which he had lain a helpless cripple for over four years, except when
lifted into the roller carriage, he felt a sudden rush of warmth.
Surprised at this first sensation he had felt for years in limbs which
had been quasi-foreign appendages, he raised up the bed-clothes and
saw that they changed color. There was some tingling for about three
minutes, and a perspiration broke out in the affected members. With
this he found he could move his feet: half alarmed, half exulting, he
sent for his physician, L. Weiss, who found that the patient could
stand and walk with considerable freedom. I was then consulted, and
found the patient presenting a picture of incomplete transverse
myelitis. He could walk, turn about, stand with closed eyes with
slight swaying, and his knee-phenomenon was of short excursiveness,
but exceedingly spasmodic, and this symmetrically so. He was carefully
watched, and against the advice of his physician engaged in peddling
cigars, and subsequently took a position as attendant at the pauper
asylum on Ward's Island. Here he was on his feet fully twelve hours a
day, and his motion, which had continued improving until it was to all
practical intents and purposes normal, aside from a slight stiffness,
again became impaired, and a joint trouble in the metacarpo-phalangeal
articulation of the right little toe, which had troubled him a week
after his partial recovery, recurred.[104] On January 15th of the
present year I again examined him. His knee-phenomenon was greatly
exaggerated, cutaneous sensations scarcely impaired, gait paraparetic,
but he could walk great distances, and claimed to suffer less from the
exertion than from the tenderness accompanying the joint trouble
referred to. There had, therefore, occurred, without any assignable
cause—for the patient was not under treatment for a year or more
before the event—an almost instantaneous restoration of sensation,
locomotion, and sexual power; all of which faculties, notwithstanding
the infraction of every medical direction given, remained established
for two years, with prospects of so continuing a longer period.
[Footnote 104: This was a trophic joint trouble.]
TREATMENT.—Most of the therapeutic propositions relating to the
treatment of the acute myelitic process are based on the theory that
it is of a congestive character or associated with congestion.
Accordingly, the internal administration of such drugs as ergotin,
which diminish the calibre of the blood-vessels, and local measures,
such as depletion, wet cupping, and counter-irritation, intended to
act in the same way by derivation, are unanimously recommended by
authorities. The suggestion of Hammond, that the patient occupy a
ventral or lateral, and not the dorsal, position, is based on, and
entirely consistent with, this same view. It is difficult to say what
effect is attributable to these measures. Remarkable spontaneous
changes—retrogressions as well as advances of the morbid process—occur
equally under expectant as under active treatment. I have never seen
any improvement in the active phase of simple myelitis which {823} I
felt confident I could attribute to any special remedy employed with a
view of acting directly on the morbid process. Indeed, improvement has
been claimed by Jewell as a result of the use of strychnia—a drug
which under the very dogmas governing the orthodox treatment of the
disease might be expected to do positive damage.[105]
[Footnote 105: Jewell gives very large doses of this alkaloid. L. C.
Gray, in a discussion held before the American Neurological
Association, cited numerous observations directly conflicting with
those of Jewell. I cannot, in view of a recent observation in a
typical case of acute anterior poliomyelitis, in which by accident the
toxic effects of strychnia were obtained, consider this dispute as at
all settled. In direct connection with the toxic symptoms the
abolished patellar jerk returned in an exaggerated form; motion also
returned, and rapid improvement ensued.]
In relapses of acute myelitis which had been brought on by chilling of
the feet I have obtained good results by derivation to the lower
extremities, and on many grounds think that the morbid process in the
cord, if it can be affected at all, can be affected by treating the
periphery where the symptoms are noted more readily than by applying
the cautery or bleeding over the proven site of the disease. Exposure
of the dorsal region to cold has not yet been noted as a cause of
acute myelitis, whereas such exposure of the lower extremities is a
frequent one. This seems to show that the spinal cord is more
vulnerable to influences affecting its nervous distribution than to
those which are topographically nearer. If this is true as regards
morbid influences, it may be urged that it is plausible as regards
remedial influences if these are to drive out the disease tendency by
the same door it entered.
Rest is imperative during the active progress of the disease. It may
be stated as a canon that the earlier the patient takes to his bed,
and the more thoroughly he obeys the injunction to attempt no motion
of the affected members, the better, cæteris paribus, will the result
obtained be. Countless cases are on record where a relapse was
directly traceable to a walk undertaken prematurely or carried farther
than was wise. As convalescence or partial restitution advances,
gradually increasing exercise is to be attempted, not waiting for the
danger-signal of a tired feeling to discontinue it; for that feeling,
developed, means positive harm already done. It is therefore necessary
to allow the returning function to be utilized only within small
limits at first, and extending them slowly.
