[Reprinted from The Post-Graduate, No. 10, 1892.] 
A CONTRIBUTION TO THE STUDY OF CHRONIC 
MYELITIS, BASED ON A RECORD OF 
TWENTY CASES. 
by 
JOSEPH COLLINS, 1£d., New Vork, 
Late Instructor of Nervous Diseases at the New York Post-Graduate School; Attending 
Physician to the Out-door Department of Bellevue Hospital, Section of 
Nervous Diseases; and Assistant at the Ophthalmic and 
Aural Institute. 
The term chronic myelitis is in its usage a very flexible one 
and is unfortunately often applied to certain symptoms as a dis- 
ease entity, having entirely different pathological lesions. The 
term should include cases of myelitis that arise slowly and gradu- 
ally, although it is commonly applied to those cases that have be- 
gun as acute myelitis and have not eventuated in recovery. The 
various forms of sclerosis were at one time considered as varieties 
of chronic myelitis, but as our histological knowledge of the spinal 
cord became more perfect we have been able to isolate many of 
them, so that now their lesions are limited to special sets or sys- 
tems of fibres or disseminated in some regular order. There are 
left yet, however, a large number of cases which cannot be classified 
with any regular systemic or focal lesions in the cord ; but it is 
more than probable that as time goes on, and progress is made in 
our knowledge of the causation and pathology of these diseases, we 
will be able to separate many of them, as tabes dorsalis, dissemi- 
nated sclerosis, amyotrophic lateral sclerosis, etc., have already 
been separated. 
The following paper is a study of twenty cases of chronic myeli- 
tis as applied above. They occurred at the clinics under the 
control of Professor Charles L. Dana, and to him I wish to express 
my sincere thanks for his permission and assistance in making the 
following report: 
Etiology.-The average age of the patients at the onset of the 
disease was forty-seven, the eldest being sixty-four and the youngest 
twenty-three. Fifty per cent of all the cases occurred in the 
fourth and fifth decades. Of the twenty cases sixteen were males 
and four females. Eight of the patients gave a history of an 
initial specific lesion occurring from two to twelve years previous to 
the onset of their present symptoms. Of the twenty, eight were 2 
moderate drinkers, three alcoholics by their own confession, and 
the remaining nine indulged but rarely. As regards nationality, 
nine were Irish and two of Irish extraction, three were natives of 
this country, two were Scandinavians, and four were of English 
birth. It may be a mere coincidence, keeping in mind the marked 
predilection of phthisis for the Irish race, especially when trans- 
planted to this country, but in eleven cases occurring in the Celts 
three presented signs of personal phthisis and six gave striking 
family histories. For instance, one patient, R. H., aged twenty- 
four, said her parents, brothers, and two sisters had died of 
phthisis. Another had lost one parent and two brothers from the 
same disease. Of course one is led, when thinking of this, to ex- 
plain this coincidence in one of two ways. First, it may be due 
to the fact that before tuberculosis can manifest itself there must 
be an overwhelming perversion of nutrition, which is unquestion- 
ably greatest in the organ or organs where the germ is going to 
take up its abode, but associated with this is a general depreciation 
of nutrition which favors the development of degeneration in the 
spinal cord when there is already an inherent or acquired predi- 
lection for such a disease. On the other hand, some of the cases 
may have been primarily tubercular in their nature. But, aside 
from both of these theories, the fact is ever apparent that the 
tendency to the development of degenerative diseases in the Irish 
when transformed into Americans is manifest as well in this as 
in other diseases. 
Most text books, in their description of chronic myelitis, say that 
an inherited neuropathic predisposition can almost always be 
traced. In this series of cases, however, no such tendency could 
be detected, with possibly one exception in a patient whose father 
became insane and died of general paresis. Repeated exposures 
and chilling after perspiring, together with a history of previous 
attacks of what was called rheumatism, occurred in twenty per 
cent of the cases. Three of the patients gave a history of trauma- 
tism-either a direct fall on the back from a height or a severe 
blow. In two of the cases the symptoms came on very gradually 
after acute diseases, one after diphtheria and one after deli- 
rium tremens; and another patient was sure that the first symp- 
toms of her trouble came on while she was carrying her child. 
Naturally, these cases having presented themselves at hospitals 
and dispensaries for treatment, they were drawn from the lowest 
walks of life, where overcrowding, bad air, filth, improper nutri- 
tion, and other factors so prone to lower the vital resistibility of 
tissue cells are prominent. These, combined frequently with the 3 
history of some prolonged or extra-fatiguing labor which caused 
rheumatic pains in the back or legs, were the only points that 
many of these patients could have their trouble attributed to. 
