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Spinal Irritation
 
 
 
 
SPINAL  IRRITATION.
                   BY


     WILLIAM A. HAMMOND, M.D.,

PROFESSOR OF DISEASES OF THE MIND AND NERVOUS SYSTEM AND OF CLINICAL MEDICINE
  IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE, PHYSICIAN-IN-CHIEF TO THE NEW
     YORK STATE HOSPITAL FOR DISEASES OF THE NERVOUS SYSTEM, ETC.
[Read before the New York County Medical Society, January IT. W10.]
[FROM THE JOURNAL OF PSYCHOLOGICAL MEDICINE. APRIL, 1870.]
            NEW YORK:
D. APPLETON AND COMPANY
         90, 92 & 94 GRAND STKEET.
               1870. 
 Elliot's   Obstetric  Clinic.

     A Practical Contribution to  the Study of Obstetrics and the Dis-

         eases of  Women and  Children.   By George  T.  Elliot, Jr.,

         A.  M., M. D., Prof,  of Obstetrics  and the Diseases of Women

         and Children in the Bellevue Hospital  Medical College,  Physi-

         cian to Bellevue Hospital  and to the New York  Lying-in Hos-

         pital,  etc., etc.   8vo,  pp. 468.     .         .         Cloth, $4.50


    This volume, by Dr. Elliot, is based upon a largj experience, including fourteen

 years of service in the lying-in department of Bellevue Hospital of this city.  The

 book has attracted marked attention, and has elicited from the medical press, both
 of this country and Europe, the most  flattering commendations.  It is justly be-

 lieved that the work is one of the most valuable contributions to obstetric literature
 that has appeared  for many years, and, being eminently practical  in  its character,

 cannot fail to be of great service to obstetricians.

   " The volume by Dr. Elliot has scarcely less value, although in a different direction, than
 that of the Edinburgh physician (Dr. Duncan, Researchtr. in Obstetrics).  The materials com-
 f rising it have beon  principally gathered through a service of fourteen years in theBullevue
 [ospital, New York, during the whole of which time the author has been ensaged in clini-
 cal teaching.  The cases now collected into a handsome volume  illustrate faithfully the anx-
 ielies and disappointments, as well as the fatigues  and successes, which are  inseparable
 from the responsible practice of obstetrics—a line of practice which, under difficulties, de-
 mands the greatest moral courage, the highest  skill, and the  power of acting promptly on a
 sudden emergency.  Dr. Elliot's favorite subject appears to  be operative midwifery;  but
 the chapters on the relations of albuminuria to pregnancy, ante-partum haemorrhage, the in-
 duction of labor, and the dangers which arise from compression of the funis, are aL' deserving
 of careful perusal. The pleasure we feel at being able to speak  so favorably of Dr. Elliot's
 volume is enhanced by the circumstance that he was a pupil at the Dublin Lying-in Hospital
 when Dr. Shekelton was master.  We can certainly say that his teachings reflect great credit
 upon his Alma Mater."—London Lancet, April  11, 1868.
   " This may be said to belong to a class of books ' after the practitioner's own heart.'  in
 them he finds a wider range of cases than comes under his observation in ordinary practice;
 in them be learns the application of the most recent improvements of his art; in  them he
 finds the counterpart or cases  which have caused him the deepest anxiety ; in them, too, he
 may find consolation, for the regret—the offspring of limited experience, which has always
cast a shadow on the remembrance of some of his futal cases—will pass away as he reads of
 Biiailar ones in which far greater resources of every kind failed to avert a fatal termination.
   " There are not many books of this kind in our language;  they can probably all  be num-
 bered on the fingers of a simile hand. * * * Many circumstances concur, therefore,  to influ-
 ence us to extend to this work a cheerful welcome, and to commend  it as fully as possible.
 We do thus welcome it; as the production of a gentleman of great experience, acknowledged
 ability, and high position—as an emanation from one of the leading schools of our country
 and as an honorable addition to  our national medical  literature. '—American Journal of
 Medical Science, April, 1868.                                                      ^
   "As the book now stands, it is invaluable for the practitioner of obstetrics, for he will
 hardly ever in practice find himself in a tight place, the counterpart of  which he  will not
find in Dr. Elliot's book."—New York Medical Journal, February, 1868.
   "The book has the freshness of hospital practice throughout, in reference to diagnosis
pathology, therapeutical and operative  proceedings.  It will  be found to possess  a  <Teat
amount of valuable information in the department of obstetrics, in an attractive and "easy
6tyle, according to the most modern and improved views of the profession."— Cincinnati
 Lancet and Observer, April, 1868.
   " As a whole, we know of no similar work which has issued from the American press
which can be compared with it. It ought to be in the  hands of every practitioner of mid'
 wifery in the country."—Boston Medical and Surgical Journal.
   "One of the most attractive as well as forcibly  instructive works  we have  had the
pleasure of reading.  In conclusion, we recommend it as one  having no equal in the English
language, as regards clinical instruction in obstetrics."— Am. Jour, of Obstetrics, Aw.. 1868.
    Many ripe, elderly practitioners might, but few young  could, write a book so distin-
guished by candor, want of prejudice, kindly feeling, soundness  of judgment, and extent of
erudition.  While we do not say the book is faultless, we say there is no book in American
obstetrical literature that surpasses this one.   *  *  *  * The work now under review is
his first-born book or volume, and shows how fine opportunities  he has had, chiefly at Belle-
 vue Hospital, for acquiring experience, and how diligently he has availed himself of them.
 But his book shows much more.  It is the work of a physician of high education, a qualifi-
 cation m which obstetric authors are often deficient—it shows qualities of mind and skiL
 of hand rarely attained by so young a man."—Edinburgh Medical Journal, Feb., 1368. 
SPINAL  IRRITATION.
BY
     WILLIAM A. HAMMOND, M.D.,

PROFESSOR OF DISEASES OF THE MIND AND NERVOUS SYSTEM AND OF CLINICAL MEDICINE
  IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE, PHYSICIAN-IN-CHIEF TO THE NEW
     YORK STATE HOSPITAL FOR DISEASES OF THE NERVOUS SYSTEM, ETC.
[Read before the New York County Medical Society, January 17,1870.]
[FROM THE JOURNAL OF PSYCHOLOGICAL MEDICINE, APRIL, 1870.]
            NEW YORK:
D. APPLETON AND COMPANY
         90, 92 & 94 GRAND STREET.
               1870. 
mo
i

b 
SPINAL  IRRITATION.
                        HISTOKY.

     It has  been  questioned  by  several  distinguished
 authors whether  such an  affection as spinal irritation
 really exists  as a distinct disease.   Thus Valleix ' as-
 cribes the  most important  of  its manifestations  to
 hysteria, and regards the  spinal  tenderness present as
 being  due  to simple  intercostal  neuralgia;  Innian2
 considers the pain produced by pressure over the spinous
 processes of the vertebrae  as  existing in  the muscular
 attachments, and as indicative of what he calls myalgia.
 Mr. Skey3  evidently looks upon all cases  of spinal irri-
 tation as hysterical  in their character, and Memeyer4
 speaks incredulously on  the  subject, without giving

   1 Traits dos nevralgies ou affections douloureuscs des nerfs. Paris, 1841,
p. 345.
   2 On Myalgia: its Mature, Causes, and Treatment, etc. Second edition,
London, 1860, p. 225, et seq.
   'Hysteria, etc., New York, 1867, p.  72, et seq.
   4 A Text-Book  of Practical Medicine.  American edition, Yew York,
1869, vol. ii., p. 258.
           1
*/J6/6 </ 
4
SPINAL IRRITATION.
any very decided opinion.  It would be easy to bring
forward other authorities who have expressed  similar
views, and  I may have  to  allude  to  some of them
more  fully  hereafter.
    My own opinion is,  that there is  a well-defined
disease of the spinal cord, which, if designated by its
pathology, may properly be called spinal irritation, but
which, in a system of nomenclature based upon morbid
anatomy, would preferably be named spinal anaemia.
In  the  recently-published nomenclature of the Royal
College of Physicians,1 the affection has no place unless
it be included under the head of hysteria.
    The first author who  distinctly grouped together
the symptoms of spinal irritation was J. Frank,4 who,
under  the name of  rachialgia, described the disorder
with  considerable  accuracy, and laid the principal
stress  upon  the local  pain.  He  Avas followed  by
Stiebel,3 who, however, contributed little to our knowl-
edge of the subject.
  Mr.  J. R.  Player4  was among  the  first English
physicians, if not  the very first, to call attention to
the fact  that eccentric  derangement of function may
be the result of irritation of  the spinal cord.  Thus he
says:  " Most medical practitioners who have attended
to the  subject of spinal  disease must have observed
that its symptoms  frequently  resemble various  and
dissimilar maladies, and that commonly the function of
every organ  is impaired whose nerves  originate near