In all cases of severe myelitis where the formation of bed-sores is to
be apprehended the water-bed should be employed. Owing to the low
temperature which the rubber sac constituting it has, it is necessary
to cover it with some well-warmed and non-conducting material and to
have the room well warmed. If bed-sores are already formed, they are
to be treated according to ordinary surgical principles. Antiseptic
means should be in the foreground in the case of the malignant
bed-sore. It is to be remembered that the latter is a gangrenous
process, and, in so far as the formation of a line of demarcation
between the necrotic and the conserved tissue is concerned, the
ordinary expectant rules of surgery govern the case: the water-bath
appears to yield the best results. Ordinary bed-sores yield readily to
mechanical protection and stimulating ointments or the balsam of Peru.
Iodoform is recommended, but it produces granulations of an indolent
character as compared with those obtained through the use of resinous
ointments.
The warm bath is probably the most useful measure in acute myelitis.
{824} In cases due to exposure I do not believe it can be applied too
soon. Its temperature should, in the beginning at least, not be higher
than about 88° F., and the duration about seven minutes. The continued
administration will depend on the immediate effect on the patient, and
the sittings can be ultimately prolonged to half an hour or even
longer. It should be administered once daily, and, when the patient is
not disturbed by the manipulation connected with its use, even
oftener. Cold baths are recommended by the Germans, but it seems
rather in the passive period of the disease than during its active
phase.
The management of the bladder trouble is one of the most critical
points in the treatment of most cases. The results of retention of
urine are more frequently the cause of a fatal issue than any other
single complication. Where there is complete retention continuous
catheterization is to be employed, as recommended by Strümpell.[106]
In other cases the bladder should be emptied thrice in the twenty-four
hours. The catheter is to be thoroughly disinfected, and if the
slightest sign of cystitis is noted the bladder should be washed out
with astringent and disinfectant solutions. The continuous irrigation
with a solution of corrosive sublimate, 1:2000, appears to give the
best results.
[Footnote 106: A. Nelaton's catheter is introduced into the bladder,
and kept in place by strips of adhesive plaster fixed to the inner
aspect of the thighs. A perforated condom fixed to the catheter, and
then fastened to the inguinal region, is in my opinion a better
measure, especially in patients who have some motor power left. The
catheter is connected with a rubber tube, which should run on a
decline in order to effect complete drainage.]
If there be a syphilitic taint present—and more particularly is this
true of cases where no other cause can be assigned—large doses of
iodide of potassium[107] should be administered, and mercurial
ointment energetically applied, even to the point of salivation.
[Footnote 107: Here, if anywhere, the so-called heroic doses are
applicable.]
I am unable to say anything with regard to the local use of
electricity in the active period of the disease. Ascending currents
are recommended by Erb, weak currents of about five minutes' duration
being employed over the part supposed to be affected. In order to
secure sufficiently deep deflection of the current large electrodes
are applied. The use of galvanism and faradism on the affected
periphery, the former being preferred where atrophic, the latter where
anæsthetic conditions preponderate, is to be instituted early and
continued through the duration of the disease. The rules stated in the
section devoted to electro-therapeutics are to be followed. In cases
where the bladder or rectum are paralytic, these organs should have
galvanism applied to them by means of electrodes shaped like catheters
or sounds.
After the acute phase of myelitis is passed, the secondary period is
to be managed according to the principles laid down in the section on
the Treatment of the Sclerotic Processes.
{825}
THE CHRONIC INFLAMMATORY AND DEGENERATIVE AFFECTIONS OF THE SPINAL
CORD.
BY E. C. SPITZKA, M.D.
The intimate dovetailing of parenchymatous and connective substance in
the spinal cord renders the determination of the precise origin of a
morbid process often difficult if not impossible. Whatever the mode of
origin, the typical termination of inflammatory and degenerative
spinal disorders is sclerosis—a condition in which the essential
nervous elements suffer diminution or destruction, while the
connective substance is either absolutely or relatively in
preponderance. The clinical result is nearly the same in all cases,
and with few exceptions depends less upon the histological character
than on the topographical distribution of the lesion. It is for this
reason that we shall follow rather the topographical than the morbid
histological principle in classification.
The chronic disorders of the spinal cord here considered have as a
common character the slow and progressive displacement of the normal
conducting nerve-tubes by a grayish, reddish, or otherwise discolored
tissue, which is firmer in texture than normal nerve-substance. Minute
examination shows that it is above all the myelin of the nerve-tubes
that is wasted or destroyed, while the axis-cylinders may share in
this dissolution, or, as in one form of sclerosis, they may persist
and even continue in their conducting function. This increased
consistency is found to be due to the increase of connective-tissue
trabeculæ and of the neuroglia. In some cases this increase is active
and absolute, like the increase in certain phases of hepatic
cirrhosis; in others it is rather relative and passive, being merely a
condensation of the connective framework after the intervening
elements have wasted away, just as the texture of a compressed sponge
is more compact than that of an expanded one.
