sanguine electro-therapeutist must admit that the action of galvanic
currents on the spinal cord is an exceedingly uncertain one. It is
questionable whether weak ones deflect sufficient current-loops to
reach the cord and to exert any material effect. As to currents
powerful enough to produce an effect, it is not known, except in the
loosest and most empirical way, what that effect is. The procedure
followed by Erb is to use large electrodes, the cathodal one being a
little smaller than the anodal, the former being placed stabile, over
the upper cervical sympathetic ganglion of one side, the latter
labile, on the opposite side of the vertebral spines, moving gradually
downward, the session not exceeding three minutes. This is repeated
daily or every alternate day.[169] It would prove a strong proof that
this treatment really affected the morbid process in a remedial
direction if any of the exact signs of the disease were to be modified
by it, be it ever so slightly. If, after galvanization of the cervical
cord and the sympathetic nerve, the initial myosis of tabes were
temporarily lessened or the reflex contraction to light restored for
ever so short a time, a brighter future would dawn for
electro-therapeutics than seems now to be in store for it.[170]
[Footnote 169: Why, if the procedure be really remedial or efficiently
palliative and devoid of evil consequences, it is not recommended to
be repeated oftener I am at a loss to explain or understand. There are
some factors involved in practical electro-therapeutic which it is
scarcely possible to discuss without encroaching on delicate ground.]
[Footnote 170: In healthy persons the extent of the knee-jerk is
increased by the spinal ascending galvanic current, and possibly this
observation may lead to the establishment of a rational basis for its
use in cases where the reflex is abolished or diminished.]
Peripheral Treatment.—A number of therapeutical applications are made
to the periphery where the symptoms of the sclerotic process are
localized. The rationale of such applications is based on the
assumption that peripheral conditions are capable of modifying the
nutrition and functions of the cord. This is proven not alone by a
host of observations made {903} on the normal cord, but is also
disastrously illustrated in the part played by surface chilling in the
etiology of many acute and chronic diseases of the cord.
Notwithstanding this latter, a large and influential body of German
neurologists recommend cold baths and cold spinal douches in these
affections. I have seen such excellent results from the use of warm
baths that I am compelled to plead, in defence of my ignorance of the
effect of cold ones, that I have never dared to use them. In numerous
cases the beneficial effect of a warm bath is almost instantaneous.
Warmth in any shape, whether atmospheric or in the shape of baths, is
usually agreeable to patients suffering from the various forms of
sclerosis. Cold, on the other hand, is disagreeable, aggravates the
symptoms, and in many cases at least hastens the progress of the
disease. A winter spent in the latitude of New York or Boston means so
much ground lost by the patient, and a sojourn during the colder
months in Southern California, New Mexico, Florida, or the West Indies
enables the patient to avoid this loss. As regards the choice of
climate and baths for sclerotic patients, I should be inclined to
roughly formulate the indications as being identical with those of
chronic rheumatism. The reaction against the use of warm baths in
Germany, where they once were popular,[171] is due to the employment
of too high temperatures. Hot baths, in the strict sense of the term,
including the various forms of vapor-bath, act badly. They increase
instead of calming the irritative symptoms, as moderately warm baths
do, and they entail too sudden a change in the bodily state. That, for
the present, it is advisable not to adopt unreservedly either the
extreme plan once in vogue or the equally extreme one which
constitutes the reaction against it, is shown by the observations of
Richter of Dalldorf, who records some discouraging results obtained by
the use of cold baths in cases of tabes dorsalis. It is but necessary
to refer to the fact that the lancinating pains of the latter disease,
the rigidity of diffuse myelitis, and the spasms of lateral sclerosis
are usually most severe in cold weather, and that the diseases
mentioned appear to be rare in warm countries, to show the need of
caution in using a therapeutical measure so similar in its action,
even if it be but momentary and followed by a reaction, to those which
provoke or aggravate the original disease. Eulenburg has seen five
recoveries in tabes, and under such different plans of treatment that
the latter is not credited by him with the good result. Three were
treated with warm baths, one with cold baths, and one with nitrate of
silver. It is seen here that the warm baths were used with good
results more frequently than the cold.