   1 The Nomenclature of Diseases drawn up by a Joint Committee ap
pointed by the Royal College of Physicians of London. London, 1869.
   8 De Rachialgitide in Prax.  Med. Univ., P. II., t. i., p. 37.
   8 tiber Neuralgica Rachitica, Rust's Magazine, t. i., c. xvi., p. 549.
   4 Quarterly Journal of Science, vol. xii., p. 428.  Quoted by Teale. 
SPINAL IRRITATION.
5
the seat of disorder.  The occurrence of pain in distant
parts  forcibly attracted my  attention, and  induced
frequent examination of the spinal column; and, after
some years' attention, I considered myself enabled to
state that, in a great number of diseases, morbid symp-
toms may be discovered about the origins of the nerves
which proceed to the affected parts, or of those spinal
branches which unite them ; and that, if the  spine be
examined, more or less pain will  commonly be felt by
the  patient on the application of pressure about or
between  those vertebrae  from  which  such  nerves
emerge."
    The term " spinal irritation " appears to have been
first used by Dr. C. Brown,1 of Glasgow, who, in  a very
excellent paper, gives a picture  of the disorder which
cannot fail to  be recognized as truthful and exact by
those who have witnessed several cases of the affection.
He insists upon not confounding  the complaint with
those organic diseases of the vertebrae and  spinal cord
which some  of its symptoms  cause  it to resemble,
points out the variation of the  phenomena according
to the seat of the spinal tenderness, and inculcates the
employment of rest and counter-irritation  as the most
effectual remedies.  His ideas of the pathology  of the
disease are: "That the immediate cause of the pain of
the  back and  breast is spasm of one or other  of the
muscles arranged along the spine  altering the  position
of  the vertebrae,  or otherwise compressing them as
they issue from the spinal marrow.
    " That this spasm  in many instances is strictly a
local disease, produced by  fatigue, wrong posture, or

  1 On Irritation of the Spinal Nerves. Glasgow Medical Journal, No. II.,
May, 1828. 
6
SPINAL IRRITATION.
 other causes, and quite unconnected with the state of
 the brain, spinal marrow, or nervous  system in gen-
 eral.
    " But that, in other formidable instances, this par-
 tial, spasmodic, or wrong action of the muscles is ow-
 ing to a faulty state, perhaps  an enlargement, of the
 vessels of the brain or spinal marrow.   This state of
 the brain, as in many other diseases, gives rise to spasm
 or even to convulsion of certain muscles; which partial
 symptom from its severity attracts the chief attention.
 This local affection is confined to those portions of the
 spine where there is the greatest motion, and where, of
 course, the muscles  having the greatest activity  are
 most  liable to deranged  action or spasm.   I imagine
 that this view of the subject is illustrated and perhaps
 confirmed by various symptoms which were observed
 in the different cases, and which without  it were very
 incomprehensible.  The partial palsy, the affection  of
 the sight, the giddiness of the head (for I find that
 this was a prominent symptom in several cases, espe-
 cially in that of A. S.), all give some confirmation  to
 the notion that the  brain is affected in  these  severe
 cases."
    Dr.  Darwall,1 of Birmingham,  describes several
 features  of the affection with accuracy, such as those
 simulating cardiac and gastric diseases.  He is inclined
 to believe that the morbid condition of the spinal cord
 depends  mainly upon irregularity of the circulation,
 generally congestion.
   But no essay upon the subject of spinal  irritation,
 which had yet appeared, was equal in thoroughness to

  1 On some Forms of Cerebral and Spinal Irritation.  Midland Medical
Reporter, May, 1829. 
                  SPINAL IRRITATION.                 7

that of Mr. Teale,1 and it is to him that the views now
generally  held  relative to  the  connection  between
various eccentric phenomena, such as pain, spasm, and
visceral disturbance,  and a peculiar condition of the
spinal cord, are  to be attributed.  He, however, com-
mitted the great error of regarding the  affection as
being due to inflammation, and, in what for those days
was logical accordance with this  theory, he combated
it with strong  antiphlogistic measures.   His book
may  be studied  with advantage,  as presenting an ad-
mirable account of the many  diverse  phases which
spinal irritation may assume.
    Mr. Tate,2 in  his work on hysteria, attributes many
of the protean manifestations of this disorder to spinal
irritation, limited, however, to the dorsal region.  He
fails  to recognize it as an independent  disease.  His
treatment  consists in the application of tartar-emetic
ointment along  the  whole length of the dorsal ver-
tebrae, and strong purgation.  He discountenances the
use of leeches and blisters.
    Mr. "W.  B-.  Whatton3  insists chiefly  upon  the
liability to mistake spinal irritation for  disease of the
vertebrae.   He gives a very excellent account  of the
symptoms.   The treatment he recommends consists in
the abstraction of blood, by leeches or cups, from the
parts where the tenderness is felt, repeated every three
or four days, and the application of small blisters on
 jach  side of the painful spots.  Any debility ensuing
m consequence of this  treatment is to be remedied
by the preparations of iron and quinine.
  'A  Treatise on Neuralgic Diseases dependent upon Irritation of the
Spinal Marrow and Ganglia of the Sympathetic Nerve.  London, 1829.
  2 A Treatise on Hysteria.  London, 1830.
  3 On Spinal and Spino-Ganglial Irritation.  North of England Medical
and Surgical Journal, No. III., 1831. 
8                SPINAL IRRITATION.
    Iii a  clinical lecture  delivered in  Dublin,  Dr.
Corrigan1  relates the  particulars of  several  cases  of
spinal irritation, successfully  treated  by  local anti-
phlogistic  measures, and  the  internal  use  of iron.
He does not, however, add any thing of importance  to
our previous knowledge of the subject.
    Dr. Isaac Parish,2 of Philadelphia, appears  to have
been the first American author who called attention to
the affection in question.  He relates the details of sev-
eral cases, recommends the use of counter-irritants, espe-
cially tartar-emetic ointment, and concludes:
    " First, that tenderness on pressure in some portion
of the spinal cord is an attendant  on  many chronic
neuralgic affections, and that, by relieving it in the man-
ner proposed, these complaints are either entirely eradi-
cated or temporarily suspended.
    " And secondly, that the precise  indications  which
this circumstance affords are not sufficiently understood
at the present time to justify the establishment of any
definite pathological principles applicable to the whole
class of neuroses."
    Dr. W. Griffin and his  brother, Mr. D. Griffin,3  of
Limerick, were the next  to write upon the  subject.
The joint work of these gentlemen is based upon one
hundred and forty-eight cases, all of which are thor-
oughly analyzed, and from which very  definite  deduc-
tions of pathology and treatment are drawn.  The es-