Crudely, the affections of the cord characterized by this change may
be divided into two great groups—the regular and the irregular. The
former are characterized by their limitation to special nerve-tracts.
Thus, in primary lateral sclerosis we find a special tract in the
posterior part of the lateral columns occupied by the lesion. A number
of spinal diseases with well-defined symptoms are due to active morbid
processes which similarly follow the normal distribution of the great
nerve-tracts of the cord, with the same, almost mathematical,
regularity with which the medullary white develops in the fœtal and
infantile cord. In another class of cases we find that the same tracts
are involved in like manner—not in the way {826} of primary disease,
but through the interruption of the physiological continuity of the
nerve-tract by some other disease, to which the sclerosis is therefore
secondary. These are the so-called secondary degenerations.
The irregular affections of the cord comprise cases in which the
sclerotic foci are either disseminated through the cerebro-spinal axis
in numerous foci, or diffusely involve a greater or lesser length and
thickness of the medullary cylinder, or, finally, extend in the
transverse plane completely or nearly so across the section area of
the cord at a definite level.
As the symptoms of the regular affections of the cord are by far the
most readily recognizable, and a preliminary knowledge of them will
facilitate the better understanding of the irregular forms, we shall
consider the former first. They may be subdivided into two groups. The
largest, longest known, and best studied consists of acquired, the
other, containing less numerous cases and varieties, and rendered
familiar to the profession only within the last decade, comprises the
spinal disorders due to defective development of the cerebro-spinal
and spinal-fibro systems.
Tabes Dorsalis.
SYNONYMS.—Locomotor ataxia and ataxy, Posterior spinal sclerosis;
Graue degeneration der Hinterstränge (Leyden), Rückenmarksdarre
(popular), Rückenmarksschwindsucht; Tabes dorsualis (Romberg); Ataxie
locomotrice progressive (Duchenne).
HISTORY.—Undoubtedly, this disease must have been observed by the
ancient masters of medicine, but their descriptions group together so
many symptoms of other organic as well as functional diseases of the
cord that it is impossible to obtain a clear idea as to what special
form they had in view when they spoke of tabes dorsualis. This term
was adopted by the German writers of the last and the earlier part of
this century as designating all wasting affections of the cord; and it
was not till Romberg in 1853 and Duchenne in 1858 differentiated the
characteristic clinical signs, and Cruveilhier and Todd (1847)
determined the distribution of the lesion in the posterior columns,
that the medical profession began to recognize the distinctness of
this the most common form of organic spinal ailment.
At this time, when tabes dorsalis became recognized as a clinical
entity depending on sclerotic degeneration of the posterior segment of
the cord, the inco-ordination or ataxia manifested in the peculiar
gait of the patient was regarded as the most characteristic,
essential, and constant symptom of the disease. It was regarded as an
axiom in physiology that the posterior segment of the cord was
subservient to centripetal and sensory conduction, and nothing
appeared to follow more naturally than the conclusion that the patient
exhibited inco-ordination because, his sensory conduction being
interrupted or destroyed, he had lost the necessary gauge for judging
of the required extent and force of a given movement. Since then both
spinal physiology and pathology have undergone a profound revolution.
So far are we to-day from regarding anterior and motor or posterior
and sensory as convertible terms that we locate the {827} most
important centrifugal tract of the cord behind the plane which divides
it into anterior and posterior halves, while the most recently
differentiated centripetal tract is represented by Gowers as lying in
front of it. It has been determined, through Türck, Bouchard, and
Flechsig and his pupils, that the posterior white columns of the cord
contain several systems of fibres, whose functions—where
determinable—are of an exceedingly complex nature. The elaborate
investigations of Charcot, Schultze, and Strümpell, made during the
past decade, have shown that the distribution of the diseased field in
the posterior segment is not uniform, but is most intense in special
areas. These were found to be affected with a remarkable constancy and
regularity. Almost coeval with this discovery came the recognition of
symptoms found in the earliest phases of the disorder by Westphal,
which, attributable as they were found to be to the involvement of the
special reflex mechanisms of the cord, enable us to demonstrate the
existence and extent of the disease at periods which previously were
not within the ken of the clinician. The reproach which Leyden was
justified in making, that most tabic patients pass through the
pre-ataxic phase of their disorder under the diagnosis of rheumatism
or some similar affection, can now no longer be made. Our ability to
recognize the advent of this disease has reached such a degree of
refinement that the question arises whether we are always justified in
alarming a patient who has a prospect of remaining free from
invalidating complications for many years with the announcement of a
disease which, above all other spinal affections, is looked upon with
dread as equally hopeless, insidious, and distressing.
