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WV V^gtf | W 3NIDI03W dO A8VH9IT IVNOIIVN >« -^r "x < o- V NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 3NiDia3w do Aiivaan ivnoiivn .f . = V o NATIONAL LI8RARY OF MEDICINE /Vi |^\ 3NIDI03W dO A8VM9IT IVNOIIVN s/ 1 3NIDIQ3W dO Aavafln IVNOIIVN \ ■si' \Hvk;~\ n -3 y^-T^rV °- > / ii '-TV- t, 3NOIQ3W jo Aavagn ivnoiivn 3NIOIQ3W dO Aava9IT IVNOIIVN ■3K X Ah v ■ | ✓ v NATIONAL LIBRARY OF MEDICINE NLM001023010 3NIOI03W jo Aava9n IVNOIIVN 3NOI03W JO A»va9n IVNOIIVN 3noi<33w jo Aavaan ivnoiivn NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE ^4f NATIONAL LIBRARY OF MEDICINE "~^X\ 3NIDia3W JO Aavagn IVNOIIVN I ^ 1 NATIONAL LIBRARY OF MEDICINE .—err-. * W, 3NIDI03W JO Aava9M IVNOIIVN ^14^\?%^1 3NiDia3w jo Aavasn IVNOIIVN 3NIDI03W JO Aava9IT WNOI1VN \^ -X x /" X, NATIONAL LIBRARY OF MEDICINE f ^aiL rf xX?X ■•' ✓ • "**^/s; J* x V/X( -" NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 3NOIQ3W jo Aavaan ivnoiivn \T I / X/ NATIONAL LIBRARY OF MEDICINE •. ,~»7X I X^o-K . 3NIOI03W jo Aava9n IVNOIIVN 3NiDia3w jo Aavasn IVNOIIVN X U^¥ \ 2 /^^ X " frD-v£> A i ' i s'#^ i 1 ,* V NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE e-^ CYCLOPAEDIA OF THE PRACTICE OF MEDICIIE Edited by Dr. H. von ZIEMSSEN, PBOFESSOB OF CLINICAL MEDICINE InTBuniCH, BAVABIA. VOL. XIII. DISEASES OE THE SPINAL CORD AND MEDULLA OBLONGATA. BY Prop. WILHELM HEINRICH ERB, of Heidelberg, Baden. Q£ranslat*3j Jj EDWARD G. GEOGHEGAN, M.D., of London; EDWARD W. SCHAUFFLER, M.D., of Kansas City; DAVID F. LINCOLN, M.D., of Boston; and JOHN A. McCREERY, M.D., of New York. ALBERT H. BUCK, M.D., New York, ^5^— '/ ',- EDITOB OF AMEBICAN EDITION. ('(7U^. NEW YORK: WILLIAM WOOD AND COMPANY, 27 GREAT JONES STREET. 1878. WB V, IS Entered according to Act of Congress, in the year 187S, by WILLIAM WOOD & CO., In the Office of the Librarian of Congress, at Washington. ALL RIGHTS RESERVED. Trow's Printing and Bookbinding Company, 205 to 213 East Twelfth Street, NEW YORK. CONTENTS. PAGE Introduction.............................................................. 3 Anatomical Introduction................................................. 7 Bibliography................................................ 7 Physiological Introduction................................................ 33 Bibliography................................................ 33 Sensory conduction.................................................. 35 Motor conduction.................................................... 37 Co-ordination of movements.......................................... 39 Vaso-motor paths and centres......................................... 42 Trophic centres and paths........................................... 44 Reflex action........................................................ 4G Inhibition of reflex action............................................ 51 Centres and paths for the innervation of the viscera.................... 52 General Symptomatology................................................. CG Disturbances of sensibility........................................... G6 Diminution of sensory action, anaesthesia.......................... 67 Exaggeration of sensory action.................................... 73 Disturbances of motility........,---................................. 79 Diminution of motility, weakness and paralysis.................... 79 Imperfect co-ordination of movements, ataxia...................... 83 Various characteristic gaits....................................... 96 Increase of motility-spasm........................................ 97 Alteration in the velocity of the motor conduction.................. 104 Electric reaction of the motor apparatus........................... 105 Disturbances of reflex activity........................................ 107 Vaso-motor disturbances............................................. Ill Trophic disturbances................................................. 113 Disturbances in the urinary and sexual apparatus....................... 129 Disturbances of digestion and defecation.............................. 138 Disturbances of respiration and circulation............................. 140 Disturbances of the oculo-pupillary fibres, the various cerebral nerves, and the brain itself............................................. 141 General Etiology........................................................ 146 Neuropathic disposition.............................................. 146 IV CONTEXTS. PACE Sexual excesses and irregularities..................................... 147 Influence of age and sex............................................. 150 General disturbances of nutrition..................................... 151 Propagation of neighboring morbid processes.......................... 15'- Exposure to cold.................................................... 151 Disturbances of circulation, excessive exertion and psychical influences .. 152 Poisoning and the local development of various infectious diseases....... 153 Acute diseases..................................................... 153 Irritation and disease of peripheral organs............................. 154 General Diagnosis....................................................... 155 General Therapeutics.................................................... 1G0 External remedies................................................... 162 Cold............................................................ 1G2 Warmth........................................................ 163 Baths.......................................................... 104 Climate........................................................ 175 Electricity...................................................... 178 Blood-letting and derivatives..................................... 185 External frictions................................................ 186 Internal remedies.................................................... 187 Symptomatic remedies and methods................................... 192 General method of life............................................... 196 Diseases of the Membranes of the Spinal Cord.......................... 199 Hyperemia of the Meninges and the Cord itself............................. 199 Bibliography................................................ 199 Etiology and pathogenesis...........................................o 200 Pathological anatomy....................................... _ 202 Symptomatology...........................„........................ 203 Diagnosis............................................. 20G Treatment............................................ _ 207 Meningeal Hemorrhage................................................. 208 Bibliography............................................... 208 Etiology and pathogenesis.......................................... 209 Pathological anatomy................................................ 210 Symptomatology.................................................... 211 Course and termination.............................................. 213 Diagnosis........................................................... 214 Prognosis and treatment............................................. 215 Inflammation of the Spinal Dura Mater................................... 216 Bibliography................................................ 216 Pachymeningitis Spinalis Externa..................................... 217 Pathological anatomy.......................................... 218 Symptomatology,............................................. 219 Diagnosis....................................................... 220 Prognosis and treatment........................................221 CONTENTS. V PAGE Pachymeningitis Spinalis Interna.....................................221 Etiology and pathological anatomy................................ 222 Symptomatology................................................. 223 Diagnosis, prognosis, and treatment.............................. 225 Inflammation of the Spinal Pia Mater..................................... 226 Bibliography............................................... 226 The Acute Form..................................................... 229 Etiology........................................................229 Pathological anatomy............................................ 231 Symptomatology................................................ 234 Course, duration, termination....................................244 Diagnosis....................................................... 245 Prognosis....................................................... 247 Treatment.......•............................................... 248 The Chronic Form..................................................252 Etiology........................................................ 252 Pathological anatomy............................................ 253 Symptomatology................................................ 255 Course, duration, result......................................... 257 Diagnosis....................................................... 258 Prognosis....................................................... 259 Treatment...................................................... 260 Tumors of the Spinal Membranes......................................... 262 Bibliography................................................ 262 Pathological anatomy................•.......................... 2G4 Etiology........................................................ 268 Symptomatology................................................ 268 Course, duration, termination..................................... 273 Diagnosis ...................................................... 274 Treatment...................................................... 276 Addendum.............................................................. *'' Anatomical Changes in the Spinal Membranes, without clinical signifi- cance ............................................................. 277 Diseases of the Spinal Cord............................................. 279 Introduction ....................................................... 279 Hyperaemia of the Cord ............................................. 280 General remarks................................................. 280 Anasmia of the Cord...................................................... 281 Bibliography................................................ 281 Pathogenesis and etiology............................................ 282 Pathological anatomy................................................ 285 Symptomatology.................................................... 286 Course, duration, termination.........................................288 Diagnosis, prognosis................................................. 289 Treatment............................................ ............. 290 vi CONTENTS. PAGB Spinal Apoplexy......................................................... ""1 Bibliography................................................. ^"** Pathogenesis and etiology............................................ ~''^ Pathological anatomy................................... ............ 294 Symptomatology.................................................... 297 Course, duration, termination......................................... 301 Diagnosis........................................................... 30~< Prognosis and treatment.............................................. 304 Wounds of the Cord..................................................... 305 Bibliography................................................. 305 Etiology............................................................306 Pathological anatomy................................................308 Symptomatology.................................................... 310 Course, duration, termination........................................ 316 Diagnosis and prognosis.............................................. 317 Treatment......................................................... 318 Slow Compression of the Cord............................................ 319 Bibliography................................................ 319 Etiology and pathogenesis............................................ 320 Pathological anatomy................................................ 324 Symptomatology.................................................... 327 Course, duration, termination........................................ 328 Diagnosis...........................................................339 Prognosis........................................................... 