   1 Medico-Chirurgical Review, July, 1831, p. 182.
   2 Remarks  on Spinal Irritation as connected with  Nervous Diseases :
with Cases.  American Journal of the Medical Sciences, vol. x., 1832, p.
223.
   3 Observations on the Functional Affections of the Spinal Cord and
Ganglionic Nerves, in which their Identity with Sympathetic, Nervous, and
Simulated Diseases is illustrated.  London, 1834. 
SPINAL IRRITATION.
9
 say is not  excelled in importance by  any previous
 contribution, and  constitutes a really valuable study.
 The conclusions which they draw are so instructive
 that I do not hesitate  (though by no means indorsing
 them all) to transfer them without abbreviation:
    " 1. That tenderness at one or more points of the
 spine  is an  attendant  on almost all  hysterical  com-
 plaints, on numerous cases of functional disorder when
 the hysteric disposition is not so obvious, and in many
 nervous or neuralgic affections.
    " 2. That many of the symptoms of these affections
 evidently depend  upon  a peculiar  state of  certain
 nerves, probably at their  origin, may be reproduced at
 any moment by pressure, and are often relieved by
 remedies applied there.
    " 3. That, in all cases of tenderness of the cervical
 and upper dorsal spine, there was nausea, or vomiting,
 or pain of stomach, or affections of the upper extremi-
 ties ; but no pain of the abdomen, dysury, ischury, hys-
 teralgia, or affections of the lower extremities.
    " 4. That, in all cases  of dorsal tenderness, pains
 affecting the abdomen, bladder, uterus, testes, or lower
 extremities, were usual symptoms ;  while nausea, vom-
 iting, or affections  of the upper extremities, were never
 complained of.
    " 5. That nausea and  vomiting appeared to have
 more relation to tenderness of the cervical spine, pain
 of  stomach  to  tenderness of  dorsal; but that, when
 there was soreness of both, nausea or  vomiting was
 still more frequent, and pain of the stomach scarcely
 ever absent.
    " 6. That, when several points or a great extent of
the spinal column  is painful  and tender on pressure, 
10
SPINAL IRRITATION.
local remedies are generally less effectual, and there is
a strong disposition to transference of the disordered
action from one organ to another;  the pain or tender-
ness, in all such cases of transference,  shifting its place
to a corresponding part of the spinal column, leaving
the original point free, or with a very diminished de-
gree of tenderness.
   " 7. That spinal tenderness is seldom or never  met
with in cases of pure inflammation, except when these
accidentally occur in persons previously suffering from
irritation of the cord; and that, when appearances of
inflammation present themselves in any  organ accom-
panied by a corresponding spinal tenderness, they  can-
not commonly be removed by the remedies applicable
to inflammatory cases, and are often rendered worse by
them.  '
   " 8. That there does not appear to be a complaint
to which the human frame is liable, whether inflamma-
tory or otherwise, which may not be occasionally  irri-
tated in disturbed states of  the cord; and  hence that
this  disturbed state is one  vast source of  those com-
plaints called hysterical or nervous.
   " 9. That those functional disorders connected with
spinal tenderness are very often attended by some  dis-
turbance of the functions of the uterus, but that they
are by no means always  so, since they  occur in those
who are regular in this respect: in girls long before the
menstrual period of life, in women after it has passed,
and, lastly,  in men of nervous susceptible habits, and in
boys.
   " 10.  That in fact  they are not  necessarily depend-
ent upon any one organ;  since they are found indiffer-
ently coexisting with  disturbance of the digestive or- 
SPINAL IRRITATION.               11
gans solely, or the uterus solely, or of the  circulatory
or respiratory s}-stem.
    "11. That from the  cases-detailed we have reason
to suppose spinal tenderness may arise  from uterine
disorder, from dyspepsia, from worms in the alimentary
passages, from affections of the liver, from mental emo-
tions, from the poison of typhus, from marsh miasma-
ta, from erysipelatous, rheumatic, and eruptive  fevers,
and from the irritation arising from local injury.
    "12. That it is almost invariably found, in connec-
tion with  gastric or  abdominal tenderness, in fever;
and this tenderness is  probably like the  soreness of
scalp, pains in the limbs, etc., dependent on the mor-
bid state of the cord.
    " 13. That, whether in fever or in other complaints,
it is met with in the situation of the eighth or  ninth
dorsal  vertebra  much more frequently than at any
other part  of the spine.
    " 1-4. That affections attended by spinal tenderness
are seldom fatal; that, even in those cases of intense
irritation of the cord  under which patients suffer ex-
tremity of pain for years, the event is generally  favor-
able.
    " 15. That they frequently, as well as hysteria, oc-
cur with all the appearances of a primary affection  of
the nervous system.
    " 16. That affections are occasionally met with pre-
senting all the marks of the hysteric character, and per-
fectly resembling cases  described as those of spinal  ir-
ritation, but unattended by spinal tenderness or any
other direct indication of a morbid state of the cord."
   The treatment recommended consists in the removal
of the cause if this still continues in action, purgatives, 
12
SPINAL  IRRITATION.
 the application of blisters and leeches to the skin, the
 internal administration of hyoscyamus and belladonna,
 to lessen the nervous irritability, alum in cases of gas-
 tric derangement, and change of air and scene.
    In  a subsequent work, the  Messrs. Griffin' again
 discuss  the subject, but bring forward no  additional
 facts.
    Dr. John Marshall2 is confident that many visceral
 affections, such as heart-diseases, asthma, phthisis, dys-
 pepsia, diabetes, chorea, and  even phlegmasia  dolens,
 are frequently really produced or simulated by  spinal
 irritation.  Some of  his cases of supposed  functional
 disorder  of the spinal cord  are,  however,  obviously
 organic, consisting of congestion, inflammation, or  soft-
 ening of the organ.
    In his classical work, Ollivier3 devotes considerable
 space to  what he calls " an Affection described under
 the name of Spinal Irritation?  He  considers  the
pathological condition  to be  one of congestion of the
meninges of the cord, and bases this opinion in great
part on the success which, according to him, ensues on
the use of leeches, blisters, and  counter-irritant oint-
 ments.   In addition, he favors  the administration of
 opium, digitalis, hyoscyainus, belladonna, and  subcar-
bonate of iron.
    Ttirck4 regards the phenomena of spinal irritation
as being due, first, to disorder of other organs, whereby
   1 Medical and Physiological Problems: being chiefly Researches for
correct Principles of Treatment in Disputed Points of Medical Practice.
London,  1845.
  2 Practical Observations  on Diseases of the Heart, Lungs, Stomach,
Liver, etc., occasioned by Spinal Irritation, and on the Nervous System in
General as a Source of Organic Disease.   London, 1835.
  3 Traite des maladies de la Moelle Epiniere.  Troisieme edition.  Paris,
1837, t. seconde, p. 209.
  * Abhandlung liber spinal Irritation,   u. s. w. Wien.  1843. 
SPINAL IRRITATION.
13
a morbid impression is propagated along the incident
excitor nerves to the spinal cord, or, second, to derange-
ment of  the capillary circulation of the  cord.  That
is, the disease may be  either of eccentric or centric ori-
gin.  He does not advance our knowledge beyond the
point reached by previous authors.
    Coming again to our own country, we find that in
1844 a very valuable  paper  was published  by Prof.
Austin Flint,1 based upon fifty-eight cases of functional
disorder connected with  an abnormal condition of the
spinal cord.  In this memoir, without going  into  any
discussion relative to the pathology of the affection, Dr.
Flint considers the disorder as giving rise to tenderness
over the vertebral column, causing alterations of sensi-
bility, as affecting the muscular system, as producing ab-
normal mental manifestations, as affecting the digestive
organs, the  genito-urinary organs, the heart and circu-
lation, and as causing  paroxysms of sinking.  He then
considers the physical habits of the patients, the re-
sults  of medical treatment, the probable remote causes,
and then, at some length, the remedial measures which
he has found most successful.  Under this head, Dr.
Flint advises the use of  counter-irritants to  the spine,
especially cupping, and generally without scarification.
Issues he found inapplicable, death ensuing in the one
case in which he used them.  There is no doubt, how-
ever,  that in this instance he had an organic disease to
deal with, and that the issues had nothing to do with
the fatal result.  Tonics, especially iron, he found to be
of great advantage.
    In a very full analysis of the medical reports of the
Stockholm Hospital, by  Dr. Magnus Huss,2 the subject
  1 Observations on the Pathological Relations of the Medulla Spinalis.
American Journal of the Medical Sciences, April, 1844, p. 269.
  2 British and Foreign Medical Review, October, 1846, P- 463. 
14
SPINAL IRRITATION.
of spinal irritation  receives due consideration.  Dr.
Huss classes the symptoms of the disorder as follows:
1.  Pain of various parts of the vertebral column, ex-
isting either idiopathically or  developed  by pressure.
2.  Cramps, either of a clonic or tonic nature, in those
parts subjected to the influence of the spinal cord.   3.
Loss of power in the same  portions of the body, ran-
ging from simple stiffness  and weakness to complete
paralysis. 4. Altered sensibility, either by excess or by
great diminution of  sensation.
   It will be observed  that  in this enumeration the
author confines his specification of morbid phenomena
to those which  relate to sensation and the  power  of
motion.
   The treatment is fully and  philosophically consid-
ered.   Of external remedies he prefers counter-irritants,
using the milder forms first, and then the severer, such
as the moxa and the actual cautery, should the first fail.
Venesection, either  general or local, should be  cau-
tiously employed, and is not generally indicated.  He
is the first, so far as  my researches extend, to mention
electricity, a means which he thinks may be employed
with advantage in chronic and debilitated cases.   Pot-
ash-baths are also recommended.
   Of internal remedies he specifies iron, opium, strych-
nia, phosphorus, and valerian,  as being preeminently
useful.
   Axenfeld1 devotes a considerable  portion  of his
treatise to spinal irritation.   He regards it as being
produced either by a trouble of innervation  or conges-
tion.  In the treatment, leeches occupy the first place,
and  in  light cases  blisters,  sinapisms, dry  cups, and
stimulating  frictions, are useful.  Internally  he recom-
mends nothing  but quinine and iron.
             'Des Nevroses, Paris, 1863, p. 284. 
SPINAL IRRITATION.
15
    Dr. Radcliffe1 writes very  sensibly on the subject
of spinal irritation, and gives  a  typical case which  is
quite  instructive.   He incidentally  gives  it  as his
opinion, that the pathological condition is one of anae-
mia,  and  he consequently  discourages  the  use  of
leeches, relying mainly on blisters and tonics.

    I have thus cited the principal authorities upon
spinal irritation, without, however, by any  means, ex-
hausting the bibliography of the subject.  Notwith-
standing the  eminence of many of  those  who  have
contended for the  existence of a definite affection of
the spinal cord,  characterized by tenderness on pressure
over one or more of the vertebrae, and certain eccentric
disorders involving sensibility, the power of motion, and
functional derangement of many of the viscera, it must
be confessed that the great mass of the medical profes-
sion has regarded the whole theory with suspicion, if
not with absolute  distrust.  The principal  reason for
this is undoubtedly to  be found  in  the fact that, like
many other new theories, that of spinal irritation has
been applied to explain conditions which it  could not
logically be made to cover.  Thus many cases of disease
or disorder of the heart, due  to organic difficulties of
that organ, or excited by disease of other viscera through
the sympathetic system, have been attributed to spinal
irritation.   The same is true also of the uterus, stomach,
liver, and other organs, and even of the spinal cord it-
self, which  often,  when the seat of organic diseases,
such  as  congestion, meningitis, inflammation, tumors,
etc., has been regarded as  simply in a state of irrita-
tion.   It is very certain, also, that numberless cases of
hysteria have been attributed to irritation of the spinal
     Reynold's System of Medicine, London, 1868, vol. ii., p. 640. 
16
SPINAL IRRITATION.
 cord.  In the following remarks I will endeavor to  be
 as explicit as possible, and not to claim too much for a
 pathological condition which I am very sure exists, and
 which I therefore think is entitled to recognition.  If
 I contribute any additional information, it will be main-
 ly due to the fact that our means of examination are
 much  more perfect  and  extensive, and  our knowl-
 edge of physiology, pathology, and therapeutics, more
 thorough than when most of the authors I have quoted
 wrote  upon the subject.  My observations are based
 upon a careful study  of eighty-three cases which have
 occurred in my private practice during the last five
 years, and of which I have full notes, and twenty-nine
 cases of which I have less complete data—in all, one
 hundred and twelve cases.