A history of sexual excess was given in two cases, one occurring 
in a prostitute, and the other in a man who was tender on pres- 
sure over the tibiae and sternum, both of whom, however, denied 
an initial lesion; but credence can hardly be given to their state- 
ments, as the primary symptoms so often escape observation in 
this class of people. Whether or not toxic substances, such as lead, 
arsenic, malarial poisoning, etc., so often prominent factors in the 
production of acute changes in nerve structure, have any relation 
to the causation of chronic myelitis, does not have any light thrown 
on it by this series of cases. Unquestionably this form of de- 
generation may be the result of mechanical pressure, but that it 
may be the result and follower of an acute process some of us, at 
least, are not so ready to affirm. 
Symptoms.-The prominent initiatory point about all the cases 
was the slow and gradual development of the symptoms. In four 
cases only was pain a prominent symptom in the beginning of 
the disease, and in but one of these was it described as sharp and 
lancinating. This was a patient with a syphilitic history dating 
back three years, whose attention was called to her present trouble 
by darting pains in the lumbar region, extending up the spine as 
far as the inferior angle of the scapula, and then seeming to dart 
around the chest in the course of the intercostal nerves, and this 
after a few months gave way to a girdle sensation. The other 
three complained of a dull, aching pain in the small of the back 
and legs, but not of any severity. 
Thirteen of the patients complained of prominent subjective 
symptoms, such as a sensation of tingling, formications, feeling of 
heat and cold, not continuous, and sometimes limited to one special 
area-for instance, one patient complained that she had these sensa- 
tions in her ankles alternately and nowhere else. The histories 
show that nine of the cases presented the girdle sensation at or 
about the level of the lesion. Vaso-motor disturbances, although 
not a prominent symptom in any of the cases save one, were met 
with in several-as in one patient who had coldness in the entire 
left portion of the body from the lumbar region downward, and 
another whose feet were continually covered with a cold perspira- 
tion. Another patient says that he has occasionally a peculiar 
sensation, starting from the point of dull aching in the lumbar 
region and travelling up the spine to his head ; then he may have 
specks before his eyes and tinnitus aurium ; and then objects get 4 
black before him and he loses consciousness for a moment, but 
quickly recovers it and is apparently as well as ever, with the excep- 
tion of a feeling of cramps in the flexor muscles of the forearm 
occasionally. Myotatic irritability was increased in all the cases, 
varying from a slightly exaggerated knee reflex in one to an ex- 
tremely well-marked ankle clonus in others. 
In twelve of the cases the bladder symptoms were very troublesome, 
generally the bladder reflex being exaggerated. One patient would 
on some days have incontinence, and again on others would be unable 
to void any urine whatever ; but the dribbling of the urine was the 
most common complaint. The bowels in fifteen of the patients 
were constipated, and in seven they were obstinately constipated. 
The impairment of motorial power was the symptom that all 
the patients had in common, and this varied from a feeling of tired- 
ness and weight in the extremities to complete paralysis. Most of 
the patients complained of numbness in the feet and a tired, dead 
sort of a feeling in the legs-a sensation as if they were made of 
lead-particularly after rising in the morning, which would dis- 
appear somewhat after they were up and about for a time, but to 
come on with renewed severity after making any particular mus- 
cular exertion. Muscular twitchings and spasms, particularly in 
the legs and occasionally in the forearms, when the patient was in 
the recumbent posture, was a symptom that caused a considerable 
distress to five of the patients. 
The muscular atrophy present followed no regular order in its 
development, and generally the irritability to the galvanic current 
was not very much diminished; while the faradic irritability of the 
nerves was very greatly diminished in eleven of the cases, and some- 
what diminished in nearly all as far as the records were kept. The 
gait in most of the patients was spastic in character, while some 
presented a more or less ataxic gait. In advanced cases of the 
disease, or where the lesion had been located high up in the cord, 
static ataxia was well marked. Seven of the patients complained 
of inability to walk in the dark, and four of these also had occa- 
sional diplopia. In one of the cases, who presented head pressure 
and band dizziness, the speech was slow and syllabic, and some diffi- 
culty was experienced in swallowing, it is probable that a dissem- 
inated sclerosis followed an attack of transverse myelitis. Of the 
distribution of the anaesthesia and loss of temperature sense little 
definite could be made out; but, as a rule, it was first manifest on 
the soles of the feet and then next most often on the anterior sur- 
face of the legs. In two of the cases delayed sensorial conduction 
was very manifest. In most of the male patients the sexual power 5 
was greatly diminished, and in many not alone the ability but the 
desire as well. In the females this was rarely inquired into, but it 
is to be noted that the menstrual function continued undisturbed. 