341 Treatment ......................................................... 342 Concussion of the Spinal Cord............................................ 344 Bibliography................................................344 Etiology and pathogenesis............................................ 345 Pathological anatomy................................................346 Symptomatology....................................................348 Diagnosis........................................................... 353 Prognosis........................................................... 355 Treatment.......................................................... 356 Spinal Irritation......................................................... 357 Bibliography................................................ 357 Etiology............................................................ 360 Symptomatology.................................................... 361 Course, duration, termination......................................... 363 Diagnosis........................................................... 365 Prognosis and treatment.............................................. 367 Spinal Nervous Weakness................................................. 369 Bibliography................................................ 369 Etiology............................................................. 371 Symptomatology....................................................372 Course, duration, termination.........................................376 CONTENTS. vii PAGE Diagnosis........................................................... 378 Prognosis..........................................................379 Treatment.......................................................... 380 (Translated by David F. Lincoln, M.D.) Myelitis................................................................ 382 Bibliography................................................ 382 Introduction.................................................... 383 History......................................................... 385 Myelitis acuta....................................................... 387 Etiology and pathogenesis........................................ 388 Pathological anatomy............................................391 Symptomatology................................................. 402 Course, duration, termination..................................... 414 Diagnosis........................................................ 418 Prognosis....................................................... 420 Treatment......................................................422 Myelitis Chronica.................................................... 426 Etiology and pathogenesis........................................427 Pathological anatomy............................................ 429 Symptomatology................................................438 Course, duration, termination..................................... 448 Different forms of chronic myelitis................................ 449 Diagnosis........................................................ 453 Prognosis....................................................... 4;G Treatment...................................................... 457 Myelomalacia............................................................ 467 Bibliography................................................ 467 Pathogenesis........................................................ 468 Pathological anatomy................................................ 470 Symptomatology.................................................... 470 Diagnosis, prognosis, treatment....................................... 471 Multiple Sclerosis........................................................ 472 Bibliography................................................472 History......................................................... 473 Etiology and pathogenesis............................................ 475 Pathological anatomy................................................ 477 Symptomatology.................................................... 483 (Translated by John A. McCreery, M.D.) Course, duration, termination.........................................505 Diagnosis........................................................... 507 Treatment.......................................................... 512 Vlll CONTENTS. PAGE Tabes Dorsalis.......................................................... 51o Bibliography................................................. 51o History......................................................... 517 Etiology and pathogenesis............................................ 522 Pathological anatomy................................................531 Symptomatology.................................................... 540 Course, duration, termination......................................... 596 Theory of the disease................................................ 599 Diagnosis............................................................ 6C3 Prognosis........................................................... 607 Treatment.......................................................... 608 Spasmodic Spinal Paralysis..................................„............ 620 Bibliography................................................ 620 Introduction .and history.......................................... 621 Etiology and pathogenesis........................................... 624 Pathological anatomy................................................ 625 Course, duration, termination......................................... 635 Theory of the disease................................................ 636 Complications....................................................... 638 Diagnosis........................................................... 642 Prognosis.......................................................... 644 Treatment.......................................................... 645 Hemiplegia et Hemiparaplegia Spinalis.................................... 646 Bibliography................................................ 646 History......................................................... 646 Etiology and pathological anatomy.................................... 648 Symptomatology.................................................... 649 Pathological physiology.............................................. 654 Course, duration, termination......................................... 660 Diagnosis........................................................... 661 Prognosis ......................................................... 662 Treatment.......................................................... 662 Poliomyelitis Anterior Acuta.............................................. 663 Bibliography................................................663 History......................................................... 664 Definition....................................................... 666 Etiology and pathogenesis............................................ 667 Pathological anatomy................................................ 670 Symptomatology.................................................... 681 The poliomyelitis anterior acuta in children........................681 The poliomyelitis anterior acuta in adults..........................699 Course, duration, termination......................................... 701 Diagnosis........................................................... 703 Prognosis............................................................ 706 Treatment.......................................................... 707 CONTENTS. IX PAGE Poliomyelitis Anterior Chronica........................................... 712 History......................................................... 713 Etiology............................................................. 714 Pathological anatomy................................................ 716 Symptomatology....................................................717 Diagnosis........................................................... 728 Prognosis........................................................... 731 Treatment.......................................................... 731 Paralysis Ascendens Acuta............................................... 732 Bibliography................................................ 732 History......................................................... 732 Etiology and pathogenesis............................................ 735 Pathological anatomy................................................736 Symptomatology.................................................... 737 Diagnosis........................................................... 743 Prognosis........................................................... 745 Treatment..........................................................746 Intramedullary Tumors.................................................. 747 Bibliography................................................ 747 Pathological anatomy................................................ 748 Etiology............................................................ 752 Symptomatology....................................................753 Diagnosis........................................................... 755 Prognosis and treatment............................................. 756 Secondary Degenerations................................................. 757 Bibliography................................................ 757 _ History......................................................... 758 Etiology and pathogenesis............................................ 759 Pathological anatomy................................................767 Symptomatology.................................................... 774 Diagnosis........................................................... 776 Prognosis........................................................... 777 Treatment.......................................................... 778 Deformities and Malformations............................................ 779 Bibliography................................................. 779 General classifications................................................ 779 Symptoms of spina bifida......................................... 787 Diagnosis....................................................... 790 Prognosis....................................................... 791 Treatment...................................................... 791 Rare and Doubtful Diseases.............................................. 794 Syringomyelia....................................................... 795 Bibliography................................................ 795 Pathogenesis and pathological anatomy............................ 796 . Symptomatology.................................................800 X CONTENTS. PAGE Saltatory Spasm..................................................... 801 Bibliography................................................ "^ Symptomatology................................................ ""1 Etiology....................................................... 806 Treatment......................................................808 Tonic Spasms....................................................... 808 Bibliography.................................................... 808 Symptomatology................................................809 Etiology........................................................ 814 Treatment..................................................... 814 Intermittent Spinal Paralysis......................................... 814 Bibliography................................................ 814 Symptomatology................................................ 815 Diagnosis....................................................... 817 Treatment...................................................... 817 Toxic Spinal Paralysis................................................ 816 Bibliography................................................ 817 General remarks................................................ 818 Paraplegia dependent on Idea....... ................................ 819 Bibliography................................................ 819 Etiology........................................................ 819 Symptomatology................................................ 819 Diagnosis....................................................... 821 Treatment...................................................... 