CLINICAL HISTORY.—The development of tabes dorsalis is typically slow
and its precise commencement usually not determinable. In some cases
this or that one of the characteristic symptoms of the disease
preponderates from the beginning, and continues throughout the illness
as a prominent feature; in others distinct stages can be recognized,
each marked by one or several symptoms which were absent or slight in
the other stages. In some cases the progress of the affection is
marked by episodes which are absent or rare in other cases. As a rule,
however, it may be stated that tabes is a progressive affection,
marked by pronounced temporary changes for better or worse, which are
often developed with astonishing rapidity, and subside as quickly,
terminating fatally unless its progress be arrested by treatment or
interrupted by some other fatal affection. The latter is by far the
more frequent termination in the well-to-do class of sufferers.
For purposes of convenience we may consider the symptoms of the
earlier period of the illness as pre-ataxic, and those of the later as
the ataxic. It is to be remembered, however, that in the strictest
sense of the term there is usually some disturbance of co-ordination
even in the early period, while the symptoms of the pre-ataxic period
continue over the ataxic period, and may even become aggravated with
it. Often the patient does not himself suspect a spinal, or indeed any
nervous, disorder, and consults the physician either on account of
rheumatic pains, double sciatic neuralgia, bladder disturbance,
diminished sexual power, amaurosis, diplopia, or even gastric
symptoms, which on closer examination are revealed to be evidences of
tabes. The determination of the initial symptoms is retrospective as a
rule.
{828} Of the subjective signs, one of the commonest, if indeed it be
ever entirely absent, is a tired feeling, particularly noted in the
knees and ankles. This sensation is compared to ordinary muscle-tire,
but is provoked by slight exertion, and not as easily remedied by
rest. Often a numb feeling is associated with it, although no
objective diminution of cutaneous sensation be determinable. This
combined feeling of tire and numbness, described as a going-to-sleep
feeling in the ankle, has indeed been claimed by one observer[1] to be
pathognomonic of early tabes. Next in frequency, and almost as
universal, are peculiar pains: these are manifold in character and
distribution, but so distinctive as to alone suggest the existence of
the disease from the manner in which the patient describes them. One
variety, the lightning-like, is compared to a sudden twinge of great
intensity shooting through the limb. The sciatic and anterior crural
branches are the lines usually followed by this pain, but there are
cases where perineal and abdominal regions are affected. Often the
pain is so severe that the patient cries out or the limb is violently
contracted under its influence. It differs from rheumatic pain in the
fact that it is distinctly paroxysmal and that the intermissions are
complete; that it is not greatly aggravated by motion nor relieved by
rest, while the rheumatic pain is; that tabic pain is usually
relieved, and rheumatic pain aggravated, by pressure, while
hyperæsthesia is present with the former, and either absent or barely
indicated with the latter. The lightning-like pains are sometimes
combined with another form, which is even more distinctive in
character. This form does not affect the distribution of special
nerves, but is found limited to a small area which the patient is able
to localize definitely: it may not exceed a centimeter or two in
diameter, and within this area the pain is excruciating. It is either
of a burning character or compared to the firm pressure of a vise or
heavy weight, or to the tearing, boring, and jumping of a violent
toothache.
[Footnote 1: Canfield, _Lancet_, 1885, vol. ii. p. 110.]
While some patients escape these pains almost entirely,[2] others are
tormented with them at intervals for years, their intensity usually
diminishing when the ataxic period is reached. There is little
question among those who have watched patients in this condition that
their pains are probably the most agonizing which the human frame is
ever compelled to endure. That some of the greatest sufferers survive
their martyrdom appears almost miraculous to themselves. Thus, in one
case the patient, who had experienced initial symptoms for a year,
woke up at night with a fulminating pain in the heels which recurred
with the intensity of a hot spear-thrust and the rapidity of a flash
every seven minutes; then it jumped to other spots, none of which
seemed larger than a pin's head, till the patient, driven to the verge
of despair and utterly beside himself with agony, was in one continued
convulsion of pain, and repeatedly—against his conviction—felt for the
heated needles that were piercing him. In another case the patient,
with the pathetic picturesqueness of invalid misery, compared his
fulminating pains to strokes of lightning, {829} “but not,” he added,
“as they used to appear, like lightning out of a clear sky, but with
the background of a general electrical storm flashing and playing
through the limbs.”
[Footnote 2: I have at present under observation two intelligent
patients (one of whom had been hypochondriacally observant of himself
for years) who experienced not a single pain, as far as they could
remember, and who have developed none while under observation. Seguin
mentioned a case at a meeting of the Neurological Society with a
record of but a single paroxysm of the fulgurating variety. Bramwell
(_Brit. Med. Journ._, Jan. 2, 1886) relates another in which the pains
were entirely absent.]