In one case only was trophic change, in the shape of a bedsore, pre- 
sent, and this was readily cured, and without doubt could have been 
prevented if ordinary precautionary measures had been taken, so 
the citation of this is of but little value as an integer in the history 
of the disease. 
In the light of the pathology of the present day it seems nearly 
paradoxical to say that the variety of symptoms quoted above, last- 
ing, as they do, from two to twenty years, can be caused by a lesion 
which comes within our conception of inflammation or the results 
of inflammation. The term chronic myelitis is taken to include so 
much by many writers, placing under it, as some do, almost all de- 
generations involving simultaneously more than one conducting 
path in the cord, whether it be a focal lesion or otherwise. Probably 
most pathologists will admit that the disease in question does not 
partake of any of the phenomena known as inflammatory ; that it 
is a degeneration pure and simple, and is caused, and follows the 
same course as degenerations in other parts of the body under like 
conditions. The pathological finds in these cases are not at all 
consistent with our theories of inflammation. At no stage in this 
disease do we find the vascular changes, nor the exudative changes, 
and very little which corresponds with the parenchymatous changes 
as ordinarily taught to be the necessary parts of an inflammation. 
It is a familiar and demonstrable fact that the nerve fibres atrophy 
before the interstitial process becomes apparent. 
Treatment.-Taking these facts into consideration, the treatment 
simmers itself down to one thing, viz., to improve the nutrition of 
the patient, and particularly the nutrition of the nervous system; 
and this can best be done by changing the surroundings, the mode of 
life, the climate and scenery, and by the administration of those sim- 
ple medicinal food stuffs which we know to be blood-formers and 
tissue-builders. All forms of bodily and mental exercise leading to 
exhaustion are to be absolutely interdicted ; and frequently the rest 
plan of treatment for a short time in the beginning, combined with 
the use of electricity to prevent any retrograde change in the mus- 
cles from their forced quietude, will often be of service. Probably 
most of the patients will do best when put on cod-liver oil and a 
supporting plan of treatment, at the same time putting the haema- 
topoietic organs in the best condition possible. Two of the pa- 
tients in this series had their symptoms very much ameliorated and 
the progress of the disease seemingly checked by a sea voyage of 6 
long duration. Others would come to the Post-Graduate clinic and 
almost beg to be suspended, saying that it was the only thing that 
gave them relief. 
Hydrotherapy offers, perhaps, as good results in the treatment 
of this disease as any other measures. We have no more potent 
factor in stimulating vascular tonicity, when properly applied, 
than water. In the early stages of the disease, when the degene- 
ration is at its beginning, it seems a physiological deduction to 
say that cold water, applied by means of a graduated spray, needle 
bath, or perhaps a modification of the Scottish douche, may so act 
upon the circulation in the cord as to, in a measure, prevent or 
counteract the degeneration. Something may also be said in favor 
of counter-irritation to the back at about the seat of the lesion; 
it is doubtful, however, if the effects are more than transitory, but 
especially does it seem to do good when sensory symptoms, such 
as pain, are preventing the patient from getting the necessary 
amount of rest. It is in this way also that bathing with a solution of 
red pepper, or packs of brine to the back, are sometimes of use. The 
administration of such drugs as ergot, which was at one time so 
highly recommended on the grounds that the lesion was inflamma- 
tory in character and would so contract the blood vessels and di- 
minish the hypersemia, cannot be otherwise than harmful. Iron, 
mercury, quinine, phosphorus, etc., only do good, if at all, by 
enriching the blood and preventing the retrograde process in the 
cord. In cases where there is a marked proclivity to muscular 
degeneration and wasting, the administration of strychnine in 
full doses may be productive of some good. Of the use of elec- 
tricity but little need be said ; its use is but symptomatic, and in 
the shape of the faradic wire brush it is remedial when the paraes- 
thesiaa are troublesome; and the same may be said of static elec- 
tricity, the patients often assuring us they feel better after being 
treated to a sitting. Central galvanization will be disappointing. 
Moral factors in the treatment of this disease, as they do in all 
chronic diseases, enter as important elements in the management 
of our cases. It is indispensable to keep the mind in a content 
and hopeful frame, as contributing to making both the patient 
and his physician happy. 
153 Lexington avenue.