821 (Translated by Edward W. Schaufiier, M.D.) Diseases of the Medulla Oblongata.....................................825 Anatomical Introduction................................................. 825 Bibliography................................................ 825 Physiological Introduction................................................ 851 Bibliography................................................ 851 Motor conduction.................................................... 853 Sensory conduction.................................................. 854 The respiratory centres.............................................. 857 Centres for the cardiac movements....................................858 Centres of speech.................................................... 859 Centre of deglutition.................................................860 Vaso-motor oentre................................................... 861 Nutritive centres for certain nervous regions............................ 862 Centres for certain secretions......................................... 862 Pathological Introduction................................................. 863 Hyperaemia and Hemorrhage............................................. 865 Bibliography................................................ 865 Etiology and pathogenesis............................................. 865 CONTENTS. Xi PAGE Pathological anatomy................................................ 867 Symptomatology.................................................... 868 Diagnosis ..........................................................874 Prognosis...........................................................875 Treatment.......................................................... 875 Anaemia................................................................ 876 Bibliography................................................876 Pathogenesis and etiology............................................877 Pathological anatomy................................................878 Symptomatology.................................................... 880 Diagnosis..........................................,................ 884 Prognosis........................................................... 880 Treatment.......................................................... 887 Injuries and Wounds..................................................... 887 Bibliography................................................ 887 Pathogenesis and etiology...........................................888 Pathological anatomy................................................ 891 Symptomatology.................................................... 893 Diagnosis.......................................................... 897 Prognosis............................................................ 899 Treatment.......................................................... 900 Acute Bulbar Myelitis...................................................900 Bibliography...................\.............................900 Etiology............................................................ 901 Pathological anatomy................................................ 901 Symptomatology.................................................... 902 Diagnosis........................................................... 904 Prognosis........................................................... 904 Treatment.......................................................... 904 Progressive Bulbar Paralysis............................................. 905 Bibliography................................................ 905 History........................................................ 906 Pathogenesis and etiology...................... ..................... 908 Pathological anatomy................................................ 910 Symptomatology.................................................... 915 Course, duration, termination........................................933 Complications ...................................................... 933 Theory of the disease...............................................938 Diagnosis......................................................... 939 Prognosis........................................................... 942 Treatment.......................................................... 943 Other Chronic Diseases................................................... 947 Bibliography................................................947 Sclerotic Centres.................................................... 947 Diffuse Sclerosis.....................................................949 Xii CONTENTS. PAGH Tumors of the Medulla.................................................. 950 Bibliography................................................ 950 Pathological anatomy................................................ ^50 Etiology..................................................:---.....953 Symptomatology.................................................... 953 Diagnosis......................................-....................956 Prognosis........................................................... 9o7 Treatment........................................................ 957 (Translated by Edward G. Geoghegan, M.D.) DISEASES of the SPINAL COED AND ITS ENVELOPES. ERB. INTRODUCTION. Our knowledge of the diseases of the spinal cord is rapidly extending. This numerous, important, and interesting class of maladies, long neglected, is at present receiving the profound attention of various classes of observers, and the labors bestowed upon it are bearing fruit in many ways. This improvement forms but a part of the general forward movement of the last twenty or thirty years, in which special pathology has shared equally with other branches of scientific medicine. There are, however, three sources from which our knowledge of the diseases of the spinal cord has been especially enriched. First in order, and most important, stands the improvement in the experimental physiology of the spinal cord, which has been made within the period of twenty or thirty years. The study of this subject has led to extremely remarkable and important results, many of which yet remain a matter for con- troversy or doubt. Unexpected, even insurmountable difficul- ties, have risen to obstruct what we at first thought an easy quest; but these difficulties have served only as incentives to deeper and fuller investigations, which have proved abundantly fruitful of isolated facts, often of the greatest value in path- ology. The improved methods of pathologico-anatomical examina- tion have been equally important in developing our knowledge of the diseases of the cord. Although in use for little more than ten years, they have been constantly receiving improvements, and have already added greatly to our knowledge and compre- 4 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. hension of the facts. By their means many diseases have been discovered, whose existence was not even suspected by those using the former imperfect methods of examination ; through them a hitherto unknown degree of exactness in localizing dis- ease has been rendered possible, and we have learnt to refer nu- merous morbid phenomena to definite local changes in the cord. Conjoined with physiological research and an improved, intel- ligently directed method of clinical examination, the study of pathological histology has thrown great light upon the general pathology of the spinal cord, and has led to the most interesting conclusions in respect to pathological as well as physiological processes. Finally, we may mention the progress of therapeutics, which has lent the impulse of a new interest to the study of many forms of disease of the spinal cord. We have lately learnt to cure a number of such diseases, formerly thought'incurable ; or, at least, we have been enabled to improve the prognosis in many such. This we mainly owe to the science of electro-therapeu- tics, which has made so many contributions to the pathology of the nervous system ; not a few of the advances that have been made in spinal pathology are associated with the names of electro-therapeutists. Nor is balneo-therapeutics (the scientific aspect of which has greatly improved of late) less deserving of credit in this respect. The diseases of the spinal cord have thus come to furnish a most attractive and interesting field for scientific research, and one most fruitful of important practical results ; we can say that the progress made in its cultivation has been of late years extremely satisfactory. And yet it must be stated with emphasis, that we only stand at the beginning of a successful development of the subject, and that an extremely large amount of work remains to be done. We cannot help seeing that the rich results of physiological research are still very defective and uncertain in many essential points; the results, indeed, often change from day to day with each new method and new observer, and they are far from always possessing that degree of exactness and trustworthiness to which physiological research would lay claim. The excessive difficulty INTRODUCTION. 5 of the subject explains why it is that in many points we have perhaps not yet reached the root of the matter. Nor is it less certain that the researches and results of path- ological anatomy are still far from trustworthy, that the points thoroughly explained are but few, and that the general patho- logical significance of the commonest and most important morbid processes in the spinal cord is not yet clear. The impossibility of observing with exactness all the characters of a fresh spinal cord, the errors and uncertainties attending the examination of hardened specimens, and finally, the undeniable fact that these researches have given us no information at all in regard to not a few diseases, or stages of diseases, of the cord—these circum- stances ought to make us very cautious about viewing these dis- eases as if their key were held by pathological anatomy alone. Practical experience, finally, shows us that the treatment of diseases of the cord is still without hope in many respects. The number of desperate cases which mock at all kinds of treatment shows us, with continually fresh emphasis, how much remains to be discovered and achieved. All the more encouraging is the way in which the work is going forward. Numerous investigators are busy with the phys- iology and pathology of the spinal cord ; every day brings fresh discoveries, new additions to our knowledge, a broadening and clearing of our views. It is obvious that it is extremely hard to write a text-book of diseases of the spinal cord in the midst of this crowding rapidity of growth of knowledge. It is perhaps impossible to state in any decided terms the daily changing position of our knowledge; and a dogmatic statement like the present, com- pelled as it must be to shun the prolixity of a monograph, and to refrain from the thorough discussion of debatable questions, requires every species of caution in its presentation. The preceding remarks will make it sufficiently plain why we consider the clinical point of view as the most important one at the present time. We write for the practising physician, who encounters the actual diseases from day to day. For him it is important that a description should possess unity and clearness, and should give him something to work by. We have therefore 6 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. laid the chief stress upon the clinical presentation, in making which we have rested mainly upon the basis of pathological pl^siology, bestowing meanwhile a due share of attention upon pathological anatomy. One thing more should be added. After long deliberation, we have decided that the special descriptions of disease should be preceded by a general account, which has grown to a great size, but will not, we hope, be found superfluous or worthless. The anatomical introduction, the brief statement of the macro- scopic and microscopic anatomy of the cord and its membranes, with a synopsis of the physiology of the cord, which we have placed first, are justified by the facts that these things are indis- pensable to the understanding of the diseases ; that they mostly escape the memory of the practising physician in the course of time; that they have to be sought in text-books and journals which are not often possessed by practising physicians, and that, even in such works, they are not always treated with regard to the pathology, nor even with a proper understanding of the latter. An account of the general symptoms seemed to us most desirable in aiding the student to understand the pathological phenomena, and in saving rerietitions and explanations in the special division of the work. We have, therefore, taken pains to present in this part a brief and clear account of researches in physiology and pathological anatomy, and of clinical observa- tions, pointing out by the way the chasms which exist in our knowledge. Finally, it seemed not undesirable to describe the general treatment, especially as regards electro-therapeutics and balneo- therapeutics—very important branches, which, at the present time, have hardly received a connected scientific treatment; although, even here, we have had to point out many defects and obscurities—perhaps more than had been anticipated. I. Anatomical Introduction. Cf. Longet, Anat. et physiol. du systeme nerveux. German transl. by Hein. 1847.