism, and have in 
association a distinct spinal lesion. An almost pathogno- 
monic symptom is anaesthesia of the skin, associated with ex- 
cessive weakness of the muscular and other structures, reach- 
ed by deep pressure. There is a form of this disease called 
by some authors acute multiple neuritis or malignant multiple neu- 
ritis, which differs from the common type herein described in 
the rapidity of its march from the periphery. Few have wit- 
nessed cases of this variety, and some dispute has arisen in 
regard to the identity of this type of the disease. The con- 
stitutional symptoms in this variety would be more pronounced 
and pyrexia would continue throughout the attack. Trophic 
changes in this variety are pronounced, and appear early in 
the disease. The common course that the greater number 
of these cases pursue is as follows: The disease continues 
four or five weeks, then frequently remaining stationary ; the 
patient then slowly regains strength and recovers in a period 
varying from two to six weeks. In other cases the disease 
continues to grow worse at once, and the stationary period 
does not appear until the patient has suffered for months and 
is reduced in strength; often then for months the disease 
remains stationary, and the patient is helpless, may move 
around on crutches, but there is no apparent improvement. 
A slow progress toward recovery then takes place, requiring 
often years and years to regain substantial strength. In the 
more acute variety, which I think in the future wTill be shown 
to have an etiology of its own, and entirely disassociated from 
the more chronic variety. The destructive work is done so 
rapidly that in a fortnight the patient is prostrate and dying 
from the exaggerated sensibility and muscular weakness; the 
pain and suffering through morbid dread of paralysis and 
helplessness, very frequently induces mental symptoms of an 
emotional type. We can look for an explanation of this in 
the great reflex phenomena in the nervous system. Delirium 
and hallucinations occur in cases where alcoholism has been 7 
the exciting cause. What the future may reveal on this sub- 
ject it is impossible to forecast, but one fact is apparent, that 
the sub-acute variety of this disease is frequently witnessed in 
those who have a tubercular family history. 
I found a very pronounced phthisical history, to anti-date 
four cases of the nine I have had the privilege to study. The 
diagnosis of this disease is not always an easy task. In the 
earlier stages the chief points to depend on are the motor and 
sensory symptoms herein described; on their localization in 
the distal points of the limbs, and on the tenderness of the 
nerve trunk and the muscles. The early pains can be differen- 
tiated from rheumatic pains by their location. Pains along the 
track of the great nerves of the body, together with a burning, 
tingling sensation in the distal ends of fingers and toes should 
excite suspicion that they are of nerve origin, even before the 
muscle weakness makes the nature of the disease unmistaka- 
ble. This disease is often confounded with polio-myelitis. 
The distinction rests on the symmetrical localization of the 
neuritic pains while that of polio-myelitis is random in dis- 
tribution. Other designations are the persistence and severity 
of the neuritic pains; the location of the inflamed nerve trunk, 
and the anaesthesia in the area of their distribution, symptoms 
never present in polio-myelitis. A history of alcoholism and 
phthisis affords grounds for a presumptive diagnosis. The 
treatment for this disease is stated briefly. At the onset of the 
attack the treatment should be that suitable for a local inflam- 
mation anywhere over the body; absolute rest is of the highest 
importance in the more acute cases; all excitement should be 
avoided; nourishing food should be administered without 
stimulants. I wish to outline particularly the treatment most 
suitable in the chronic variety. If alcohol has been taken in 
excess it should at once be abandoned. If there is a phthisical 
history, cod-liver oil and preparations of malt should be given. 
Warm baths should be given daily at a temperature of 106° F. 
and should continue for a half hour, if the patient can endure 8 
it. Friction to the skin is useful-it may be employed almost 
from the beginning; later on a complete massage treatment 
will be endured readily. My practice is to instruct the mas- 
seur to avoid the hacking and muscle twisting movements. 
J find friction with a flesh brush a very good exciter of circula- 
tion to the periphery. In the later stages of the disease gal- 
vanism is indicated: the best method to apply this is to place 
the positive pole along the spine and the negative by means of 
a dampened sponge electrode to the limbs. If the digestive 
organs are not normal, I have confidence in forced feeding- 
made so popular of later years by Weir Mitchell. Where the 
legs lose their strength and movements of the body are tiresome 
and uncertain, I advise the use of crutches, believing that it is 
wise to lift the weight of the body off of the affected limbs. A 
course of anti-rheumatic treatment is advisable in all instances 
where there is a suspicion of a rheumatic diathesis. Where the 
feet become oedemic, as in cases of an alcoholic type, and where 
the kidneys may be failing in their functions, I use freely 
citrate of potassium and acetate of potassium, often giving the 
two in conjunction with some compound tincture of bark. The 
chief anti-rheumatic treatment I have employed is the salicy- 
late of sodium. 
I cannot conceive that iron is of any profit, unless there is 
anaemia, then iron and arsenic are indicated. Quinine is 
only indicated where there is suspicion of malaria, for the 
primary physiological effect of the quinine on the nerve cen- 
tres is to congest them; hence it would be no useful remedy 
to continue during the progress of the disease. Strychnine is 
indicated in the latter stages of the disease, and is a valuable 
resort in cases with cerebral complications. Iodide of potas- 
sium and mercury, although having been freely used have few 
advocates. Where the disease is of an inflammatory nature 
principally affecting the sheath, and throws out inflammatory 
product, making adhesions and thickenings, these remedies 
are given in large doses and have a salutary influence. 9 
Arsenic is useful in anaemic and chlorotic patients and where 
there is a notable impairment of the digestive functions. Cod- 
liver oil, when intolerable to the stomach, might be used as an 
injection. Relief of pain, in the earlier stages of the disease, 
is a problem that confronts us, and unless we are strong in 
resolution we will yield to the first impulse and first desire of 
the patient and give opium or its salts. Antipyrine, or ace- 
tan elide, will invariably relieve pain. I cannot too strongly 
condemn the use of opium in this or any other disease of the 
nervous system, where the use of it can be avoided. In cases 
where there is the slightest tendency to mental depression the 
habit of opium is certain to be acquired.