[Footnote 171: The mud-baths of Cudowa in Gallicia had a very high
reputation.]
One of the most singular delusions of modern
therapeusis—nerve-stretching—has, following the prediction made by
several on both sides of the Atlantic, become obsolete. Introduced by
Langenbuch, a surgeon, and attacking the disease at the sciatic
nerve—a point where, as well-versed students knew, it was not
located—the operation was looked upon with distrust from the
beginning. The enthusiasm with which it was taken up by surgeons and
by the interested portion of the laity—ever hopeful as tabic patients
are of new drugs and methods of treatment—has led to a large number of
trials, now numbering several hundred, and from which the useful
lesson can be gathered that the good ripens slowly. Nerve-stretching
in an organic disease of the spinal cord may take its {904} place
among the needless vivisections; it has not influenced the progress of
a single case in any essential feature. On the contrary, it has more
than once been directly responsible for acute myelitis, spinal
hemorrhage,[172] and pyæmia. In a number of cases reported by
Langenbuch,[173] Benedict, Erlenmeyer, Schweminger, Debove, and W. J.
Morton, the ataxia of the patient has been reported as relieved; in
one case, exhibited by the latter operator before the American
Neurological Association, this appeared quite evident, but not because
the disease proper had been influenced, but for the same reason that
prevents the development of marked ataxia in combined sclerosis. Just
as the lateral-column lesion inhibits the ataxia which is due to the
posterior-column lesion, so the motor paresis produced by stretching
the sciatic nerves neutralizes the manifest features of the ataxic
gait. As soon as the paresis is recovered from, the ataxia returns in
its original form, unless, happily, one of the common spontaneous
changes for the better occur. As a therapeutic procedure
nerve-stretching is to-day properly limited to affections of the
peripheral nerves.
[Footnote 172: Zacher, _Archiv für Psychiatrie_, xv. p. 430.]
[Footnote 173: Westphal showed after the autopsy of Langenbuch's first
successful case that there had been no spinal lesion whatever.]
One of the most useful peripheral remedies in the sclerotic processes
is the faradic wire brush. It is both an anodyne and remedial for
anæsthesia. A number of the tabic patients to whom I referred as not
having deteriorated within long periods are provided with a portable
faradic battery, and apply the brush to the spots affected by
terebrating pains the moment these commence, obtaining instantaneous
relief. As has been shown by Rumpf,[174] the cutaneous space-sense
becomes more delicate in healthy and improved in tabic patients under
its continued use. And while the inco-ordination of tabes is in part
independent of the disturbance of cutaneous sensibility, yet if the
latter can be refined the ataxic disturbance may be mitigated—a result
occasionally obtained through the methodical use of the wire brush.
[Footnote 174: Report of a discussion, _Neurologisches Centralblatt_,
1885, p. 526.]
It is frequently found that sufferers from tabes dorsalis and other
forms of sclerosis accompanied by ataxia walk much better in their
stocking feet and in slippers than they do in the conventional street
shoe or boot. The reason for this is obvious. The patient's gait is
impaired by the disease, and, whether the ataxia be a pure
co-ordinatory trouble or no, subjective uncertainty regarding contact
with the ground which is experienced by most ataxic patients is an
aggravating factor. Our modern foot-clothing, with its inflexible
soles and raised heels, handicaps the patient as it were, depriving
him of the use of what little tactile sensibility may be left
him.[175] The use of low-heeled shoes with thin and flexible soles is
therefore advantageous.
[Footnote 175: The question whether tabes dorsalis is a disease of
civilization has not been raised in any treatise I am acquainted with.
Myelitis, both acute and chronic, occurs, however, rarely in the lower
animals, as do also central dilatation of the cord and congenital
defects of the latter. Posterior sclerosis I can find no record of in
veterinary pathology. The influence of the repression of normal aids
to locomotion by the foot-gear of civilized life as a possible
predisposing factor in the etiology of ataxic troubles is a legitimate
subject of inquiry. The lateness of the infant of civilized parents in
acquiring the art of skilled locomotion may be in part, as
philosophers claim, a penalty of exuberant development of the higher
and inhibitive centres. But what part has the artificial obliteration
of solar sensibility and pedal flexibility played in this inherited
feature? What is its influence in establishing a pathological
vulnerability?]