— Eoelliker, Mikroskop. Anatomie. Handb. der Gewebelehre, 5. AufL—Stilling, Neue Untersuchungen iiber den Bau des Riickenmarks. 1857.—Bidder und Rupffer, Untersuch. liber die Textur des Riickenmarks u. s. w. 1857.—Schroe- der van d. Kolh, Bau und Function der Medulla spinalis und oblongata. Braunschweig, 1859.—Goll, Denkschrift der med.-chir. Gesellsch. des Cantona Zurich. 1860.—Frommann, Untersuch. iiber die normale u. pathol. Anatomie des Riickenmarks. 1864.—Betters, Untersuch. iiber Geliirn und Riickenmark des Menschen u. s. w. 1865.—M. Schultze in Strieker's Handb. der Gewebelehre. — Gerlach, ibidem.—Henle, Handb. der Anatomie. III. Bd. 2. Hiilfte.— Wundt, Physiologische Psychologie. Leipzig, 1874.—G. Lange, Ueber chron. Riicken- marksentziindung. Kopenhagen, 1874; see Schmidt's Jahrb. Bd. 168. p. 238. 1875.—Leyden, Klinik der Riickenmarkskrankheiten. I. 1874.—Huguenin, Allg. Pathol, der Krankheiten des Nervensystems. 1873.—Boll, Histiologie und His- tiogenese der nerv. Centralorgane. Arch. f. Psych, und Nervenkrankheiten. IV. p. 1. 1874.—Schiefferdecker, Beitr. zur Kenntniss des Faserverlaufs im Riicken- mark. Arch. f. Mikroskop. Anatomie. X. 1874; and numerous other authorities. The spinal cord is suspended in the vertebral canal, hanging almost free, and with a considerable degree of mobility. It is unnecessary to describe the vertebral canal in this place. As points of practical importance, it may be stated that its ante- rior wall is perfectly firm and solid, being composed of the bodies of the vertebrae, with the interposed disks of cartilage, while its posterior and lateral walls have numerous vacant spaces, which are only filled up by ligaments and other soft parts, as nerves, blood-vessels, etc. The lateral spaces (intervertebral foramina) exist along the entire canal; the posterior, on the contrary (inter- vertebral fissures), are distinctly marked in no place, except in the cervical region—particularly at the two uppermost vertebrae —and again from the tenth dorsal vertebra downward, especially in the lumbar part. Throughout the greatest part of the dorsal 8 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. vertebral column these fissures are completely closed by the ver- tebral arches, which cover each other like the tiles of a roof. From this it is manifest what portions of the cord1 are most exposed to external injuries. The cord and its envelopes are far from filling up the entire canal; and this circumstance protects the cord from injurious pressure in the most movable parts of the column, namely, the cervical and lumbar regions. The width of the canal varies ; it is greatest in the regions of the neck and loins, least in the dorsal region, especially from the sixth to the ninth dorsal vertebra; within the sacrum it rapidly diminishes. The shape of its trans- verse section is nearly circular in the dorsal region, while in the cervical and lumbar, regions it is drawn out laterally, and assumes nearly the form of an obtuse-angled triangle, with its basis directed forward ; in the sacrum it has the form of a half- moon, with the convexity directed backward. The length of the cord is much less than that of the canal. Its extreme tip (the end of the conus terminalis) lies in adults at or near the boundary between the first and second lumbar ver- tebras. Fehst2 asserts that a difference exists between the sexes in this respect; in men, the lower edge of the first, in women, the lower edge of the second lumbar vertebra forming the extreme limit of the cord. It is a matter of some practical importance to be able easily to distinguish the different regions of the canal, in order to define with accuracy the location of a given disease; this is done by palpation and counting the spinous processes. Thus, we easily recognize the spinous process of the second cervical vertebra, and that of the seventh (vertebra prominens), from which points the separate processes can easily be counted by palpation. It is not so easy to recognize the spinous process of the twelfth dorsal by the insertion of the twelfth rib. The greatest part of the cavity of the canal is lined with a hard periosteum, covering the bony walls in every part. Within the canal, the cord is covered, first, by a cylindrical 1 Spinal cord : the term will be thus used henceforward. 2 Centralbl. f. d. med. Wissensch. 1874. No. 47. ANATOMICAL INTRODUCTION. 9 fibrous sac of wide dimensions, the dura mater spinalis, which begins at the foramen occipitale magnum, to the edges of which it is firmly attached, and terminates by contracting itself around the filum terminale, finally losing itself in the periosteum of the coccyx. The outer surface of the dura is not closely connected with the walls of the canal, but is separated from them by a loose, moist, connective tissue, with abundance of fat, which envelops every part of the dura in a layer of greater or less thickness. The inner surface of the dura is smooth and shining, and covered with several layers of pavement epithelium. The neurilemma of the nerve-roots which perforate the sac of the dura unites with the tissue of the latter. The dura is supplied with arterial blood by the vertebral, intercostal, and lumbar arteries ; its venous blood passes off by veins which form large plexuses in the loose cellular tissue of the anterior and posterior surfaces of the dura, connected with the external vertebral plexuses. Numerous nerve-fibres are supplied to the tissue of the dura and the periosteum of the canal. The pia mater spinalis, the so-called vascular coat, lies much closer to the cord. It envelops the cord in the closest manner from top to bottom; it forms an exactly fitting cylindrical sheath for the cord, containing the blood-vessels that belong to it, and closely united in every part with it ; it sends numerous sheath- like processes into the interior of the cord, which divide into many branches, spreading in all directions among the nervous elements of the cord, forming a framework for the support of these elements, and imparting to the cord a due degree of firm- ness ; the largest of these processes, easily visible to the naked eye, lies in the anterior median fissure of the cord, while a smaller one is seen in the posterior fissure ; but numberless finer processes pass into the substance of the cord from the entire periphery of the pia. The pia mater is a membrane of connective tissue of consider- able toughness and firmness ; it consists almost wholly of waved connective tissue, is extremely rich in blood-vessels (which will be further described in speaking of the blood-supply of the cord), and is also rich in nerves, which originate from the posterior roots. Often, especially in old people, the pia is strikingly rich 10 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. in pigment, so as to have a light gray or brownish tint; this is commonest at the cervical part, and is by no means always path- ological. The pia is joined to the dura on either side by from twenty to twenty-three processes of a three-cornered shape; they are arranged in two perpendicular rows, one on each side of the cord, with their bases inserted into the pia, and their points into the dura. They constitute the ligamentum denticulatum. The pia accompanies the filum terminale to the end of the canal, and is there united with the dura and the periosteum of the coccyx. Between the dura and the pia lies the arachnoid. Henle describes it as an unusually loose, watery, areolar tissue, which becomes compacted in the direction of the dura to a connected, delicate, resistant layer {arachnoid proper), while its inner por- tion passes directly into the tissue of the pia. Between the inner and the outer thickened layers (viz., the pia and the arachnoid) there exists, therefore, a loose areolar tissue, which is designated, and with propriety, as subarachnoid tissue. The fluid which this tissue contains in abundance is of great importance, and forms that part of the cerebrospinal fluid which is contained in the spinal canal. It is clear, contains but a small amount of solids, and appears poor in microscopic elements. Its quantity in the adult amounts to about sixty grammes, but varies considerably. It exists under a certain positive though moderate pressure. When the dura is pierced and the arachnoid also injured, it flows off. The function of this fluid is, without doubt, that of protect- ing the cord from mechanical injuries ; by keeping it floating in a fluid, it preserves as equal a pressure as possible, and perhaps also regulates the circulation and the pressure in the blood- vessels. A sudden evacuation of this fluid in cases of injury to the dura is followed by serious disturbances, which are, how- ever, doubtless due in part to cerebral implication. The spinal fluid is not in a state of repose, but, as Quinckel has recently given exact proof, is constantly undergoing a 1 Zur Physiologie der Cerebrospinalfliissigkeit. Reichert's and Du Bois-Reymond'8 Archiv. 1872. Heft 2. ANATOMICAL INTRODUCTION. 11 double motion: first, it moves to and fro in the subarachnoidal tissue, under the influence of respiration ; and second, it is con- tinually secreted under a definite pressure by the blood-vessels, and as continually passes off by certain channels into the lymphatic vessels. These channels for the spinal fluid are chiefly situated in the nerve-trunks which leave the spinal canal. It is obvious that these motions in the spinal fluid may be of the greatest importance in the propagation of morbid meningeal processes, in the removal and transportation of inflammatory and other products. The spinal cord (medulla spinalis) is a cylindrical cord, some- what flattened in front for a great part of its length, and not in every part of equal thickness. It does not nearly fill the sac of the dura, but is closely wrapped by the pia. After removal of the attached roots, it is easy to discern two swellings, the cervi- cal enlargement and the lumbar enlargement. While the thin- nest part of the cord, that in the dorsal region, has a transverse diameter of about 10 mm., and a sagittal diameter of about 8 mm., the cervical enlargement measures 13 or 14 by 10 mm., and the lumbar enlargement 12 by 9 mm. The diameter of the upper cervical region remains about 11 or 12 mm. The spinal cord begins where the medulla oblongata termi- nates, but without any sharp line of demarcation. Its upper- most limit is best placed just above the point of exit of the first pair of cervical nerves, lying at about the height of the upper edge of the posterior arch of the atlas. Its conical tip (conus terminalis) is situated opposite the body of the first or second lumbar vertebra. The lumbar enlargement reaches from the beginning of the conus terminalis upward to the tenth dorsal vertebra; the cervical enlargement, from the second dorsal upward to near the middle of the cervical column, at the third or fourth vertebra. The lower end of the conus terminalis is prolonged into the filum terminale, which reaches to the end of the canal. The average length of the cord is from 35 to 40 cm. The consistency of the cord varies somewhat in individual cases ; in the perfectly fresh state it is quite tough and elastic, and easy to cut; its cut surface is then smooth, and seldom pushes over the edges ; shortly after death it begins to grow soft 12 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. and deliquescent, and thus offers much greater obstacles to examination. Besides these features, we observe in the cord a number of grooves, which, even when .seen from without, give a hint of the internal construction of the cord. On the somewhat flattened anterior aspect, we find the ante- rior median groove ranning down the whole length of the cord, which, sinking into the cord, forms the broad fissura longitudi- nalis anterior,1 reaching nearly to the centre of the cord, and containing a large process of the pia mater. On the posterior aspect a similar groove runs from top to bottom, the posterior median groove, which, in like manner, sinks to a fissura longitudinalis posterior,2 directed in the sagit- tal line towards the centre of the spinal cord. This fissure also contains a process of the pia mater, though a much smaller one, closely attached to the adjacent walls of the fissure. These two fissures divide the cord in two symmetrical lateral halves, which are united by a narrow bridge composed of the white and gray commissures. The anterior fissure is broader than the posterior, but shallower. After these fissures, the first thing to observe are the nerve- roots which leave the cord, arranged in a double row, one on each side. The posterior root-fibres lie in a perpendicular line above one another, and form an almost continuous row, which maintains a given distance from the posterior median fissure, but gradually approaches it as they descend. If all the root-fibres are removed, their points of exit form a sort of longitudinal groove, called the sulcus lateralis posterior, or posterior lateral fissure. The anterior root-fibres do not leave the cord in a single row but are scattered over a stripe about 2 mm. broad, on the anterior portion of each side of the cord. Their distance from the ante- rior median groove is also definite, but by degrees becomes less. When the root-fibres are removed, this stripe is plainly marked and is designated as the anterior lateral fissure—sulcus lateralis anterior. 