extenuated and of a loose texture. We observed no signs of compression
in the lingual and brachial nerves, as high as their exit from the
basis of the cranium and the vertebrae of the neck; but they appeared
to us more compact than they commonly are, being nearly tendinous. The
dura mater was in a sound state, but the pia mater was full of blood
and lymph; on it several hydatids, and towards the falx some marks of
suppuration were observed. The ventricles were filled with water, and
the plexus choroides was considerably enlarged, and stuffed with
grumous blood. The cortical surface of the brain appeared much browner
than usual, but neither the medullary part nor cerebellum were
impaired. We chiefly took notice of the Medulla Oblongata, this was
greatly enlarged, surpassing the usual size by more than one third. It
was likewise more compact. The membranes, which, in their
continuation, inclose the spinal marrow, were so tough that we found
great difficulty in cutting through them, and we observed this to be
the cause of the tendinous texture of the cervical nerves. The marrow
itself had acquired such solidity as to elude the pressure of our
fingers, it resisted as a callous body, and could not be bruised. This
hardness was observed all along the vertebrae of the neck, but lessened
by degrees, and was not near so considerable in the vertebrae of the
thorax. Though the patient was but nine and thirty years old, the
cartilages of the sternum were ossified, and required as much labour
to cut them asunder as the ribs; like these they were spungy, but
somewhat whiter. The lungs and heart were sound. At the bottom of the
stomach appeared an inflammation, which increased as it extended to
the intestines. The ileum looked of that dark and livid hue, which is
observed in membranous parts tending to mortification. The colon was
not above an inch in diameter, the rectum was smaller still, but both
appeared sound.--From these appearances, we were at no loss to fix the
cause of this gradual palsy in the alteration of the medulla spinalis
and oblongata."
Dr. Bellett offers the following explanation of these changes. "I
conceive, that, by this accident, the head being violently bent to the
right, the nervous membranes on the left were excessively stretched
and irritated; that this cause extended by degrees to the spinal
marrow, which being thereby compressed, brought on the paralytic
symptoms, not only of the left arm, but at last in some measure also
of the right. This induration seems to have been occasioned by the
constant afflux of the nutritive juices, which were stopt at that
place, and deprived of their most liquid parts; the grosser ones being
unable to spread in the boney cavity, by which they were confined,
could only acquire a greater solidity, and change a soft body into a
hard and nearly osseous mass. This likewise accounts for the increase
of the medulla oblongata, which being loaded with more juices than it
could send off, swelled in the same manner as the branches of trees,
which will grow of a monstrous size, when the sap that runs into them
is stopt in its progress. The medulla oblongata not growing so hard as
the spinalis, was doubtless owing to its not being confined in an
osseous theca, but surrounded with soft parts, which allowed it room
to spread. The obstruction from the bulk of this substance must have
affected the brain, and probably induced the thickening of the pia
mater, the hydatids, and the beginning of suppuration, whereas the
dura mater, being of a harder texture, was not injured[11]."
[Footnote 11: Medical Observations and Inquiries, Vol. III.
p. 257.]
In some of the symptoms which appeared in this case, an agreement is
observable between it and those cases which are mentioned in the
beginning of these pages. The weakened state of both arms; the power
first lessening in one arm, and then in a similar manner in the other
arm; the affection of the speech; the difficulty in chewing and in
swallowing; as well as of retaining, or freely discharging, the
spittle; the convulsive motions of the body; and the unimpaired state
of the intellects; constitute such a degree of accordance as, although
it may not mark an identity of disease, serves at least to show that
nearly the same parts were the seat of the disease in both instances.
Thus we attain something like confirmation of the supposed proximate
cause, and of one of the assumed occasional causes.
Whilst conjecturing as to the cause of this disease, the following
collected observations on the effects of injury to the medulla
spinalis, by Sir Everard Home, become particularly deserving of
attention. It thence appears, that none of the characteristic symptoms
of this malady are produced by compression, laceration, or complete
division of the medulla spinalis.
"Pressure upon the medulla spinalis of the neck, by coagulated blood,
produced paralytic affections of the arms and legs; all the functions
of the internal organs were carried on for thirty-five days, but the
urine and stools passed involuntarily[12].
[Footnote 12: A coagulum of blood, the thickness of a
crown-piece, was found lying upon the external surface of the
dura-matral covering of the medulla spinalis, extending from
the fourth vertebra colli to the second vertebra dorsi. The
medulla spinalis itself was uninjured.]
"Blood extravasated in the central part of the medulla, in the neck,
was attended with paralytic affection of the legs, but not of the
arms[13].
[Footnote 13: The sixth and seventh vertebra colli were
dislocated, the medulla spinalis, externally, was uninjured;
but in the centre of its substance, just at that part, there
was a coagulum of blood nearly two inches in length.]
