Traumatic Paralysis.
There is another class of paralyses, not less interesting, viz., those in which the lesion affects only a single limb, the upper or the lower, and among these paralyses, traumatic paralyses merit particular attention. Inciden tally mentioned by Campbell, Ramsbotham, Scanzoni, Romberg, Jacque mier, Imbert Goubeyre, Bedford, Burns, Tarnier, Siredey, Jaccoud, Axenfeld, Simon, Hervieux, Depaul, Maringe, Rosier and Froge, these paralyses were carefully studied by Bianchi in his thesis of 1867, and we were able to collect eleven cases. Since then, in 1867, Lefebvre has cited four new examples, and Brivois, thesis 1880, two new cases, one personally observed and one borrowed from Winckel. The total number is seventeen, not great to be sure, but important in view of the clearness and precision of the facts. Bianchi, first recalling the cases of paraly sis produced by tumors pressing against sacral nerves at their origins, compares the fcetal head to a hard, voluminous tumor, which exerts ener getic, although brief pressure, causing paralysis, generally temporary, but sometimes persisting after delivery. • Reducing the question t,o a mechani cal problem, he states that there exists: 1. An active agent or force (uterine iontraction). 2. A compressing body (fcetal head). 3. A re sisting surface (maternal pelvis). 4. Organs exposed to compression. These are the fcetal head, the pelvis, the perineal muscles, the hypogas tric vessels, the bladder, the rectum, the nerves, particularly the obtu rator, and the sacral plexus, particularly the great sciatic nerve. Incom pletely protected against puerperal traumatism, this nerve is necessarily compressed in all labors, but to a variable extent. Generally, the only results are, at the end of labor, cramps in the calves and the great toes. If the nerve is, however, too long and too forcibly compressed, bruised by the fcetal head or by instruments, disturbances which are often serious and lasting, or even true paralyses, may develop in the inferior extremi ties, where the terminal branches of the nerve are distributed. To-day these traumatic paralyses are universally admitted, and with Bianchi we may cite among their determining causes all conditions augmenting the duration and the intensity of the compression. Thus: the length of labor, whether due to weakness of uterine contractions or to considerable resistance, large size of the child, posterior positions, pelvic deformity, perinea' resistance, first labors, particularly the use of forceps, and finally the patient's age. The majority of cases occur in women over thirty years old, and especially in primiparte. These paralyses ars, nevertheless, rare, and one might assume a certain individual predisposition, which would be favored in some cases by the patient's age, the fact of not having borne children, and the situation of the foatus.
Symptoms and Diagnosis.—These paralyses always occur after labor, but, in certain cases, are preceded by some phenomena which we might consider precursors almost like the first stage of a disease. These are very violent pains, which some patients experience in the sciatic nerve, during labor. Noted by all obstetricians, these pains, which
occasion in many women cramps, formication and numbness of the limbs, are sometimes so pronounced as to give the labor a pathologi cal aspect. Generally moderate, they assume, in some cases, an extreme severity and impede labor. Sometimes they specially affect the crural nerve (then they are felt on the anterior surface of the thighs), sometimes the obturator (and then they are felt on the internal aspect of the thighs), most frequently the great sciatic nerve, occasionally all the nerves at once, but, generally, various nerves in succession, thus indicating the progress of fcetal engagement. Thus, the /pins due to compression of the crural and of the obturator are felt before those of the sciatic nerve, and at an earlier period of labor. It is, in fact, upon this last nerve that all the compression exercised by the fcetal head is concentrated, and this is par ticularly true at the end of labor. If this compression has been too long continued or too energetic, these pains, which generally disappe,ar very rapidly after labor, tnay last a longer or shorter time and paralyses may 'succeed them. This particularly happens when this contraction has been farther augmented by tractions upon the forceps, especially when these tractions are wrongly directed and either too violent or too long continued. Whether these original pains exist or not, paraplegia is developed in all the cases, very nearly at the time for labor. • Paralyses appear after twenty-four or forty-eight hours, or after some days, at the latest. They might appear later without our being able to deny that they were due to traumatism, (Niemeyer, Follin, Velpeau, Bastien, Tillaux.) Sensation may be abolished, diminished, augmented or perverted. This abolition of sensation may be complete or partial, and may consist of anal gesia, antesthesia or, most frequently, of the two combined. There may even exist thermo-analgesia, i.e., insensibility of the skin to different temperatures. Sensibility may, on the contrary, be augmented, now con stituting a true, traumatic, diffuse, disseminated neuralgia, without deter minate limits, and often extremely severe, now corresponding to the course of the compressed nerve, or localizing itself in certain points. Sensibility may be perverted, and then the patients experience prickling, tickling and painful formication, symptoms which may announce the beginning of a true hypersesthesia, and may onV be transitory, or may lead to a par alysis of sensation. Motor disturbances may, in the same way, vary from a simple impairment of motility, awkwardness, torpor or weakness, up to complete loss of motility. The prolonged absence of innervation re sults, generally after a long time, in a certain amount of muscular atrophy. The disturbances of secretion and vital beat are more directly dependent upon the sympathetic system. The lowering of the temperature in the diseased limbs is referable to local retardation of the circulation, due to pa ralysis of the vaso-motor filaments derived from the cerebro-spinal system, which results in vascular contraction.