                     SYMPTOMS.
    Centric Symptoms.—1. Tenderness at some one or
 more Points over  the  Spinal Column,  increased  by
 Pressure.—This is the essential symptom of spinal  ir-
 ritation, though  varying in  intensity from the slight
 degree of pain experienced upon strong pressure to the
 acute hyperaesthesia, which does not allow of even the
 contact of the clothing without the production of great
 suffering.   It is generally complained of by the patient,
though occasionally it has to be sought for by  the
physician.   The  brothers  Griffin found this symptom
present in all but five out of one hundred and  forty-
eight cases, and it is very probable that these five were
not cases of spinal irritation, a supposition which the
authors themselves evidently entertain.  Certainly the
details of the cases do not support the view which would
ascribe their phenomena to any affection of the spinal
cord.   Most of the  other  authors I have cited refer to 
SPINAL IRRITATION.
17
this tenderness as a prominent feature.   Parish thinks
it  alone is to be relied upon as indicating irritation;
Mr. Whatton declares that it is never wanting; Axen-
feld  regards it as the  dominant  and  characteristic
symptom;  and Radcliffe,  while admitting that it  is
not equally well marked in every case, states the rule
to be that  spinal tenderness  and spinal irritation  go
together.
   On the other hand, Flint does  not  regard tender-
ness as an invariable and essential element of the af-
fection under  consideration.  He found it absent or
indistinct in five of his fifty-eight cases, while the other
attendant circumstances furnished unequivocal evidence
that the diagnosis was correct.
   My own opinion would lead me to consider no case
as one of si3inal irritation in which tenderness on press-
ure over the vertebrae was absent.  In the one hun-
dred and twelve cases noted by me, this symptom was
present in all.   There are diseases  of the  spinal cord,
which produce derangements of other  organs of the
body, and  which  are  not characterized by vertebral
tenderness, but these  are far more serious  affections
than spinal irritation,  and of altogether different pa-
thology.
   The seat of the tenderness is generally in the dorsal
region of the spine. The Griffins found cervical tender-
ness in twenty-three cases, cervical  and dorsal tender-
ness in forty-six, dorsal  alone in twenty.three,  dorsal
and  lumbar  in fifteen, lumbar  in  thirteen, and the
whole spine tender in  twenty-three.  Of one hundred
and forty-eight cases, therefore, one  hundred and seven
exhibited tenderness in the dorsal region.
   Dr. Flint found cervical and dorsal tenderness  in
three cases, lumbar and dorsal in ten, and  dorsal alone
in twenty-one cases.
        2 
18
SPINAL IRRITATION.
    Of my own cases, fifteen  had cervical tenderness
 only, thirty-two cervical and  dorsal, thirty-four dorsal
 only, twelve dorsal and lumbar, nine lumbar only, and
 in ten the whole spine was tender. Eighty-eight cases,
 therefore, of one  hundred and twelve were character-
 ized by  dorsal tenderness, and in thirty-four it  was
 limited to this region.
    The degree and character of the tenderness are  sub-
 ject to great variation.  In some cases  strong pressure
 is required  to develop it, while  in others the least
 touch is insupportable.  Sometimes there are shooting
 pains, which radiate from  the tender spot, while at
 others the hyperaesthesia is quite  circumscribed.  In a
 gentleman now under my care with well-marked  spi-
 nal irritation, and who has a tender spot over the third
 lumbar vertebra,  pressure not only causes intense suf-
 fering at that point, but  develops pain along  the
 whole course of the  crural nerves  and their  branches
 as far as  their terminations  on the inner  sides of the
 feet.  Another, a lady, who has spinal tenderness over
 the eighth cervical and first dorsal vertebrae, experiences,
 from pressure, intense pain along the course of the  first
 intercostal, the internal anterior thoracic, and  all  the
 nerves of the left upper extremity.  Why in these  and
 other cases particular nerves should  be  affected, is a
 question  which will be more fully considered here-
 after.
    The pain developed by pressure is not always of
the same character.   Sometimes it is dull and  aching:,
and at  others sharp  and  lancinating.  I  have  not
noticed that any very definite relation exists between
the character of the  pain and  the severity of the other
symptoms, though, as  regards the degree of pain of
each kind, there  is  a  marked connection.  By this I 
SPINAL IRRITATION.
19
 mean that a dull, aching sensation may indicate as pro-
 found a pathological  condition, and be  accompanied
 by as intense eccentric phenomena, as a sharp and lan-
 cinating pain, though a severe aching pain and a severe
 lancinating pain always indicate more serious disorder
 than when these sensations are not so emphatic.
    The character of the pain varies in accordance with
 the tissue in which it is felt.   The  dull aching sensa-
 tion is only developed by strong pressure, and is seated
 in the muscular, tendinous, or  cartilaginous structures
 about the vertebrae.  The sharp, piercing twinges ex-
 cited by slight pressure arise from the skin, and  sub-
 cutaneous cellular tissue.   With these species of sensa-
 tions, the aesthesiometer always shows increased sensi-
 bility of the skin, over and in the vicinity of the pain-
 ful centres.
    To ascertain whether or not the tissues outside of
 the spinal  canal are in a  state of hyperaesthesia, the
 pressure should be  applied with  gradually-increasing
 force, by means of the thumbs applied to the spinous
 processes and the intervertebral spaces, as recommended
 by Flint.  The examination should be thorough, and
 extend  throughout the whole extent of the vertebral
 column.   The fact that the patient  denies the exist-
 ence of tenderness should have no weight  with the
 physician.   Only a few  clays ago  a young  lady con-
 sulted me  for severe  infra-mammary pain, headache,
 and nausea.  I at once suspected spinal irritation, but
 she declared, in answer to my inquiries, that there was
 no sign of tenderness anywhere over the spinal column.
 I insisted, however, on a manual examination, and to
her great surprise found three spots that were exceed-
ingly painful to slight pressure.   This young lady had
been treated for dyspepsia for  several years, without 
20
SPINAL IRRITATION.
deriving any benefit from the measures used, but  was
cured by the treatment which I shall  presently fully
consider.  Occasionally it happens that the tenderness
is  not perceived for some  time  after the pressure is
made.   In a recent case I found the interval to be over
a minute, and then acute pain, following the course of
the nerves, was experienced.  I  am  not  prepared  to
offer an explanation of this  phenomenon.
   2. Pain in the Spinal Cord.—The tenderness  just
noticed is seated primarily  externally to the vertebral
canal, and is developed by pressure.  That which is
now to be considered is located in the spinal cord, and
is  therefore  capable of being produced  by pressure
upon non-tender spots.   It  is a very common  symp-
tom,  having been present  in one hundred and one
of my  cases.  Generally it  is confounded with  spinal
tenderness, from which, however, it  is quite  distinct.
It is aggravated by motion of the  spinal column, by
action of the muscles which have their  attachments to
the spinous and  transverse processes, by  percussion
and sometimes by the erect posture.  In the case of a
gentleman of this city, it was so great when he stood
up that he was forced to keep the recumbent position
nearly the whole time.  When I first saw  him he was
wearing an apparatus designed to keep the weight of
the head from  the vertebral column, and to prevent
the vertebrae pressing upon each other, under the idea
that he had  disease of the intervertebral substance.  I
removed the instrument, and, treating him for spinal
irritation, he recovered his health in  a few weeks.
   Pain in the spinal cord, in the disorder under con-
sideration, is usually seated near the  point of external
tenderness, though it  is often at a distance, and some-
times is felt throughout the whole extent of the cord. 
SPINAL IRRITATION.
21
 The eccentric phenomena  bear a distinct anatomical
 and physiological relation  to it, as do those which are
 connected with spinal tenderness.   There is likewise a
 similar connection existing between the pain in the
 cord and the vertebral tenderness.
    To ascertain the existence of spinal pain, when it
 is not spontaneously felt or superinduced by muscular
 exertion, percussion should be practised.  The ends of
 the fingers will answer for this purpose, though I pre-
 fer a little vulcanized india-rubber hammer, and a ples-
 simeter,  such as are sometimes used for percussing the
 chest.   Even  over sj3ots which exhibit much tender-
 ness, the deep-seated pain in the cord itself can clearly
 be distinguished.
    Eccentric  Symptoms.—By far the most important
 and noticeable symptoms of spinal irritation are to be
 found in distant  parts of the body.   These vary in
 their character and seat, according to the part of the
 spinal cord affected.  Following the example of the
 Griffins,  I shall consider these symptoms as they  de-
 pend upon irritation of the several regions of the cord
 with which they are connected.
    a. The Cervical Region.—Of the cases upon which
 this paper is based, in fifteen the irritation existed in
 the cervical region only, of the spinal cord; in thirty-
 two, the cervical tenderness was conjoined with dorsal
 tenderness, and in ten  with tenderness of the whole
 spine.  Taking the uncomplicated cases as presenting
 the clearest features, the following would  appear to
 be  the more prominent symptoms  of  cervical spinal
 irritation.
   Vertigo was an accompaniment in seven cases, and
headache in nine;  noises in the ears in five, and  dis-
turbances of vision in four.  Fulness  and a sense of 
22              SPINAL IRRITATION.
constriction across the forehead were complained of in
several cases, as was also tenderness of the scalp.  In
addition, the mind was more or less affected in every
case, and in  six the aberration was of such a character
as almost to amount to insanity.   In one of these, a
married lady, aged thirty, there were several paroxysms
of maniacal excitement every day; and in another, that
of a young lady aged twenty-three, so furious were the
exacerbations that, for fear she would injure herself or
others, she had to be restrained by two strong nurses,
who held her while the fits  lasted.  The predominant
type, however, was melancholia.
   Sleep was deranged in every case,  generally in the
form of insomnia, though in three  cases  the tendency
to somnolence was excessive.   In every case the dreams
were  of an  unpleasant character;  in  two there was
nightmare, and in one somnambulism.
   Neuralgic pains were present  in twelve of the fif-
teen cases.  If  the upper part of the cervical  region
was the seat of the irritation, these pains  were experi-
enced in the  scalp and face; if the lower, they were
seated in the neck, the shoulders, upper part  of the
chest, and the upper extremities.  Sometimes the pain
was of a dull, burning character, and was then gener-
ally seated in the muscles of the nucha.  Muscular ef-
fort  always  increased the  suffering.   In  accordance
with Teale's experience, it several times occurred  that
the neuralgia was intermittent, the paroxysms coming
on about sundown and lasting through the night.  In
none of these cases was there anaesthesia.
   Motility was interfered with in twelve cases.  Some-
times there  were fibrillary twitchings, in three cases
there were clonic  spasms of the  muscles of the face
and neck; in two, general chorea • in two, contractions 
SPINAL IRRITATION.
23
of the flexors of the arm on one side, so that the elbow
was rigidly bent;  in two, the contractions were in the
flexors of the hands, and in four, of the fingers.  In one
case there was complete loss  of power over the hand ;
in one, aphonia ;  and in one, almost constant hiccough
while the patient was awake.
    Nausea was present more or  less in  seven  cases,
and, in one, part of every thing taken into the stomach
was almost immediately rejected.  Fain in  the  stom-
ach was not met with in any case.
    b. The Dorsal Region.—I found the dorsal region of
the spine tender in eighty-eight cases.  In  thirty-two
of these it was conjoined with cervical, in twelve  with
lumbar tenderness, and in ten it was affected with the
whole spine, leaving thirty-four uncomplicated cases.
    The most prominent symptoms in these cases  were
connected with the viscera, the stomach being the or-
gan commonly involved.  Thus gastralgia was present
in every case, nausea and vomiting in seven cases, py-
rosis in three, gastric flatulence in thirty-two, and acidi-
ty, as evidenced by heartburn, in twenty-one.
    Next in order came  the heart.   There were palpi-
tations  in  eighteen cases, fits  of oppression, during
which the heart beat  with  irregularity  as regarded
force and rhythm, in seven cases, and attacks of syncope
in five.
    There was difficulty of breathing in fourteen  cases,
and cough in eleven.
    Intercostal neuralgia  existed  in five,  and infra-
mammary pain in twenty cases.
    There  were no muscular spasms, contractions, or
paralysis.
    In the thirty-two cases in which the dorsal tender
ness was conjoined with cervical tenderness, the symp- 
24
SPINAL IRRITATION.
toms characteristic of each region were more or less in-
termingled.   In two cases there was  epilepsy, and m
three chorea paralytica.