{905} The tremors of sclerotic affections, particularly those
accompanying the disseminated forms, are from their distressing
character prominent objects of special treatment. The bromides have
been given with alleged good effect which I am unable to confirm.
Curare has caused the tremor to disappear for two days in one of
Erlenmeyer's patients. I have seen good results from the descending
galvanic current applied in long sittings to the head and neck,
sliding in to the point of tolerance, and sliding out before
discontinuing. The mydriatics, atropine, and particularly hyoscyamin,
often remove tremor radically for the time being; unfortunately, it is
necessary to give them in almost toxic doses to obtain this effect.
Recently, Feris recommended veratrum in doses of half a milligram
repeated every four to five hours. It acted very well in every case in
which I tried it, but, as it became necessary to increase the dose,
the same objection was encountered as in the case of hyoscyamin. All
these measures should be used as emergency remedies only; they cannot,
in the nature of the case, prove curative, while their continued use
produces a physiological indifference to their effect, and to that
extent decreases their value as the case progresses.
MANAGEMENT OF SPECIAL SYMPTOMS AND COMPLICATIONS.—Among the most
distressing features of many sclerotic affections is pain, which is
usually associated with sleeplessness. The fulminating variety may be
often relieved by the use of the actual cautery applied over the
affected level of the cord and along the course of the nerve involved.
But in the majority of cases morphine will have to be resorted to. Erb
cautions against the use of this anodyne in cases where there is much
reflex irritability of the cord, as morphine is said to increase this
irritability when administered in small doses, and to reduce it again
only when larger ones are administered. It is the latter alone which
are serviceable with pain, and I have not yet seen any bad effects in
the direction apprehended by Erb from such doses as it is necessary to
give. That the physician administering it should be always on guard
against the possible formation of a drug habit it is unnecessary to
add. But it is also unnecessary to add what alternative he shall adopt
when his choice lies between the lesser evil of the opium or morphine
habit and the terrible martyrdom which some patients would be
compelled to submit to if not allowed to indulge in it.[176] The evil
effect of opium and its preparations on the visceral functions is to
be neutralized, as far as possible, by the administration of laxatives
and bitter tonics.
[Footnote 176: Few sufferers from spinal disease use anodynes
habitually; opium and its preparations are not fascinating to the
majority of persons. On the other hand, there are two cases of tabes
dorsalis now under my observation in which the patients have been
compelled to use hypodermic injections of Magendie's solution for two
and three years without any materially bad effect.]
The deep-seated diffuse pains, such as are found in disseminated and
diffuse sclerosis, are not as markedly relieved by opium as the
terebrating and lightning-like variety. Frequently spastic or other
signs of increased reflex excitability are associated with them; and
as both are favorably influenced by the bromides, the latter are
doubly indicated in such conditions.
With pains of a rheumatic character static electricity has been
recommended. It undoubtedly relieves such pains, as skilfully-applied
{906} galvanism would. Its chief effects, it seemed to me from a six
months' trial with it, are on the imagination and hopes of the
patient.[177]
[Footnote 177: A large apparatus of the new and improved make was at
my disposal at the nervous department of the Metropolitan Throat
Hospital. It was very popular with sufferers from rheumatism, who had
been allowed to accumulate in the class before I took charge, and with
a paretic dement who suffered with the rheumatoid pains often found
with diseases such as his.]
The bromides and camphor[178] are recommended for the obstinate
priapism found in some cases of early tabes and transverse myelitis. I
have seen better results from warm hip-baths and general baths in this
condition than from any drug. As a general rule, the exercise of the
sexual function, where not already forbidden by the results of the
disease, should be limited as much as possible. The frequency of
normal seminal emissions in a given case is a guide to the amount of
indulgence in this direction which may be permitted. Where there is
the slightest indication of irritative or destructive lesions in the
upper lumbar cord sexual acts should be entirely prohibited, for under
these circumstances no greater injury could be done the weakened
centres than to permit them. This is particularly noticed in those
cases of tabes dorsalis which are marked by satyriasis in the early
period.