1 Anterior median fissure of Quain. 8 Posterior median fissure of Quain. ANATOMICAL INTRODUCTION. 13 In the upper half of the cord another fissure or groove is visible, lying about half-way between the posterior median and the posterior lateral fissures, and designated as the sulcus inter- medins posterior. These fissures are commonly used to bound the regions of the white substance of the cord. In each lateral half, the white mass lying between the anterior median and the anterior lateral fissure is called the anterior column; the mass lying between the anterior and the posterior lateral fissure is called the lateral column ; and the white matter between the posterior lateral and the posterior median fissure is named the posterior column. In the upper division of the cord, this posterior column is again divided by the sulcus intermedius posterior into two columns, which are genetically quite distinct (Pierret), and which claim a very special significance in pathology; the median portion of the posterior column, adjacent to the posterior median fissure, is called the wedge-shaped column of Goll, or funiculus gracilis (zarter Strang); while the lateral portion, which adjoins the posterior lateral fissure, is called funiculus cuneatus (Keilstrang). Most of these divisions of the white mass of medulla are more or less arbitrary ; the finer anatomy of the cord recognizes only the sharp division of the anterior and posterior median fissures. Pathological facts, however, not only justify the above division of the posterior cords, but permit a division, not sharply made, into outer and inner anterior column, and posterior and ante- rior lateral column. The anterior and posterior nerve-roots arising from each lat- eral half of the cord converge, and, after uniting, pierce the dura and pass to the intervertebral foramina; the posterior root of each spinal nerve enlarges to a ganglion {ganglion spinale) before entering the foramen, while the anterior root passes by this gan- glion and unites farther on with the posterior root to form a spinal nerve. The distances between the origins of roots being less than those between the intervertebral foramina, the lower roots are compelled to take a more and more oblique course in order to reach the foramina ; those from the conus terminalis run almost parallel, forming a bundle of nerves descending within the sac of the dura mater, named cauda equina. 14 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. This is nearly all that can be seen upon external inspection of the cord. In studying the inner structure of the cord it is necessary, above all, to attend to cross-sections ; they give the best infor- mation, and by mentally joining the results of the various sec- tions for the whole length of the cord, a correct idea is gained of the peculiarly complicated columnar structure of the cord. In any section we may make we recognize first a division into two substances: the central gray or gray-reddish mass, irregu- larly defined, and of a peculiar shape, generally resembling that of the letter H, called the gray substance; and a peripheral white mass surrounding the gray, filling in the irregular outlines of the latter, and giving to the whole the form of a cylinder, called the white substance. The latter is divided into the above- named columns by the fissures and the nerve-roots, a division which, in the lateral parts, is distinct only upon the surface, and does not extend clearly into the mass of the white substance. When we look closely at a section of the cord, we discover in its centre a fine canal, often filled with tissue elements or patho- logical products—the canalis centralis. This canal opens up- ward into the fourth ventricle ; at the lower end of the cord, at the tip of the conus terminalis, it expands to a small cavity—the ventriculus terminalis lately described by Krause1—which again opens into the cavity of the filum terminale. The central canal is surrounded by a partly gray and partly white mass, which joins the two halves of the medulla ; the gray portion of this bridge, in which the central canal lies, is behind, and is called the gray or posterior commissure ; the white por- tion lies in front, borders directly upon the anterior median fis- sure, and is called the white or anterior commissure. See Fig. 2, r and q. From this median region the gray matter extends in consid- erable mass and peculiar form into each half of the medulla. Its anterior part is rounded and broad, and pushes towards the antero-lateral column ; its posterior part is narrower and more pointed, and points directly to the posterior lateral fissure; it 1 Centralbl. f. d. med. Wiss. 1874. No. 48. ANATOMICAL INTRODUCTION. 15 bounds the posterior columns externally, and separates them from the lateral columns. The two parts of the gray substance are connected ; they are bounded outwardly by a line, which is, in general, concave on its outer side. But this line is irregularly pressed outward in many places by projecting masses of gray matter, and has scarcely the same form in any two sections. See Fig. 1. The anterior rounded part of the gray sub- stance is called the anterior cornu, or, better, when considered as extending through the entire length of the cord, the anterior pil- lar; the posterior acute portion is called the posterior cornu, or, better, the posterior pillar. Subsequent examination will show that the gray substance differs very much in elementary composition at different heights. This may be seen, without the aid of a mi- croscope, by observing that the form of the transverse section of the gray matter differs extremely in different sections of the cord, as a glance at Fig. 1 will show. The section made in the dorsal region is the smallest, and most resembles a Roman H, with its fore limbs rounded and its hinder ones pointed (Fig. 1; 4 and 5); in the cervical and lumbar enlargements it is much thicker, is provided with rounded horns, swelling into heads, and is enlarged by deposits of various shapes (Fig. 1; 2, 3, 6, 7). There is no doubt that these enlargements of the spinal cord are chiefly, if not exclusively, due to the in- crease in the gray substance. In many portions of the cord various pro- cesses are seen to leave the lateral portions of the gray matter, usually containing bundles of nerve-fibres, which radiate to various depths in the white matter; these processes meet and form a kind of network, which Sections of the human spi- nal cord taken at different heights. Magnified 3/j" l._ Upper cervical portion. 2,3. Cervical enlargement. 4, 5. Dorsal portion. 6,7. Lumbar enlargement. 8. Conus terminalis. 16 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. encloses separate portions of the white columns, rendering the outer boundary of the gray matter very uneven and jagged. These gray bundles of fibres are called processus reticulares. They are most marked at the boundary between the anterior and posterior cornua (Fig. 2, p). In the cervical and upper dorsal part of the cord a triangular prismatic process projects from the basis of the anterior cornu in front of these reticular processes into the lateral column, which has been designated the tractus intermedio-lateralis (Fig. 2, o). Fig. 2. Semidiagrammatic eection of the cord about the lower part of the cervical enlargement. Magnified '/,. a. Anterior median fissure, b. Posterior median fissure, c. Anterior column, d. Lateral column, e. Pos- terior column. /. Goll's wedge-shaped column (Zarter Strang), g. Funiculus cuneatus. A. Anterior roots. t. Posterior roots. k. Central canal. /. Sulcus intermedium posterior, m. Anterior pillar (cornu). m. Posterior pillar (cornu). o. Tractus intermedio-lateralis. p. Processus reticulares. q. Anterior or white commissure, r. Posterior or gray commissure, s. Clarke's column or columna vesicularis. An exact idea of these forms is only to be gained by the repeated examination of good sections from the hardened cord, under various powers of the microscope. All the unevenness, indentations, faults in the contour of the gray matter, are. filled out by the white substance, which sur- rounds the gray in a layer of various thickness like a cloak, and gives to the cord its external form of a more or less perfect cylin- der. The mass of white substance diminishes slowly but per- ceptibly in the downward direction (Gerlach); it disappears wholly at the commencement of the filum terminale. ANATOMICAL INTRODUCTION. 17 The white substance is traversed by numerous radiating septa of various degrees of fineness, and by the nerve-roots, which cross it from the gray matter to the surface in a similar radiating manner. The septa are connected by numerous branches, which divide up the field of white substance into numerous rhombic districts of various size, in which the nerve-fibres of the white substance are contained. The septa and septula thus compose a fine and complex network, enclosing the vessels of the cord and the nerve-fibres. At its outer border, just under the pia mater, the white sub- stance is again enclosed by a very fine layer of gray. This sur- sounds the white substance like a thin overcoat, accompanies the processes of the pia which enter the cord, and separates the nerve-bundles proper from the septa ; it sends out from the septa numerous offshoots, which penetrate among the nerve-fibres and envelop each one completely. Most later observers are agreed in considering that this substance is almost, if not entirely, com- posed of the connective substance of the cord (neuroglia). Comparing now the sections with each other, we obtain the following plastic view of the structure of the cord : Its nucleus is formed by a pillar of gray matter which tra- verses the whole length of the cord. This may be approximately compared with a channelled column of somewhat irregular form, perforated by a fine canal in its centre, and possessing four chief projections and four intervening depressions. This pillar is thin and slender everywhere, but is made thicker by accessions of new matter in the cervical and lumbar regions. Its forward projections are rounder, broader, more massy, forming the anterior cornua ; its posterior projections are sharp- er, more slender, narrower, forming the posterior cornua. The nerve-roots pass off from each of the four projections in the form of fringes. Of the four depressions, the anterior and posterior are the deeper, smoother, and more regular; the two lateral are shallower and less regular; their bases are made irregular everywhere by the deposition of gray masses, by projections and knobs upon the pillar ; in parts they are wholly filled up, and here and there a longitudinal ridge comes out into them. VOL. XIII.