   c.  The Lumbar Region.—-This portion of the spine
exhibited tenderness in thirty-one cases.   In twelve of
these it was accompanied by dorsal  tenderness,  in ten
the whole spine was affected, and in nine the tender-
ness was confined to the lumbar region  alone.   Of these
latter all were  characterized by neuralgic pa ins in the
lower  extremities,  and in three of them there were
similar pains  in the muscles of the back and  abdomen.
In four there  was spasm of the neck of the bladder, ac-
companied by severe pain, and causing great difficulty
of urinating,  in one there was incontinence of urine,
in two pain in  the uterus and ovaries, and in one  neu-
ralgia  of the rectum.
   Motility was affected in  seven cases.   In three of
these there were strong  tonic contractions of the mus-
cles of the lower extremities, and  in four  paralysis.
In all of these there were occasional  clonic spasms
simulating chorea.   Of the twelve cases in which there
was also dorsal tenderness, the symptoms were  in gen-
eral those characteristic of spinal irritation of both re-
gions.
   The whole spine was tender in ten cases, and so ex-
tensive was the hyperaesthesia that it  was scarcely pos-
sible  to  press  upon the most limited  spot without
producing pain.  Of these cases the  most  prominent
symptom  in  one was epilepsy, in one paralysis, some-
times of the upper and sometimes of the  lower extremi-
ties, and  in three contractions of the limbs.  Neuralgic
pctins either in the scalp, face, neck, chest, upper extremi-
ties, abdomen, and lower  extremities, were  present in
every case, according to  the part most severely affected 
SPINAL IRRITATION.
25
for the time being.  The heart was disordered in  two
cases, the stomach in nine, in three there was difficulty
of swallowing, from  alternating paralysis, and spasm of
the muscles of the larynx, and in one aphonia.
                       CAUSES.
    The most powerful predisposing cause is sex.   Of
the one hundred  and twelve cases, ninety-three were
females.   Age is likewise influential in determining to
the disorder.  Of  eighty-three cases in which I have re-
corded the age, fifty-one were between fifteen and twen-
ty-five, thirteen between twenty-five  and thirty-five,
ten under fifteen,  and nine over thirty-five.   The pe-
riod of life between fifteen and twenty-five is there-
fore that at which spinal irritation is most apt to occur.
    Hereditary influence was ascertained  to  exist in
eighteen cases.
    The exciting cause of spinal irritation is not always
easy to ascertain.   In seventeen of  eighty-three cases
I could not, by the most careful inquiry, find  any cir-
cumstance likely to have given it origin.  In fifteen  it
was manifestly produced by blows,  falls, or strains, in
seven it was obviously caused by sexual excesses, and
in two by onanism.  In three there was reason to as-
cribe it to anxiety and grief, in two to excessive men-
tal exertion, in  ten to insufficient physical exercise, in
twelve to innutritious and insufficient food, in three to
over-indulgence in alcoholic liquors,  and in one  to the
use of opium.  In the  remaining eleven cases it fol-
lowed exhausting  diseases, such as typhoid, scarlet, and
intermittent fever, dysentery,  and diphtheria, and  was
probably  directly the result of their influence.
   In general terms, it may be said that any cause ca-
pable of reducing the powers of the system, may  pro-
duce spinal irritation. 
26
SPINAL IRRITATION.
                    PATHOLOGY.
    I  have already stated it as my opinion that the
essential condition of spinal irritation is anaemia of the
cord.   Other writers have  ascribed it to inflammation,
congestion, hysteria, and numerous other factors.  The
reasons which have induced men to arrive at this con-
clusion are briefly as follows: Owing to the  fact that
spinal irritation is not per se a fetal disease, we rarely
have  the opportunity to verify  any views we may hold
in regard to its pathology.  In the few cases in which
post-mortem examinations were made nothing abnor-'
mal was found, a circumstance, however, far more com-
patible with the idea I have expressed than  with any
other.
    1. It is a well-recognized fact that  irritation  is
often a result  of a deficient supply or a poor  quality of
blood. Thus headaches  are frequently caused by cerebral
anaemia, and are promptly relieved by increasing the
amount of blood in the cerebral blood-vessels.   Irrita-
bility of the mind is also a constant accompaniment.  A
feebly-nourished stomach rejects food, and is the seat of
pain. An anaemic heart beats with great rapidity, weak
muscles are affected with tremor, and an exhausted gen-
erative system is brought into a state of unnatural ere-
thism by the slightest kind of excitation.  Analogy,
therefore, supports the theory I have suggested.
    2. The diagnosis of diseases of the spinal cord has
become so perfect that we are able to distinguish con-
gestion, meningitis, myelitis, softening, tumors, etc., by
their symptoms and by the means of research at our
command.  We see, therefore, that the  morbid phe-
nomena which result from such conditions are not such
as  we  now class under the head of spinal irritation. 
SPINAL IRRITATION.
27
This division of the subject will be more fully consid-
ered under the head of diagnosis.
    3. I have repeatedly ascertained, by actual expen
ence, that those agents which are known to lessen the
amount of blood in the spinal vessels invariably in-
crease the  severity of the symptoms due to spinal irri-
tation, while they are as effectually lessened in inten-
sity by remedies which tend to produce spinal hyper-
aemia.
    4. The general condition of patients the subjects of
spinal  irritation is always below par, and the exciting
causes are all such as tend to the production of asthenia.
    These  circumstances, I think, go  very  far  toward
confirming the  view I have expressed,  that in  spinal
irritation the vessels of the cord contain less blood, and
that this fluid is inferior in quality, than when the or-
gan is in a healthy condition.  Now  that the function
of the sympathetic nerve, as regards its action in regu-
lating the calibre of the blood-vessels, is so satisfactorily
proven, we can partially understand how local conges-
tions and anaemias may be superinduced.  It is probable,
therefore, that  the original  difficulty  in many cases of
spinal irritation resides in the sympathetic  system, and
the intimate  anatomical relations existing between the
two nervous centres is strongly in favor of this sugges-
tion.
    On  the other  hand, many of  the  phenomena of
spinal  irritation point strongly to the secondary in-
volvement  of the sympathetic system.   It  is thus that
the visceral disturbances which form such  prominent
features are mainly to be explained.
    The pathology of several others of the  more  strik-
ing symptoms of spinal irritation has been  a  subject
of frequent discussion, but at the present day presents 
28
SPINAL IRRITATION.
no difficulties.  Thus the excitation of pain in the tis-
sues to which  the cutaneous nerves are  distributed
results from the law that irritation at a nervous centre
induces pain at the points in which the nerves arising
from that centre  end.   Each compound spinal  nerve
sends a twig to the skin contiguous to it,  and  these
twigs terminate immediately over the spinous processes.
Now, whenever an irritation is thus transmitted to the
periphery,  it may be  reflected  back to  the  centre
whence it came, by local irritations.   Thus a patient
is suffering from  chronic inflammation of the  spinal
cord, and in consequence has pain and muscular spasms
in his lower extremities. An irritation applied directly
to the cord increases the pain and spasms; an irritation
applied to the lower extremities augments the pain in
the cord, and may induce pain and  spasms in distant
parts  of the body.  Hence it is  that  pressure on  the
skin over the spinous processes  not only  causes cuta-
neous  pain, but  also gives rise to spinal pain, and
neuralgic sensations in those nerves which  come from
the irritated part of the cord.
  The pain existing in the cord is aggravated by per-
cussion or muscular action.  The spinal cord, it is true,
is enclosed in a strong  and thick,  bony canal, which,
however, is  entirely filled by its contents.  A blow,
therefore, on the exterior of the column causes a vibra-
tion, which is propagated  through the bony structure
to the cord and its membranes.   If this blow be very
violent, the  concussion may be  such as to inflict  irrep-
arable  damage on the  cord.  When  any portion of
the cord is  in a state of irritation, a very light  blow
upon the spinous processes, over the disordered part,
will cause  severe  pain,  or  notably  add to  that
already present.   The  vertebral  column  is flexible, 
SPINAL IRRITATION.
29
 and  therefore  muscular  action  may, by  producing
 deviations from the ordinary line  followed, occasion
 pressure, and, in the abnormal condition of the cord,
 excite pain.
                     DIAGNOSIS.
    Recollecting that no case is to be regarded  as one
 of spinal irritation which is not characterized by spinal
 tenderness, we have our diagnostic inquiries limited to
 the distinguishing of spinal irritation from other spinal
 affections.   It is certainly true that the distinction has
 often been overlooked,  and that at times there is a real
 difficulty in forming a correct judgment.   Nevertheless,
 by carefully estimating all the circumstances,  perma-
 nent errors of diagnosis are not likely to  occur.
    There are three diseases of the spinal cord which
 may in their earlier stages be confounded with  simple
 spinal irritation.   These are  chronic myelitis,  menin-
 gitis,  and congestion.    As  the treatment of  these
 affections is in many respects the exact reverse of that
 proper for  spinal  irritation,  and  as they  are  of far
 more serious character,  it is important to make as early
 and as correct a discrimination as possible.
    In both spinal irritation and myelitis  there  is ten-
 derness over some part  of the vertebral column, which
 tenderness is increased  by pressure, but this  tender-
 ness is never due to hyperaesthesia of the  skin, whereas
 in spinal irritation it often is.
    In spinal irritation   there is never,  so  far  as my
 experience goes, anaesthesia, whereas this  is  a constant
 accompaniment  of  myelitis.
    The contractions which take place in  some cases of
 spinal irritation are painless,  while those due to mye-
litis are attended with great suffering.
    In myelitis there is a sensation as if a  tight- cord 
30              SPINAL IRRITATION.
were tied around the body at the upper  limit of the
paralysis, a sensation which is always absent in spinal
irritation.   It is true  that  Mr. Teale has  described
several cases which he classed as spinal irritation and
in which the sensation of constriction was present, but
careful examination of the  histories leaves scarcely a
doubt that these were really cases of myelitis.
    The bladder is never paralyzed in spinal irritation,
whereas, in myelitis, it generally is, if the inflammation
be located in the lower dorsal region of the cord. The
same is true of the sphincter ani.  Myelitis is always
productive of paralysis, and there is  always more or
less atrophy of the paralyzed muscles.  Spinal irrita-
tion seldom  gives  rise to  paralysis,  which, when  it
does result, is always incomplete, and is never produc-
tive of atrophy.
    The progress of myelitis is generally, unless arrested
by  appropriate  treatment, toward a worse condition,
whereas  no  such  tendency  is  manifested by spinal
irritation.
    From spinal meningitis,  spinal irritation  is distin-
guished by the circumstances that in the former disease
there are constant painful spasms of the muscles of the
back, pain in the cord, and no spinal tenderness increased
by pressure.
    From congestion of  the spinal cord and  its  mem-
branes, spinal irritation is sufficiently distinguished by
the facts that there is little or no pain in the cord in
the first-named affection, and no spinal tenderness.  In
congestion, likewise, the paralysis and other symptoms
are  always worse  after the patient  has been  lying
down, while in spinal irritation the recumbent position
always alleviates the condition.
    Another  means which in doubtful  cases will inva- 
SPINAL IRRITATION.
31
 riably  lead  to a correct diagnosis is  afforded by  the
 known effects of certain medicines.  Thus  spinal irri-
 tation is, as  I have several times ascertained, made
 worse by the administration of ergot, while each  one
 of the other diseases I have named is alleviated.  The
 reverse is true of strychnia, which in all cases aggra-
 vates the symptoms of myelitis, meningitis, or conges-
 tion, while it is an efficient means of cure in spinal irri-
 tation.  A hypodermic injection of the thirtieth of a
 grain is sufficient to settle  the matter in cases where
 the diagnosis is of difficult formation.
    The flatulence, eructations, and vomiting, are very
 symptomatic of spinal irritation, while they are rarely
 phenomena of either of the other affections.
    One other disease is liable to be confounded with
 spinal irritation, and that is angular curvature, in which
 there is spinal tenderness increased by pressure.  The
 facts, however, that strumous disease  of the vertebrae
 generally occurs in children, that the scrofulous  diathe-
 sis is always present, that  an angular  prominence  can
 be detected  by careful  examination, that the paralysis
 progressively becomes more profound, that the constitu-
 tional effects  are  more severe, are sufficient, even in
 doubtful cases, to  guide to a correct diagnosis.