[Footnote 178: Particularly the monobromate of camphor.]
The treatment of the bladder trouble and of bed-sores is carried out
in the manner described in the section on Acute Myelitis. For
bed-sores Hammond recommends the application of a stabile galvanic
element consisting of a plate of silver and one of zinc, the two being
united by a wire isolated in the usual way. The silver plate is laid
on the bed-sore; the zinc plate, covered by a piece of moistened
cloth, is laid on the unbroken skin somewhere in the neighborhood. The
result is a weak current under whose stimulant effect the healing
process takes place very rapidly. I have seen excellent results that
had been obtained by this means in indolent ulcers of the leg. It does
not, however, seem to have been tested with the malignant variety of
bed-sore.
With regard to the management of muscular atrophies by electricity,
massage, and strychnia, the same rules are to be followed which are
laid down in the section on the Myopathic Atrophies. It is only to be
specially remarked that few authorities encourage the administration
of strychnia in sclerotic affections, and fewer still in such large
doses as could be of any benefit in a wasting process.
Faradization of the affected eye-muscles is often useful in diplopia.
The current may be applied by means of a cup-shaped eye-electrode, or,
better, by using a finger as an electrode.
The moral management of sufferers from sclerotic spinal affections is
very important. The popular notion about spinal disease generally is
such that the announcement made to a patient that he is suffering from
any form of it is as alarming as would be the discovery of a tumor in
his brain or a cancer in his stomach, and exerts a depressing effect.
This it should be sought to avoid. A large number of sufferers from
sclerosis live longer and suffer less than a portion of those
afflicted with rheumatic and gouty affections; and the physician is
justified in obtaining the desirable effect which a hopeful or
resigned state of the mind undoubtedly has on the body, by laying
great stress on this undeniable fact.
{907}
CONCUSSION OF THE BRAIN AND SPINAL CORD.
BY WILLIAM HUNT, M.D.
The writer was asked to contribute a short article upon Concussion of
the Brain and Spinal Cord for this work, as these injuries are apt at
first to come under the notice, if not charge, of the general
practitioner. The article will therefore not be an exhaustive one, and
there will be little but the details of personal experience and less
quoting of authorities. Much has been written recently upon the
subject both in volume and in pamphlet.
Diverse views of equally competent judges of the matter have been put
forth, and the brains and spinal cords of the partisans appear to have
received as severe a shaking up as the real recipients of the lesions,
if absolute lesions there be.
This, in fact, is the point of controversy, for there are those who
seem to deny that there can be a jarring or shaking of the
cerebro-spinal mass sufficient to cause positive symptoms without
producing positive lesions, whilst others are as firm in their
convictions that pronounced symptoms may follow a mere disturbing
ripple of the nervous elements. How is the question to be settled? The
slightly shocked or injured recover rapidly, whilst some who only
appear to be as slightly injured or shocked at first, go on to death,
during the progress to which event there is no doubt as to the
existence of lesion and no difficulty in finding it at the autopsy.
Hence, say the lesionists, the first ones had it, but got well, whilst
the non-lesionists affirm that it never existed in them.
The logician would think that these differences in opinion were only
differences in degree about the same thing, but, nevertheless, the
question is one for serious discussion, and is of much greater
importance than would appear to be the case to the average layman.
This importance lies in the medico-legal aspects of the suits arising
out of the alleged injuries and their consequences. Judges, lawyers,
and doctors know them well. In doubtful cases authorities of equal
eminence are quoted, and the results of trials are equally as doubtful
as to whether justice or injustice has been done. These remarks, as
will be seen, are especially applicable to injuries of the spine, but
they also may have place in the consideration of consequences arising
from concussion of the brain.
{908} Concussion of the Brain.