—2 18 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. The white substance is as it were pressed into these chan- nels, as when a soft clay is used to fill up the flutings of a pillar and smooth over its irregularities. Being smoothed off exteriorly, these white masses finish the round outline of the column. The white substance may also be conceived of as com- posed of long strings or ribbons which fit exactly into the exist- ing cavities and spaces, and are laid into the channels of the central gray pillar. The whole is then covered in with a fine gray mantle, which closely embraces the cord, as does the pia mater. Blood-vessels and lymphatics of the cord. The tissue of the cord is rich in blood-vessels ; the gray substance possesses an especially rich capillary network. All the blood-vessels arise from the pia; they pass into the cord through the processes of the pia, and, following their ramifications, send an abundant network of capillaries into the gray and white substance. The arteries of the pia originate in the vertebral arteries. Each vertebral artery gives off an anterior and a posterior spinal artery. The two anterior spinal arteries unite in a single stem, which runs down along the whole length of the cord without much loss of diameter to the conus terminalis; this arteria impar is reinforced at the level of each pair of nerve-roots by small arteries which originate in the intercostal and lumbar arteries, and pass through the intervertebral foramina with the nerve-roots ; on the other side it distributes numerous fine twigs to the pia and cord, and finally, at the foot, it forms two anas- tomoses with the posterior spinal arteries.—The posterior spinal arteries, one on each side, run down underneath the posterior roots, with each pair of nerves receiving fine branches of communi- cation from the intercostals, and sending off numerous fine twigs to the pia and the cord. It therefore seems plain that the pia mater and cord are principally nourished by the vertebral arteries, and next to them chiefly by the intercostals. The capillaries of the cord discharge their blood directly into two central venous trunks, lying to right and left of the cen- tral canal within the gray commissure (Fig. 2), and running the whole length of the cord. By their numerous horizontal con- ANATOMICAL INTRODUCTION. 19 nections they distribute their blood to the outer veins of the cord; of these the greatest and most important is the vena mediana spinalis anterior, which runs the whole length of the cord, lying behind the anterior spinal artery in the anterior median fissure. Down the posterior median fissure runs the vena mediana spinalis posterior, which increases gradually in size as it descends. Numerous venous networks, which also increase in calibre as they descend, unite these external veins to each other. The latter transmit their blood (through branches which run with the nerve-roots and pierce the dura) to the great spinal plexuses, which lie in the loose fatty tissue sur- rounding the dura, and anastomose with the outer vertebral plexuses, etc. Regarding the lymphatic passages in the cord, little is known exactly. The perivascular lymph-spaces first carefully described by His (and since more fully by Boll and Adler—see Archiv f. Psychiatrie u. Nervenkr. Bd. IV. and V.), are said also to exist in the cord. They stand in connection with a large lymph-space, lying between the pia and the cord, from which the lymph is carried through the lymphatics of the pia. According to Schwalbe the subarachnoidal space is also a lymph-space, but not directly connected with the perivascular lymph-spaces of the cord. Finer structure of the cord. The cord is composed of very various tissue-elements, for the exact histological description of which we refer to hand-books of histology; as regards the finer structure of the important nervous elements, compare the article by M. Schultze in "Strieker's Manual of Histology." In this place only a brief sketch can be given. Nerve-fibres, both medullated and non-medullated, occur in the spinal cord. All these are completely destitute of Schwann's sheath, or, at all events, it has not been demonstrated by the present methods of research. The medullated fibres compose the greatest part of the white substance and the anterior commis- sure ; they occur of very various diameter, the thickest being found in the anterior columns ; the funiculi graciles contain only slender fibres. In all, the axis cylinder may plainly be seen in 20 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. cross-section, and its diameter is nearly proportioned to that of the medullary sheath. The finest medullated fibres are found in the gray matter, of which they form a preponderant element. They pass in all directions through the gray matter, both isolated and in bundles, and frequently dividing up. The non-medul- lated fibres, analogues of the naked axis cylinders, are only found in the gray matter, in which they ramify to a very great extent; their finest branches unite to form a close mesh-work, which, with the ganglion-cells, is especially characteristic of the gray substance (Gerlach). And a few bundles of larger fibres with medullary sheaths, originating in the nerve-roots, pass through the gray substance for short distances. The cellular nervous elements, the ganglion-cells, are found almost exclusively in the gray substance, and are the component which most strikes the eye ; when they are found in the white substance, they are almost always single, and close to the gray. They are large, multipolar cell-bodies, sometimes visible to the naked eye; 'they have no envelope, their nucleus is large, with a distinct glistening nucleolus, and they usually contain an accumulation of pigment granules. They are remarkable for their numerous radiating processes, almost all of which ramify abundantly (protoplasm processes), while one process (the nerve- process) remains smooth and undivided, and after a longer or shorter course receives a medullary sheath and becomes a medul- lated nerve-fibre. This undivided process is, therefore, also called the axis cylinder process. According to Gerlach, not every ganglion-cell possesses a nerve-process, but many are connected with the fine network of nerve-fibres only through the ramifica- tions of their protoplasm processes; among such, the smaller forms of cells occurring in the posterior cornua are especially named. These cells, therefore, are connected with nerve-fibres only through the intervention of the fine network of nerves. Boll, however, does not con&ider that the existence of this kind of cells is sufficiently established. The size of the ganglion-cells in the cord, like their form, is very variable. They are found small, medium-sized, and large. By far the largest are found in the anterior cornua, with a great number of processes; the smallest, more of a spindle shape, in ANATOMICAL INTRODUCTION. 21 the posterior cornua ; those of medium size and a more rounded form, in the so-called columns of Clarke. They lie in groups and heaps, forming, in various parts of the gray substance, actual columns of cells extending for a consider- able distance in the cord ; they are especially abundant and definite in their distribution in the gray anterior cornua, while in the posterior cornua they occur but sparingly and in quite irregular arrangements. The attempt has often been made to establish a close relation between the form and size of the ganglion-cells and their functions. Jakubowitch first stated expressly that the larger cells with many processes, in the anterior cornua, are motor cells, while the smaller should be regarded as sensitive, and the smallest, of a spindle shape, as sympathetic (vaso-motor). Other observers have made similar hypotheses, and, more especially of late, a trophic action has been ascribed to the ganglion-cells, upon the basis of pathological facts. Of all this only so much appears certain : that the large cells with many processes in the anterior cornua are most intimately related to the motor apparatus; but what these relations are, and how they are expressed in the form and size of the cells, in their position and grouping, is quite unknown at present; nor is anything whatever known with cer- tainty regarding the existence, position, form and size of " sensitive," " vaso-motor," "trophic," "reflectory," "automatic" ganglion-cells, although many pathological facts recently collected seem to give us at least a starting-point for the solution of these problems. The nervous fibres and cells, which are certainly the most important components of the cord, are enveloped in a basement substance of connective tissue, the so-called neuroglia, which gives support and firmness to the cord. This substance radiates inward from the pia in numerous septa, bearing the blood-vessels, which break up into a great number of branches, and finally form a very delicate network in which the nervous elements are embedded. The gray cortical layer and the greatest part of the trabecular network proceeding from it, a great part of the gray substance (especially that which is commonly named the sub- stantia gelatinosa), and the entire supporting framework of the white substance, are composed of this neuroglia. In regard to its finer structure, the opinions of the best authorities (Koelliker, Frommann, Gerlach, Henle, Boll, Ranvier, C. Lange, and others) are still divided, as the difficulty of investigating this tissue is very great. All observers agree that the neuroglia consists 22 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. chiefly of a network of fibres very closely interlaced, embedded in a more or less abundant finely granular basement substance, and containing numerous nuclei, granules an 1 cell-elements. But, as regards the significance and the exact character of these fibres and cells, a great deal of controversy still exists. Some consider the fibres as elastic (Gerlach), others as more like con- nective tissue (Henle, Ranvier), others as the processes of cells (Kolliker, Boll, C. Lange); and the interpretations of the inter- jacent cellular and nucleoid structures are equally various. Boll has very recently given a careful description of the neu- roglia, which is different from previous ones. He states that its sole component is a form of multipolar connective tissue cell, composed of countless fine processes, not ramified, and a nucleus. These cells envelop the vessels in the septula, like sheaths, then branch off from the sheaths, and at last form by themselves the septula which embrace the single nerve-fibres and groups of fibres—as finely woven twigs embrace the upright staves of a basket, or as the fingers of the two hands may be woven into a kind of tube. These peculiarly shaped cells, characterized especially by their numerous unbranched processes, are called Deiters' cells or the spider-cells of Jastrowitz, and are often particularly easy to see in pathological specimens of the cord. Among their processes there lies a small quantity of a granular interfibrillary substance. Their nuclei, according to Boll, are what Henle calls "granules" (Korner). An essentially similar description of the neuroglia is given by C. Lange.1 Very recently, Ranvier has presented another view, according to which the connective tissue of the spinal cord is quite analo- gous to the interstitial connective tissue of the peripheral nerves. It is said to consist of numerous fine fibrillary bundles of con- nective tissue, not anastomosing, but crossing in many directions, and at the points of crossing there lie flat nucleated connective tissue cells.3 It is not necessary here to decide these difficult histological points; it is enough to know that the entire spinal cord, both white and gray matter, is permeated by a fine-meshed 1 See Virchow-Hirsch's Jahresbericht for 1873, Bd. II. p. 76, and Schmidt's Jahrb Bd. 168. p. 239. 1875. 2 Centralblatt f. d. med. Wiss. 1874. No. 31. ANATOMICAL INTRODUCTION. 