                     PROGNOSIS.
   The prognosis  in cases of spinal irritation is gener-
 ally favorable.  In fact, so far as my experience extends,
I have never seen  a case which entirely resisted treat-
ment, and very few in which a cure was not ultimately
effected.   When remedies suitable for  the difficulty do
not prove successful, it is because  the patient  does  not
steadfastly persevere in their use.
   Of the one hundred and twelve cases forming  the 
32
SPINAL IRRITATION.
basis of this memoir, ninety-eight  were thoroughly
cured, seven were lost  sight of soon after  treatment
was commenced,  but were  materially improved, and
seven were relieved for the time being, but  continued
to have relapses.
                     TREATMENT.
    The principles of treatment applicable to spinal ir-
ritation are four:
    1. To remove the cause.
    2. To improve the general tone of the system.
    3. To increase the amount  of blood  in the spinal
cord, and improve the nutrition of this organ.
    4. To set up a counter-irritant action in the vicinity
of the disordered region of the cord.
    In regard to the first  indication, I have nothing
special to say.   The  cause once ascertained, common-
sense would dictate its removal as speedily and as
effectually as possible, by the proper means   according
to its character.
    The second indication is to be met by tonics, such
as quinine and iron, and especially stimulants judicious-
ly administered.  I am as well convinced of the general
applicability of alcohol in some form, in the treatment
of spinal irritation, as I am of any thing.   Whiskey,
brandy, and rum, are to be preferred  on account of
their less liability to disagree with the stomach, and as
containing a greater percentage of alcohol than vinous
or malt liquors.   Among the tonics the preparations
of zinc are  valuable, and I  think the oxide is  to  be
preferred.   Cod-liver oil is also of great  service.
    The third indication is easily fulfilled by  strychnia,
phosphorus, phosphoric acid, and opium.  The two first-
named remedies may be very satisfactorily  combined
in  a pill containing  half a grain  of extract of nux 
SPINAL IRRITATION.
33
vomica and the tenth of a grain  of  the phosphide
of  zinc,  which may be given  three  times a  day.
Strychnia may also be given  by solution of the sul-
phate in  dilute phosphoric acid, and in doses of about
the thirty-second of a grain to half a drachm of the acid.
The beneficial effects of these remedies are perceived in
a few days.   Opium is especially useful in those cases
in which there are contractions of the limbs, and  here
its action is, of course, not solely that of an agent in-
creasing the amount of blood in the cord.  I prefer to
give it either in the  form of  suppositories, composed
each of half  a grain of the aqueous extract  and a suf-
ficient quantity of the butter of cacao, or by hypoder-
mic injection of morphia.  I have frequently seen con-
tractions, which had persisted with obstinacy for sev-
eral weeks, relax in a few minutes under the  influence
of opium thus administered.
    The application of hot water to the spine is also an
admirable adjuvant.   It  should be used as hot as can
be borne.  Nothing is better for the purpose than Dr.
Chapman's india-rubber bags.
    But there is a remedy which we can employ either
to contract or enlarge the diameter of the blood-ves-
sels, and  which, when used with the latter object in
view, is more  efficacious  in removing  spinal irritation
than any other with which I am acquainted, and that
is the direct  galvanic current.   The method I follow
in cases of spinal irritation is the application of the
negative  pole at some point above the seat of the pain,
and the positive at another, an  equal distance below.
An ascending current is thus brought to  bear upon the
cord, and this powerfully conduces  to the dilatation of
the blood-vessels and the improvement  of  the nutri-
tion of the cord.   The current should not be passed at
          3 
34
SPINAL IRRITATION.
any one seance for more than fifteen minutes, and  no
one application should last longer than three or four
minutes.   For the relief of the  spinal tenderness the
negative pole should be applied directly to the painful
part, and the positive to a point distant laterally from
it a few inches.
   In  inflammation or congestion  of the cord  or  its
meninges, the method of application is directly the
reverse of this.
   The fourth indication  is  one of great importance,
and, when properly carried into effect, a cure will often
result in slight cases without any other means of treat-
ment being employed. The rationale of the action of
counter-irritants  in this and similar derangements is by
ho means clearly understood.  It is a question which I
do not, however, propose  to discuss.   Of counter-irri-
tants my experience leads  me decidedly to the employ-
ment  of blisters in preference  to  any others.  They
should be applied to the skin, immediately over the
painful part of the spine,  and  should be renewed as
often  as may  be necessary.   Tartar-emetic  ointment,
though useful, is more painful  and I think not so effi-
cacious as blisters.   Dry cups are more  admissible,
and almost always do good.   They should be applied
on each side of the spinous processes for an  extent  of
four or five inches above and below the painful spot.
Leeches,  or  any other means for  the  abstraction  of
blood, are, according  to my experience, always preju-
dicial.
   Besides these therapeutical means, there are others
of a more strictly hygienic character, which cannot be
overlooked.   Thus the food should be of a highly-nu-
tritious character, moderate physical exercise should be
taken, and as much time as possible should be spent in
the open air. 
                 SPINAL IRRITATION.              -35