Whatever doubts there may be as to concussion of the spine, there are
none, I believe, who deny the appropriateness of the expression as to
the brain, it being, by its anatomical relations, so much more exposed
to shock than the spine.
We understand that pure concussion, uncomplicated with fracture,
refers to a condition caused by external violence, direct or indirect,
which communicates a jar or shock to the cerebral mass, and which
expresses itself by certain well-defined symptoms. The nervous system
and the circulation are most manifestly involved, but in a pure case
it may be said that all of the symptoms arise from central nervous
disturbance. Even could it be shown that they were dependent on
temporary congestions, these congestions, I think it will be admitted,
would be due to vaso-motor derangements.
The anatomical appearances after early death from concussion of the
brain are often insufficient for us to comprehend the fatal result,
for we know that the organ will bear, both from disease and other
kinds of injury, vastly greater inroads upon its structure and
surroundings without causing death. Often there is mere localized
cerebral congestion, with no ruptures of vessels; then there are
slight extravasations shown as points or dots of blood in the
nerve-matter; and, again, there is what is called the bruised brain.
Sometimes there is nothing abnormal whatever to be found. Most of
these cases, under modern criticism, have been justly shut out from
the record as having no value; for it has been shown that the
post-mortem examinations of them have been very imperfect, the brain
only having been inspected, whereas the chest, the abdomen, or the
spine might readily have revealed the cause of death.
It is fair, however, to assume that there must be a capacity for
serious results in the vibratory jar, as the discoverable lesions in
many well-examined cases have been in themselves insufficient to kill.
The rapidity of recovery of those who get well also bears weight on
this point.
Of nineteen cases of recovery from concussion of the brain of which I
have record, the average stay in hospital was eight days. The range of
stay was from one to twenty-five days. Many of these were at first
profoundly shocked, some of them apparently hopelessly so when we
compared their symptoms with those who died. As they recovered,
however, in so short a time, there surely could not have been any
gross lesion to account for their symptoms. What else, then, can
account for them than vibratory jar? and if this can produce such
severe results within the line of recovery, why cannot the degree of
it be so extended as to involve, for example, the respiratory centres,
and so kill without leaving perceptible sign?
The SYMPTOMS of concussion of the brain range from a mere daze or
stunning to those of deep unconsciousness. There is no paralysis of
the extremities in pure cases. Often the patient is very restless, and
throws his limbs about in all directions. When these are quiet there
is response to irritation and electricity. Loud speaking to him may
elicit some attention, but the answers are mostly incoherent. There is
pallor, often extreme, coldness of surface, and sweating. Vomiting is
usual, and may come on immediately or later, and it continues as long
{909} as there is anything to discharge; sometimes there is retching.
In favorable cases the cessation of vomiting is accompanied by a slow
return to consciousness, which may be preceded by delirium. This
return is never sudden, and the method of it serves to distinguish the
case from that of some forms of epilepsy. The pulse is generally
frequent and feeble, often irregular; in extreme cases it may be slow
and feeble, very rarely, if ever, strong or bounding. After reaction
it becomes more natural, and if recovery follows it will not show much
variation. The temperature is depressed at first. In one
characteristic case it was 98° on the first day, reached 101° on the
third day, and receded to 98½° on the eighth day, when the brain
symptoms disappeared.
There may be retention of urine and sluggishness of the bowels, but in
bad cases coincident with the vomiting there is sometimes involuntary
discharge both of feces and urine. The respiration is irregular,
sometimes almost ceasing, and then returning with great rapidity.
Much has been said and written about the condition of the pupils in
concussion of the brain. I have made this matter a subject of
observation, and am convinced that the state of the pupils is of no
diagnostic value whatever as to determining the existence of
concussion or compression. Their state is of great value in telling us
that the functions of certain brain-centres are partially or wholly
impaired. The progress of the case will tell us whether the impairment
is due to clot or effusion, congestion or jar.
It is wrong, therefore, to say that the pupils are one way in
compression and another in concussion. It is right to say that in
either case they are sluggish or wholly irresponsive to light. In one
person they may be dilated, in another contracted, and in the same
person the eyes may present marked contrasts.