"In a case where the substance of the medulla was lacerated in the
neck, there was a paralysis in all the parts below the laceration, the
lining of the oesophagus was so sensible, that solids could not be
swallowed, on account of the pain they occasioned[14].
[Footnote 14: The seventh vertebra colli was fractured, and
the medulla spinalis passing through it, was lacerated and
compressed.]
"When the medulla of the back was completely divided, there was
momentary loss of sight, loss of memory for fifteen minutes, and
permanent insensibility in all the lower parts of the body. The skin
above the division of the spinal marrow perspired, that below did not.
The wounded spinal marrow appeared to be extremely sensible[15]."
_Philosophical Transactions_, 1816, p. 485.
[Footnote 15: The spinal marrow, within the canal of the
sixth vertebra dorsi, was completely destroyed by a musket
ball. The person lived four days.]
In two of the cases already noticed, symptoms of rheumatism had
previously existed; and in Case IV. the right arm, in which the
palpitation began, was said to have been very violently affected with
rheumatic pain to the fingers ends. The consideration of this case, in
which the palpitation had been preceded, at a considerable distance of
time, by this painful affection of the arm, led to the supposition
that this latter circumstance might be the cause of the palpitations,
and the other subsequent symptoms of this disease. This supposition
naturally occasioned the attention to be eagerly fixed on the
following case; and of course influenced the mode of treatment which
was adopted.
_A. B._ subject to rheumatic affection of the deltoid muscle, had felt
the usual inconveniences from it for two or three days; but at night
found the pain had extended down the arm, along the inside of the
fore-arm, and on the sides of the fingers, in which a continual
tingling was felt. The pain, without being extremely intense, was such
as effectually to prevent sleep: and seemed to follow the course of
the brachial nerve. Whilst ascertaining the propriety of this
conclusion, the pain was found to ramify, as it were, on the fore and
back part of the chest; and was slightly augmented by drawing a deep
breath.
These circumstances suggested the probability of slight inflammation,
or increased determination to the origin of the nerves of these parts,
and to the neighbouring medulla. On this ground, blood was taken from
the back part of the neck, by cupping; hot fomentations were applied
for about the space of an hour, when the upper part of the back of the
neck was covered with a blister, perspiration was freely induced by
two or three small doses of antimonials, and the following morning the
bowels were evacuated by an appropriate dose of calomel. On the
following day the pains were much diminished, and in the course of
four or five days were quite removed. The arm and hand felt now more
than ordinarily heavy, and were evidently much weakened: aching, and
feeling extremely wearied after the least exertion. The strength of
the arm was not completely recovered at the end of more than
twelvemonths; and, after more than twice that time, exertion would
excite the feeling of painful weariness, but no palpitation or other
unpleasant symptom has occurred during the five or six years which
have since passed.
The commencement, progress, and termination of this attack; with the
success attending the mode of treatment, and the symptoms which
followed, seem to lead to the conjecture, that the proximate cause of
the disease, in this case, existed in the medulla spinalis, and that
it might, if neglected, have gradually resolved itself into that
disease which is the object of our present inquiry.
Some few months after the occurrence of the preceding case, the writer
of these lines was called to a female about forty years of age,
complaining of great pain in both the arms, extending from the
shoulder to the finger ends. She stated, that she was attacked in the
same manner as is described in the preceding case, about nine months
before; that the complaint was considered as rheumatism, and was not
benefited by any of the medicines which had been employed; but that
after three or four weeks it gradually amended, leaving both the arms
and hands in a very weakened and trembling state. From this state they
were now somewhat recovered; but she was extremely anxious, fearing
that if the present attack should not be soon checked, she might
entirely lose the use of her hands and arms.
Instructed by the preceding case, similar means were here recommended.
Leeches, stimulating fomentations, and a blister, which was made for
sometime to yield a purulent discharge, were applied over the cervical
vertebrae; and in the course of a very few days the pain was entirely
removed. It is regretted that no farther information, as to the
progress of this case, could be obtained.
On meeting with these two cases, it was thought that it might not be
improbable that attacks of this kind, considered at the time merely as
rheumatic affections, might lay the foundation of this lamentable
disease, which might manifest itself at some distant period, when the
circumstance in which it had originated, had, perhaps, almost escaped
the memory. Indeed when it is considered that neither in the ordinary
cases of Palsy of the lower extremities, proceeding from diseased
spine, nor in cases of injured medulla from fractured vertebrae, any of
the peculiar symptoms of this disease are observable, we necessarily
doubt as to the probability of its being the direct effect of any
sudden injury. But taking all circumstances into due consideration,
particularly the very gradual manner in which the disease commences,
and proceeds in its attacks; as well as the inability to ascribe its
origin to any more obvious cause, we are led to seek for it in some
slow morbid change in the structure of the medulla, or its investing
membranes, or theca, occasioned by simple inflammation, or rheumatic
or scrophulous affection.