    Patients almost always feel more  comfortable  in
the recumbent position than any other, because there-
by the blood is allowed to settle  in the spinal vessels.
They should not therefore  be prevented lying down
during  the greater part of the day, but at the same
time they should be encouraged  to take exercise, and
especially so when there is  any loss of power in the
lower extremities.  The induced  or  Faradaic current
is almost always of service, when applied to the affected
muscles, and the direct is of great efficacy when passed
through neuralgic nervous trunks.
    In illustration of the views inculcated in this me-
moir, I append the following details of cases:
    Case I. Irritation of the Cervical Region of the
Spinal  Cord.—Mrs.  J. S. consulted me, May  7, 1868,
for what she had been informed was a  cerebral disor-
der.  The  patient was thirty-eight years of age, had
had five children, and had always enjoyed good health
till two years previously, when she had been thrown
from  her carriage.   She was not stunned or other-
wise seriously injured.  Soon  after the accident she
noticed  a rumbling noise in one ear, and in a few days
subsequently the other ear  became similarly affected.
About the same time there were flashes of light before
the eyes, and a  dull, heavy pain in this point of the
head.  Vertigo was also frequently  present.  There
was insomnia, and when she  did sleep she was very
apt to be attacked with nightmare.
   These symptoms continued to  annoy her for several
months, without, however, compelling her to  seek for
medical advice, until  at  last she had a seizure which
was certainly epileptic in its character.   This was fol-
lowed with disturbance of vision, and intense neural-
gia of the fifth pair of nerves.   She now placed herself 
36
SPINAL IRRITATION.
under the charge of a physician in a neighboring city,
where she was then  residing, who diagnosed a tumor
of the brain, and  gave an unfavorable opinion as to
the ultimate result.  He, however, advised the use of
iodide of potassium.  She took this in large doses faith-
fully for three months—during which  period she had
two more epileptic attacks—without  perceiving any
benefit, and then she went to Europe. While there she
consulted a number of physicians and surgeons of emi-
nence, all of whom  gave a  very guarded prognosis.
By the advice of several of these she took the bromide
of potassium, with, at first, some advantage, but this was
eventually lost, and her symptoms became as severe as
before.  She had several epileptic paroxysms during the
four months she  was taking the bromide.  Finally,
she travelled through Germany  and  Italy, and, still
obtaining no relief, returned  home.   I saw her a few
days after her arrival.   She was then suffering from
facial neuralgia, excessive tenderness of the  scalp, so
that she could not have her hair brushed without en-
during great pain, obscureness of vision, pain  in the
eyeballs, redness of the conjunctivae,  vertigo  almost
constantly, great  mental irritability,  amounting  at
times to positive  insanity;  wakefulness,  nightmare,
and contraction of the fingers, the nails being strongly
pressed against the palm of the hand.
    Ophthalmoscopic examination showed dilatation of
the retinal vessels, arterial  and venous pulsation, and
congestion of the optic disks of both eyes.  The pupils
of both eyes were contracted.
    Perhaps  I  should not have suspected  any spinal
difficulty, if she had not herself called my attention to
a pain which she said she constantly felt between the
shoulders.  I therefore examined the upper part of the 
SPINAL IRRITATION.
37
 spine very carefully, and found  deep-seated pain de-
 veloped by percussion over the  seventh  cervical ver-
 tebra, and great hyperaesthesia .of the skin over the
 eighth.   Her symptoms were not those in the least in-
 dicative of congestion of the cord or  its membranes, of
 meningitis, or myelitis, and the apparent  severity of
 the cerebral  symptoms, and the general  good condi-
 tion of her mind and sensorial and motor functions,
 were so incompatible, that I could not, upon reflection,
 bring myself to  the  belief that she was affected with
 any organic disease  of the  brain.  My inquiries and
 examinations all led  me to the conclusion that she was
 laboring under spinal irritation of the lower cervical
 region.
    I therefore prescribed  for  her five drops of the
 phosphorated  oil three times a day, applied a blister
 to  the painful spot,  and daily passed the direct gal-
 vanic current through the cord, by applying the nega-
 tive pole  to the fifth  cervical, and the positive to the
 sixth dorsal.   My object was, not only to improve the
 nutrition  of the cord, but also, by  irritation of  the
 sympathetic, to  contract the  vessels  of  the  brain.
 Budge and Waller had shown several years previously,
 that, when that portion of the spinal cord situated be-
 tween the seventh cervical  and sixth dorsal vertebrae
 is acted upon by the  galvanic current, the pupils are
 dilated.  Now, dilatation of the pupils is produced by
 excitation  of  the sympathetic,  and excitation of  the
 sympathetic  within  the limits mentioned  likewise
 causes contraction  of the vessels of  the brain, as can
 readily be seen by ophthalmoscopic examination while
 the current is passing.
    Under the influence  of this treatment the amend-
ment was rapid, and  at the  end of three  months she 
38              SPLNAL IRRITATION.
was entirely cured.   It was  necessary, however, to ap-
ply eleven blisters.
    Case II.  Irritation of the Cervical  Region of the
Cord.—M. S., a gentleman of sedentary habits, consulted
me, August, 1867, for intense headache and facial neu-
ralgia, with which he had suffered for several months.
The disease had come on gradually, and, although now
never entirely absent, was paroxysmal in its character,
being more severe at night than through the day.  The
external pain followed the course of the fifth  pair  of
nerves through all its branches; the internal was fixed
in the posterior part of the head, and was  evidently
due to cerebral anaemia, as it was relieved by stimulants,
and by holding the  head in a dependent  position.  Ver-
tigo was  frequently present, and the  disposition  to
sleep  was  excessive, though, owing  to the pain,  could
not be indulged in for more than a  few minutes  at a
time.   Nausea was occasionally a symptom, but  never
to the extent of being followed by vomiting.
   On examining the spine of this gentleman,  I found
tenderness over the  fourth and seventh  cervical  verte-
brae.  Two blisters were at once  applied, and Aitken's
syrup of the hypophosphate of iron, quinine, and strych-
nia, administered.  From  the first,  improvement was
manifested, and in less than a month the cure was com-
plete.
   Case  III.  Irritation of the Dorsal Region of the
Spinal Cord.—Mrs. J. B.,  aged twenty-four, consulted
me, March, 1868,  for obstinate vomiting, and neuralgic
pains in the left breast.   She was thin, pale, and anae-
mic, and had suffered for over a  year.   She  also  com-
plained of a dull,  aching pain in the middle of the back,
which was increased by even moderate  physical  exer-
cise.  The vomiting  took  place  regularly after  every 
SPINAL IRRITATION.
39
meal, and even water was at once thrown up.  She was
under the impression that the disorder was the result
of exposure for several hours to very severe cold while
in an open boat.
    Recognizing, at once, the fact that the main difficul-
ty  lay in  the cord, I carefully examined  the whole
spine, and found excessive tenderness over the spinous
processes of the sixth, seventh, and eighth  dorsal ver-
tebrae.  There was  also deep-seated spinal pain de-
veloped by percussion.
    I ordered the application of a blister, and the in-
ternal use of small quantities, frequently repeated, of
milk-punch (one ounce of brandy to  three of milk).
The first wineglassful was at once  rejected, and so was
a tablespoonful  which she  took half an hour subse-
quently. I then reduced the quantity to a teaspoonful
every half hour.   This was  retained, and was the first
nutriment of any kind which, for nearly eleven months,
had not been rejected wholly or in part.
    The next day I found  that  the blister  had drawn
well, and that the nausea and vomiting were  greatly
diminished, as were likewise the,  neuralgic pains.  A
teaspoonful of the  following mixture was then  directed
to be taken three times a day immediately after meals:
1$.  Strychnia sulph. gr. j,  ferri pyrophosph., quiniae
sulph. aa. 3 ss, acid phosph.  dil., syrupus zingiberis aa.
§ ij.  M. ft. mist.   The milk-punch was still continued,
but, in treble the dose, less frequently given.
    Gradually all the symptoms decreased in violence,
and at the end of two weeks she was enabled to retain
a moderate quantity of food at each meal.  Any excess
was still, however, followed by vomiting.  She had in-
creased five pounds in  weight, and was greatly im-
proved in personal appearance. 
40
SPINAL IRRITATION.
      In two months she had gained twenty-one pounds,
   and was as well as she had ever been in her life.   The
   spinal tenderness had entirely disappeared; seven blis-
   ters were applied in all.
      Case  IV.  Irritation of the Dorsal Region of the
   Spinal Cord.—Mrs. W. had for more than three  years
   suffered from spasmodic  movements  of the upper ex-
   tremities, not distinguishable from those of true chorea,
   which occasionally were followed by contractions of the
   flexors of the wrists and fingers.  There were also in-
   fra-mammary pain,  eructations, and vomiting.  When
   she came under my care, June 22,1869, she was reduced
   to  almost a skeleton, and was suffering, in addition to
   the symptoms above mentioned, from acute pain in the
   back.   This pain she informed me had not been ordi-
   narily very severe, but  was,  nevertheless, constantly
   present.  On examination I found tenderness over the
   first, second, and third dorsal vertebrae.  I at once ap-
   plied the constant galvanic current in  the manner al-
   ready described, and continued it for five minutes, with
   the effect of mitigating the pain in the spine and the
,   nausea.  The ensuing day I repeated the application,
   and in addition prescribed the mixture given in  Case
   III.  She retained it on her stomach,  as  she did the
   food which she ate that day.  Brandy  in ounce-doses
   was given with her lunch and dinner.   The galvanism
   was continued daily for  eighteen days, at the end of
   which time she was free from pain,  from the spasms,
   and from the vomiting.  Her appearance was immense-
   ly  improved, and she had  increased  seven pounds in
   weight.  The galvanism was now discontinued, but the
   strychnia mixture and the brandy were persevered with
   for over a month longer.  She was then well. 
SPINAL IRRITATION.
41
    Case V.  Irritation of the  Lumbar Region of the
 Spinal Cord.—E. T., an unmarried lady, aged twenty-
 nine, consulted me, August, 1869, for paralysis  of the
 lower extremities, attended with spinal tenderness and
 abdominal pains.  She had been treated for inflamma-
 tion of the spinal cord, had been cupped, leeched, and
 had had an issue made over the seat of the pain.
    When I first saw her she was unable to walk, hav-
 ing been in this condition for several months.   As she
 sat in her chair, she could readily move her legs in any
 desired direction, but to bear her weight upon them
 was an utter impossibility. There was no alteration of
 sensibility.   Her general appearance was not anaemic,
 nor  was she in  the least degree  hysterical.   Upon
 careful  examination, I was unable to find any reason to
 induce the belief that  she  was laboring under  spinal
 congestion, meningitis, or  myelitis, or that there  was
 softening of, or pressure upon, the cord. I, however, dis-
 covered great tenderness over the first and second lum-
 bar vertebrae, and found that strong  pressure in  this
 region induced deep-seated spinal pain and sharp neu-
 ralgic sensations along the course of the crural nerves.
   Regarding the case as one of  pure spinal irritation,
 I applied the constant galvanic  current  to  the back
 every alternate day, and administered the following
 prescription:  I£. Zinci  phosphidi, grs.  iij, ext. nucis
 vom. grs. xv.  M. ft. in pil. no.  xxx.   Dose, one three
 times a day.  I likewise directed the application, to the
 painful part of the spine, of  flannel, wrung out of
 spirits of turpentine  to be continued daily  till  red-
 ness and decided smarting were produced. A full and
nutritious diet with ale was enjoined.  Under this treat-
 ment she improved so rapidly in every respect that in
twenty-three days she was able to walk with a cane,
       4 
42
SPINAL IRRITATION.
and in a few days more than a month was well, being
in as good health, according to her own report, as she
had ever enjoyed in her life.
   I have full notes of a number of  other interesting
cases, but  this paper has already been extended to so
great a length, that I must defer their relation to some
other time.  Meanwhile,  I  am not without the  hope
that  I may have succeeded in presenting some interest-
ing details to the members of the Society. 
 Maudsley  on   the   Mind.