23 structure of connective tissue, consisting chiefly of fine fibrils in which numerous nuclei are embedded, and surrounding in the closest manner the nervous fibres and cells. If Boll's view should turn out to be the true one, the " granules" of Henle would at last receive their right interpretation. They have been looked upon in all pos- sible lights: as young connective-tissue cells, as young nerve-cells, as lymph-cells, as wandering colorless blood-cells without prospect of future advancement, etc. But it cannot be denied that not a few structures resembing cells and nuclei are found in the cord, whose exact interpretation is not easily made out. The arrangement of the histological elements of the spinal cord is extremely complicated, and it is very hard to make it out accurately in all its details and in all parts of the cord. Very simple by comparison is the structure of the white columns. They contain the framework of connective tissue in its simplest and most perspicuous arrangement; it is composed of the neuroglia with the vessels inclosed by it, contains a few multipolar ganglion-cells, and embraces in its meshes the nerve-fibres, sometimes singly, sometimes grouped in bun- dles of several (Fig. 3). The large majority of these fibres runs parallel to the long axis of the A p.ece of diverse section of the cord, for which reason they almost $£^£,£5 X^'eXi ft , „. j.T___• ,,T„11 l^r./-,i»ri-i embraces the nerve-fibres, which are cut always present tneir weii-Known aorosS) and are ^^ with distinct axis-cyiin- cross-section, in transverse sections deis- Maguihed**u- of the cord. But the longitudinal bundles by no means always maintain an exactly parallel direction among themselves; they deviate from it in many ways, cross here and there at acute angles, often weave into each other, or are seen to change their place in the cross-section by degrees, moving towards the centre or the circumference of the cord, forward or backward. A certain number of fibres, however, run across the white columns in a more or less exactly horizontal direction. Such are especially the entering fibres of the roots, which run in broad bundles at the level of the section, or only a little off from it. They pass more or less directly from the cortex to the gray 21 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. pillars [cornua]. The anterior roots mostly reach the gray anterior pillars in the shortest and straightest path, while the bundles of the posterior roots are much interlaced after entering the cord, and pass through a devious and irregular course before reaching the gray posterior pillars. The fibres of the white commissure are horizontal. Finally, there are a few oblique fibres and bundles in the white columns. They are partly root-fibres, which do not take a directly horizontal course to the gray substance, but first pass obliquely upward or downward in the white substance for a certain distance, and then bend to enter the gray; and partly fibres which, leaving the gray matter in a horizontal direction, change to a perpendicular. This arrangement is especially frequent at the surface of contact between the lateral columns and the gray matter, where an abundance of fibres leave the gray and turn upward or downward in the lateral columns. It is, however, doubtful (although recently reaffirmed) whether root- fibres run directly up or downward in the white columns, with- out first having passed the gray substance ; this is affirmed of some bundles of fibres in the posterior roots. The structure of the gray columns [cornua] is considerably more complicated, and has not yet been examined in at all a satisfactory way. Two kinds of gray matter are usually distin- guished in it, plainly recognizable and separable by the naked eye, namely, the spongy and the gelatinous substance. Their distribution upon the surface of a cross-section is very une- qual. The spongy substance composes the chief mass of the gray columns, while the gelatinous substance forms only a semi- lunar cap over the tips of the posterior cornua, of greater or less thickness (substance of Rolando), and surrounds the central canal in a moderately thick layer. A prismatic column, situated at the boundary between the anterior and posterior cornua laterally from the posterior commissure, and close to the apex of the white posterior column, has been considered by many entitled to rank as a special formation in the cord; it is the columna vesicularis, now best known as Clarke's column (Fig. 2, s). This formation, rich in ganglion-cells, is found only in the dorsal part of the cord, beginning at the upper end of the lum- ANATOMICAL INTRODUCTION. 2;5 bar enlargement and ending at the lower part of the cervical enlargement. Careful examination shows that probably the largest part of the gelatinous substance belongs to the neuroglia. It consists of the finely granular substance before described, which, how- ever, in this situation is traversed by a few of the finest fibres of connective tissue, and contains a remarkable number of nuclei (glia-cells). It is traversed by many bundles of fine nerve-fibres, running in gentle curves from behind forward in various courses. These bundles originate in part from the posterior root-bundles, in part from the posterior columns, and probably also from the lateral columns. Besides, the gelatinous substance is traversed by vertical bundles, parallel with the long axis of the cord, which are especially distinct in the lumbar cord, and occupy principally the middle and the anterior parts of the gelatinous substance. In them large nerve-cells are rarely found, and the fine network of nerve-fibres discovered by Gerlach is said to be also wanting. The spongy substance is far more complex in structure. It consists of a mixture of fine fibres and bundles of fibres, seem- ingly inextricable, crossing in all directions, which resolve themselves into fine networks of fibres, only to recompose them- selves in the. former aspect of bundles of fibres ; at the same time they contain numerous multipolar ganglion-cells, arranged in definite groups. The fine nerve-fibres select the spongiosa for the seat of a repeated ramification, and their branches unite to compose a network of excessive fineness, discovered by Gerlach. Very similarly, the protoplasm processes of the multipolar cells form with their ramifications a fine network ; and it is extremely probable, although not yet certainly proved by direct observa- tion, that the fine bundles of nerve-fibres and the ganglion-cells communicate at numberless points through the medium of this network. Boll has confirmed Gerlach's discovery in all points, and has added to his state- ments another, to the effect that this fine network of nerve-fibres is not merely distributed through the entire gray substance, but can also be followed through the septa of the white substance into the gray cortical layer. From this it would follow that this remarkable and important network is universally distributed through the cord. 26 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Schiefferdecker has very recently attempted to follow out with somewhat more minuteness the incredible medley of nerve- bundles in the cord, and to ascertain the course of the principal ones. The most important -result of his investigations—and it is hard to apply either physiologically or practically—is that, so to speak, all parts of the gray and some parts of the white sub- stance are placed in the most universal and manifold mutual connection by the various networks of nerve-fibre ; the entering nerve-roots form connections with all the groups of ganglion- cells ; the latter are mutually joined by strands of fibres of their own, and send forth bundles of fibres to the white columns ; and all parts of each half of the cord stand in connection with all parts of the other half ; while, finally, higher and lower seg- ments of the cord are joined by vertical fibres. The spongiosa is crossed in many places by vertical ascending bundles of fibres ; this is especially the case in the neighborhood of the white substance, where bundles detach themselves from the white columns, enter the gray matter, and after a short dis- tance return to the white. This is most developed in the proces- sus reticulares. The longitudinal commissures in the gray sub- stance, just mentioned, appear in transverse sections as vertical bundles of fibres. The groups of ganglion-cells in the gray substance are highly interesting. Their number and mode of distribution in the anterior and posterior cornua vary. They can be seen excel- lently, with their processes and ramifications, in cross and longi- tudinal sections. Repeated observations have shown that their nerve-process is directly transformed into a medullated nerve- fibre, and, in the case of the great cells of the anterior cornua, that the fibre passes directly into the anterior roots and mingles with their bundles of fibres ; but this has been shown in the case of but few cells, and in most the nerve-process takes other directions, of which the object is chiefly unknown. It is further demonstrated with certainty that the protoplasm processes of the ganglion-cells break up by repeated ramification into a fine network of nerve-fibres (Gerlach, Boll, Schiefferdecker), and it is probable that this network stands directly connected with the finest nerve-fibres and their ramifications. ANATOMICAL INTRODUCTION. 27 Most of the ganglion-cells are found in the anterior cornua ; in the cervical and lumbar enlargements, especially, a great number of them are seen in every transverse section. Their dis- tribution is not the same in all parts of the cord, but distinct groups can be made out in most sections. First, a medial group, adjacent to the anterior and inner border of the anterior cornua, often broken up into smaller groups ; next, a lateral group, situated in the anterior external portion of the anterior cornu (Fig. 4, A, a b), and containing a great many cells ; Fig. 4. Seiiii-diagramatic transverse sections of the gray substance of the cervical (A) and lumbar enlargement (#), to show the situation of the ganglion-cells. Magnified 12/i" Aa, medial group; 6, anterolateral; c, posterolateral group; d, columna vesioularis. Ba, medial group ; a', group first appearing in the lumbar region, perhaps belonging to the medial; b, antero-lateral; c, postero-lateral group. In the posterior cor- nua, only a few scattered ganglion-cells. besides which, there is found in the cervical and upper dorsal portion, in the tractus intermedio-lateralis, a third group of very large multipolar cells, which may be designated as the postero- lateral group (Fig. 4, A c). To the latter corresponds a simi- larly situated group in the lumbar region ; but in this part of the cord the division into sharply defined groups is less dis- tinct, and the cells are distributed more or less irregularly over 28 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. the greater part of the section of the anterior cornua (Fig. 4, B). The arrangement of these groups of cells in different sections is extremely variable, and the number which can be distinguished is sometimes greater, sometimes less. All these groups are found throughout the length of the anterior gray matter, forming literal columns of cells. Amongst the groups, and through the whole mass of the anterior cornua, many single ganglion cells with more than one process are found, more or less abundant in different sections. Even in the white columns in the neighborhood of the anterior cornua, a few sporadic cells occur. In the gray posterior cornua the principal column of gan- glion cells is the columna vesicularis. Its situation and extent is described above. It consists chiefly of closely-crowded fine nerve-fibres, mostly vertical in their course ; but there are fibres which run in all possible directions, establishing connections between Clarke's columns and the other groups of ganglion cells, the anterior and posterior root-fibres, etc. Among these fibres there lie many pretty large nerve-cells, mostly spindle-shaped, with their long axes in a vertical direction, and provided with numerous protoplasm-processes; a nerve-process has not yet been demonstrated in connection with them. In cross-section the cells of Clarke's columns mostly appear roundish. Their size increases towards the upper and lower ends of the cord. Besides these, the posterior cornua contain only a few nerve- cells scattered over the entire section. A large multipolar cell is seldom found; the most part are of the smaller sizes, and are distributed irregularly and in very variable quantities among the spongy tissue of the posterior cornua. Nerve-processes have not been certainly demonstrated in connection with them ; but the part they take in the formation of the fine network of nerve- fibres may be considered as established. The central gray substance, which unites the four gray col- umns and encloses the central canal, chiefly consists of a finely granular and finely fibrillated mass (neuroglia, gelatinous sub- stance), containing many cell-bodies or nuclei. This substance is traversed by a fine network of nerve-fibres with broad meshes (Gerlach), and also contains bundles of fibres, of greater or less ANATOMICAL INTRODUCTION. 