It must be too obvious that the evidence adduced as to the nature of
the proximate and occasional causes of this disease, is by no means
conclusive. A reference to the test therefore which will be yielded by
an examination of some of the more prominent symptoms, especially as
to their agreement with the supposed proximate cause, is more
particularly demanded. Satisfied as to the importance of this part of
the present undertaking, no apology is offered for the extent to which
the examination is carried on.
If the palpitation and the attendant weakness of the limbs, &c. be
considered as to the order in which the several parts are attacked, it
is believed, that some confirmation will be obtained of the opinion
which has been just offered, respecting the cause, or at least the
seat, of that change which may be considered as the proximate cause of
this disease.
One of the arms, in all the cases which have been here mentioned, has
been the part in which these symptoms have been first noticed; the
legs, head, and trunk have then become gradually affected, and lastly,
the muscles of the mouth and fauces have yielded to the morbid
influence.
The arms, the parts first manifesting disordered action, of course
direct us, whilst searching for the cause of these changes, to the
brachial nerves. But finding the mischief extending to other parts,
not supplied with these, but with other nerves derived from nearly the
same part of the medulla spinalis, we are of course led to consider
that portion of the medulla spinalis itself, from which these nerves
are derived, as the part in which those changes have taken place,
which constitute the proximate cause of this disease.
From the subsequent affection of the lower extremities, and from the
failure of power in the muscles of the trunk, such a change in the
substance of the medulla spinalis may be inferred, as shall have
considerably interrupted, and interfered with, the extension of the
nervous influence to those parts, whose nerves are derived from any
portion of the medulla below the part which has undergone the diseased
change.
The difficulty in supporting the trunk erect, as well as the
propensity to the adopting of a hurried pace, is also referable to
such a diminution of the nervous power in the extensor muscles of the
head and trunk, as prevents them from performing the offices of
maintaining the head and body in an erect position.
From the impediment to speech, the difficulty in mastication and
swallowing, the inability to retain, or freely to eject, the Saliva,
may with propriety be inferred an extension of the morbid change
upwards through the medulla spinalis to the medulla oblongata,
necessarily impairing the powers of the several nerves derived from
that portion into which the morbid change may have reached. In the
late occurrence of this set of symptoms, and the extension upwards of
the diseased state, a very close agreement is observable between this
disease and that which has been already shown, proved fatal to the
Count de Lordat. But in this case, the disease doubtlessly became
differently modified, and its symptoms considerably accelerated, in
consequence of the magnitude of the injury by which the disease was
induced.
CHAP. V.
CONSIDERATIONS RESPECTING THE MEANS OF CURE.
The inquiries made in the preceding pages yield, it is to be much
regretted, but little more than evidence of inference: nothing direct
and satisfactory has been obtained. All that has been ventured to
assume here, has been that the disease depends on a disordered state
of that part of the medulla which is contained in the cervical
vertebrae. But of what nature that morbid change is; and whether
originating in the medulla itself, in its membranes, or in the
containing theca, is, at present, the subject of doubt and conjecture.
But although, at present, uninformed as to the precise nature of the
disease, still it ought not to be considered as one against which
there exists no countervailing remedy.
On the contrary, there appears to be sufficient reason for hoping that
some remedial process may ere long be discovered, by which, at least,
the progress of the disease may be stopped. It seldom happens that
the agitation extends beyond the arms within the first two years;
which period, therefore, if we were disposed to divide the disease
into stages, might be said to comprise the first stage. In this
period, it is very probable, that remedial means might be employed
with success: and even, if unfortunately deferred to a later period,
they might then arrest the farther progress of the disease, although
the removing of the effects already produced, might be hardly to be
expected.
From a review of the changes which had taken place in the case of
Count de Lordat, it seems as if we were able to trace the order and
mode in which the morbid changes may proceed in this disease. From any
occasional cause, the thecal ligament, the membranes, or the medulla
itself, may pass into the state of simple excitement or irritation,
which may be gradually succeeded by such a local afflux and
determination of blood into the minute vessels, as may terminate in
actual but slow inflammation. The result of this would be a
thickening of the theca, or membranes, and perhaps an increase in the
volume of the medulla itself, which would gradually occasion such a
degree of pressure against the sides of the unyielding canal, as must
eventually intercept the influence of the brain upon the inferior
portion of the medullary column, and upon the parts on which the
nerves of this portion are disposed.
From this review, and assuming that the morbid changes in this disease
may not be widely dissimilar from those which occurred in the case of
Count de Lordat, the chance of relief from the proposed mode of
treatment may appear to be sufficient to warrant its trial.