     The Physiology and Pathology of the Mind.   By Henry  Mauds-

         ley, M. D., Physician  to the West London Hospital.   8vo,

         pp. xv-442 (tinted paper).     .     .      .      Cloth, $4.00


    Dr. Maudsley's aim in the preparation of this volume has been to treat of menta.
 phenomena from a physiological rather than, as has hitherto been the habit, from a

 metaphysical point of view, and in his history of the  inductive method, as appliec1

 to the interrogation of the mind, he shows conclusively that self-consciousness—the

 favorite resort of the schoolmen—is inadequate, contradictory, and unreliable.  N«

 book of the present day,  devoted to the study of the mind, has attracted more atten

 tion or caused more comment than this.   It is one of those works which mark the

 beginning  of a new era  in the study of mental science, and at the same time it is

 conceded on all sides to  be, in its practical portions, a most reliable guide for the
 diagnosis, description, and treatment of insanity.

   " Dr. Matidslcy has had the courage  to  undertake, and the skill to execute, what Is, at
 least, in English, an original enterprise.  This book is a manual of mental  science in all its
 parts, embracing all that is known in the existing state of physiology.  *  * *  Many and
 valuable books have been  written  by English physicians on insanity, idiocy, and all the
 forms of mental aberration.  But derangement had always been treated as a distinct subject,
 and therefore empirically.  That the phenomena of sound and unsound  minds are not mat-
 ters of distinct investigation, but inseparable parts of one and the same  inquiry, seems a
 juism as soon as stated. But strange to say, they had always been pursued separately, and
 Been in the bands of two distinct classes of investigators. The logicians and metaphysicians
 occasionally borrowed a stray fact from the abundant cases compiled by the medical author-
 ties ; but the physician on  the other hand had no theoretical clew to his  observations be-
 yond a smattering of dogmatic psychology learned at college.   To effect a reconciliation be-
 tween the Psychology and the Pathology of the mind, or rather to  construct a basis for both
 in a common science, is the aim of Dr. Maudsley's book."—London Sat. Rev., May 25,1861.

   " The first chapter Is devoted to the consideration of the causes of insanity.  It would bo
 well, we think, if this chapter were published in a separate form and  scattered broadcast
 throughout the land.  It is  so full of sensible reflections and sound truths, that their wide
 dissemination could not but be of benefit to all thinking persons. In  taking leave of Dr.
 Maudsley's volume, we desire again  to express our gratification with the result of his labors,
 and to express the nope that he has not yet ceased his studies in  the important  field which
 he has selected.  Our thanks are also due to the American publishers for the very handsome
 manner in which they have reprinted a work which is certain to do credit to a house already
 noted for its valuable publications."— Quar. Journal of Psychological Medicine and Medical
 Jurisprudence.

   "Then follow chapters  on the diagnosis, prognosis, and  treatment of insanity, each
 characterized by the same bold and brilliant thought, the same charming style of composi-
 tion, and the same sterling  sense that we have found all through. We lay down the book
 with admiration, and  we commend it most earnestly to our readers, as a work of extraordi-
 nary merit and originality—one of those productions that are evolved only occasionally in
 the lapse of vcars, and that serve to mark actual and very decided advances in knowledge
 and science."—N. Y. Medical Journal, January, 1868.

   " This work of Dr. Maudsley's is unquestionably one of the ablest and  most  important,
 on the subjects of which it treats, that has ever appeared, and does infinite credit  to his
 Shilosophical acumen and accurate observation.  No one has more successfully exhibited the
 iscordant results of metaphysical, physiological, and pathological studies of the mind, or
 demonstrated more satisfactorily the uselessness of an exclusive method, or the pressing
 need of combined  action,  and of a more  philosophical  mode  of proceeding."—Medical
 Record, Nov. 15,1867.

   "In the recital of the causes of insanity, as found in peculiarities of civilization, of relig-
 Ion, sex, condition, and particularly  in .thcengrossiTig pursuit of wealth, this calm scientific
 work has the solemnity of  a hundred sermons ; and after going down into this exploration
of the mysteries of our being, we shall come up into active life again chastened, thoughtfui,
and feeling, perhaps, as we  never felt before, how fearfully and wonderfully  we are madc."-
Evening Gazette.

   MDr Maudsley's treatise ia a valuable work, and deserves the careful consideration of a0
who feel an interest, not only in general metaphysical facts, but in those manifestations
which mark the boundaries between health and disease in the human  mind."—Providenct
iR. J.) Journal. 
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