In such a case then, at whatever period of the disease it might be
proposed to attempt the cure, blood should be first taken from the
upper part of the neck, unless contra-i(n)dicated by any particul(ar)
circumstance. After which vesicatories should be applied to the (sa)me
part, and a purulent discharge obtained by appropriate use of the
Sabine Liniment; having recourse to the application of a fresh
blister, when from the diminution of the discharging surface, pus is
not secreted in a sufficient quantity. Should the blisters be found
too inconvenient, or a sufficient quantity of discharge not be
obtained thereby, an issue of at least an inch and a half in length
might be established on each side of the vertebral columna, in its
superior part. These, it is presumed, would be best formed with
caustic, and kept open with any proper substance[16].
[Footnote 16: Cork, which has been hitherto neglected,
appears to be very appropriate to this purpose. It possesses
lightness, softness, elasticity and sufficient firmness; and
is also capable of being readily fashioned to any convenient
form. The form which it seems would be best adapted to the
part, is that of an almond, or of the variety of bean called
scarlet bean; but at least an inch and a half in length.]
Could it have been imagined that such considerable benefit: indeed,
that such astonishing cures, could have been effected by issues in
cases of Palsy of the lower extremities from diseased spine? although
satisfied with ascribing those cases to scrofulous action, we are in
fact as little informed respecting the nature of the affection,
inducing the carious state of the vertebrae, as we are respecting the
peculiar change of structure which takes place in this disease.
Equally uninformed are we also as to the peculiar kind of morbid
action, which takes place in the ligaments of the joints; as well as
that which takes place in different instances of deep seated pains and
affections of the parts contained in the head, thorax, and abdomen,
and in all which cases the inducing of a purulent discharge in their
neighbourhood is so frequently productive of a cure. Experiment has
not indeed been yet employed to prove, but analogy certainly warrants
the hope, that similar advantages might be derived from the use of the
means enumerated, in the present disease. It is obvious, that the
chance of obtaining relief will depend in a great measure on the
period at which the means are employed. As in every other disease, so
here, the earlier the remedies are resorted to, the greater will be
the probability of success. But in this disease there is one
circumstance which demands particular attention; the long period to
which it may be extended. One of its peculiar symptoms, Scelotyrbe
festinans, may not occur until the disease has existed ten or twelve
years, or more; hence, when looking for the period, within which our
hopes of remedial aid is to be limited; we may, guided by the slow
progress of the malady, extend it to a great length, when compared
with that within which we should be obliged to confine ourselves in
most other diseases.
But it is much to be apprehended, as in many other cases, that the
resolution of the patients will seldom be sufficient to enable them to
persevere through the length of time which the proposed process will
necessarily require. As slow as is the progress of the disease, so
slow in all probability must be the period of the return to health. In
most cases, especially in those in which the disease has been allowed
to exist long unopposed, it may be found that all that art is capable
of accomplishing, is that of checking its further progress. Nor will
this be regarded as a trifle, when, by reference to the history of the
disease, is seen the train of harassing evils which would be thus
avoided.
But it seems as if there existed reason for hoping for more. For
supposing change of structure to have taken place, it is extremely
probable that this change may be merely increase in mass or volume by
interstitial addition, the consequence of increased action in the
minute vessels of the part. In that case, should the instituting of a
purulent discharge, in a neighbouring part, act in the manner which we
would presume it may--should it by keeping up a constant discharge,
not merely alter the determination, but diminish the inordinate action
of the vessels in the diseased part; and at the same time excite the
absorbents to such increased action as may remove the added matter;
there will exist strong ground for hope, that a happy, though slow
restoration to health, may be obtained.
Until we are better informed respecting the nature of this disease,
the employment of internal medicines is scarcely warrantable; unless
analogy should point out some remedy the trial of which rational hope
might authorize. Particular circumstances indeed must arise in
different cases, in which the aid of medicine may be demanded: and the
intelligent will never fail to avail themselves of any opportunity of
making trial of the influence of mercury, which has in so many
instances, manifested its power in correcting derangement of
structure.
The weakened powers of the muscles in the affected parts is so
prominent a symptom, as to be very liable to mislead the inattentive,
who may regard the disease as a mere consequence of constitutional
debility. If this notion be pursued, and tonic medicines, and highly
nutritious diet be directed, no benefit is likely to be thus obtained;
since the disease depends not on general weakness, but merely on the
interruption of the flow of the nervous influence to the affected
parts.
It is indeed much to be regretted that this malady is generally
regarded by the sufferers in this point of view, so discouraging to
the employment of remedial means. Seldom occurring before the age of
fifty, and frequently yielding but little inconvenience for several
months, it is generally considered as the irremediable diminution of
the nervous influence, naturally resulting from declining life; and
remedies therefore are seldom sought for.