29 thickness, passing from one-half to the other of the spinal cord, before and behind the central canal, sometimes taking the direct transverse course, and sometimes ascending and descending obliquely (gray fibres of the anterior and posterior commis- sures). The white commissure consists almost entirely of nerve-fibres with dark contour, most of which run in a horizontal plane, decussate at an acute angle, and pass from one lateral half of the cord to the other, diagonally from front to rear. But a few bundles ascend obliquely, and immediately assume a perpendic- ular direction. The white commissure first connects the gray columns of one side with the anterior columns (white) of the opposite side (Gerlach), as the bundles of fibres which leave the former pass upward in the latter ; it further connects the various cell-groups in the gray columns with one another, and finally, it contains fibres which traverse the gray substance and pass into the white lateral columns. The central canal is a very narrow passage, often obliterated or occluded, presenting a roundish or elliptic, sometimes a tri- angular transverse section. It is lined with a ciliated cylindrical epithelium, and its wall is formed of dense undulated connective tissue of extremely fine fibrous structure (ependyma). It is bounded externally by the central gray substance, and is filled with a fluid, probably identical with the cerebro-spinal fluid. Anatomical data concerning the connection between the histo- logical elements, and the course of the fibres in the spinal cord. Many studies have been made by anatomists, with a view to unravelling the connection between the separate elements of the cord, the course of the entering root-fibres, their connection with other fibres, and with the ganglion cells, and finally, their ulti- mate destination, or their continuation to the brain. Unspeak- able trouble and toil have been devoted to these examinations; absurdly small and trifling have been the results; hardly any- thing is established with certainty, and the liveliest controversies 30 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. are still kept up upon almost all points. But every fresh exam- ination reveals fresh complications of the course of the fibres, which reduce the attempt to disentangle and follow them out almost to an impossibility ; and the deeper we go into the finer structural relations of the cord, the plainer it becomes that a separation and isolation of the individual groups of fibres or cells is not what is sought or reached, but rather a connection among them, as universal and complete as possible. This naturally renders it extremely hard to reach the desired goal. We shall here attempt to state, as briefly as possible, what may at present be regarded as somewhat certain, and likewise, what may be regarded as at least probable. For all details and further explanations we refer to the works of Stilling, Clarke, Koelliker, Frommann, Gerlach, Deiters, Goll, Henle, Boll, Schief- ferdecker, and others. The following points seem at present pretty well established : That all, or at least by far the greater part, of the nerve-roots pass straight to the gray substance, and enter it; this is certainly true of the anterior roots, but perhaps not of some small portion of the posterior root-fibres. That a large number of these entering root-fibres unite with the ganglion cells or their processes ; this also seems quite cer- tain for the anterior roots, but is still doubtful in respect to the posterior. That numerous fibres pass from the gray substance into the antero-lateral columns, especially the lateral columns, bend up- wards, and in the white columns take the direction towards the brain. Some of these nerve-fibres, leaving the anterior gray columns, pass into the white commissure and thence into the anterior white column of the other side of the cord (decussation within the cord), in which they probably run to the brain. Others pass into the lateral columns, in which the}^ run up into the medulla oblongata, and finally decussate in the pyramids. That numerous fibres from the posterior gray columns enter the posterior white columns (and the posterior regions of the lateral columns ?) where they bend upwards and run further in the direction of the brain. That the ganglion cells of the gray substance are mutually ANATOMICAL INTRODUCTION. 31 connected by numerous processes in the most complicated man- ner, both in the anterior and posterior cornua of each lateral half, and by means of the commissures which join the two lateral halves with each other; that moreover, processes of these gan- glion cells pass, some directly into the root-fibres, and some into the white columns, where they assume a vertical direction. That of the fibres which enter with the posterior roots, a part pass horizontally directly forward, and lose themselves in the fine network of nerve-fibres, or reach the ganglion-cells of the anterior cornua ; while another part runs upward or downward at the side of the posterior gray column, then bends again, and at last enters the gray substance. That the fine nervous network, and the nerve-bundles which by their resolution compose it, and the bundles which are recom- posed from it, serve to connect the groups of ganglion cells in all possible directions, with each other, with the entering root- fibres, with the white columns of both sides in the sagittal, trans- verse and vertical directions. The following statements may be regarded as more or less probable, but not at present certainly proved : That after the root-fibres enter into certain ganglion cells, processes from the same cells pass directly into the white sub- stance (going from the anterior cornu into the antero-lateral column, from the posterior cornu into the posterior column and the posterior part of the lateral column); in the white substance they ascend directly to the brain. That individual fibres of the anterior and the posterior roots meet each other in certain cells of the gray substance. That a few bundles from the anterior roots merely traverse the gray substance, going thence directly into the anterior parts of the lateral column, and there bending upward. Their signifi- cance is not yet clear. That the posterior root-fibres first enter into the fine network of nerve-fibres, in the gray posterior columns, and that the con- nection with the ganglion cells is accomplished through this network (Gerlach). That each single ganglion cell, by means of its branching processes, passes into a fine network of nervous fibres, from 32 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. which larger medullated fibres are again developed (connection of the cells with the nerve-fibres). That the network of nerve-fibres into which the posterior root- fibres break up is in continuous communication with the network of nerve-fibres in the anterior gray columns; that from this latter network numerous fibres originate, which cross the median plane in the gray commissure, and then ascend toward the brain, some in the vertical bundles of the posterior cornua, some in the pos- terior columns (total sensory decussation in the cord ?). The gray substance, therefore, seems to be much more intimately connected with the posterior nerve-tracts (through the fine network) than with the tracts which prolong the anterior nerve-roots. That from Clarke's columns bundles of fibres pass out into the lateral columns. That the medial parts of the posterior columns (so-called fasciculi graciles) have by their development and structure a special significance, which is at present entirely obscure. Pierret considers them as a great longitudinal commissure, intended to bring various parts of the gray substance into mutual connec- tion. All these results are defective and inadequate in the highest degree ; they hardly permit us to form an exact idea of the com- plicated course of the fibres. In general, we can only infer from all this that the root-fibres which pass from the peripheral nerves into the cord first enter the gray substance, where they have their first termination ; that they next, after many ramifications and connections, leave the gray substance and pass up the white columns to the medulla oblongata. This process is repeated step by step at the entrance of every new pair of roots. But this scanty result gives us no information regarding the precise direction of the single fibres, none regarding their connec- tions, none regarding the physiological significance of the several groups of fibres. Anatomy can at present give us no certain information upon these points; we must expect it rather from the most scrutinizing physiological research. The next section will be devoted to explaining the paths of conduction in the cord, as at present understood through the aid of physiology and the equally important aid of pathological anatomy. PHYSIOLOGICAL INTRODUCTION. 33 Let it only be remarked in this place, that the anatomical formation of the cord, which we have just attempted to sketch, is somewhat modified in its uppermost region by the accession of some new parts. We refer to the origin of the accessories, whose roots are seen leaving the lateral column as far down as the fifth and sixth cervical vertebrae. Within the cord they can be followed to the ganglion cells of the postero-lateral cell group of the anterior cornu. In analogy with this, the so-called ascending root of the trigeminus can be followed in the cervical cord to about the level of the third cervical vertebra in the form of a large bundle of fibres, which is in relation with the substantia gelatinosa of the posterior cornu, and gradually passes into it. Finally, in the uppermost part of the cord, the decussation of the pyramids produces a sort of substantia reticularis—a manifold interweaving of the bundles of fibres—which is visible in the middle of the anterior half of the cord. Concerning the further course in the medulla oblongata of the nerve-paths which leave the spinal cord, see further on, under the proper heading. II. Physiological Introduction. Of. Longet, Anatomie et physiologic du systeme nerveux; German transl. by Hein, 1847.—Schiff, Lehrb. der Physiol, des Nervensystems. Lahr, 1858-59.— Centralbl. f. d. med. Wissensch. 1872. No. 49.—Brown-Sequard, Experim. and clinical researches on the physiol. of the spinal cord, etc. Richmond, 1855. Course of lectures on the physiol. and pathol. of the central nervous system. Philadelphia, 1860.—Sanders, Geleidingsbanen in het ruggemerg. Groningen, 1866.— Wundt, Physiologic, 1873. 3. Aufi.; Physiol. Psychologie. Leipzig, 1874. —Hermann, Grundriss der Physiologic 2. Aufl. \S1L—Leyden, Klinik der Riicbenmarkskrankheiten. I. 1874.—Also innumerable articles in Reichert and du Bois-Reymond's Archiv, Virchow's Archiv, Pfliiger's Archiv der Physiologic, Zeitschr. f. wissensch. Zoologie, Zeitschr. f. rationelle Medicin, Moleschott's Unters. z. Naturlehre, the Monatsberichte of the Saxon Academy, Brown- SCquard's Journal de la physiol. de 1'homme, etc., the Archives de la physiol. norm, ct pathol., etc. VOL. XIII.— 3 34 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. The simple fact that traumatic destruction of the cord at any place, or its experimental section, completely suspends the sensi- tive, motor, and vaso-motor connection between the brain and the periphery of the body, was sufficient to prove that the channels for maintaining this connection lie in the spinal cord ; in making a step beyond this it became necessary to employ a great variety of experiments to establish with accuracy the course and the situation of these various channels. In order to accomplish this, physiology has made colossal efforts, and has produced a series of most valuable studies, incomplete though they be in many respects. Of late years, pathology has contributed not a little to enlarge our knowledge of the physiology of the cord. Unfortunately, the physiological as well as the pathological methods of investigation, and especially those of pathological anatomy, are still very imperfect. In the experiments by section, which are the most frequently employed, the effect of the primary shock and of the secondary inflammation are hard to separate from that of the simple severing of the channels of con- duction ; secondary degeneration also frequently occurs, and disturbs the result of the experiment. This manifestly gives rise to uncertainty and confusion in the statement of results, which is increased by the difficulty of obtaining from animals exact objective reports of the disturbances of function. In man, on the contrary, it is comparatively easy to ascertain in patho- logical cases the nature, the degree, and the extent of the dis- turbance of function; but it is less easy, and in fact, quite a mat- ter of chance, to obtain for anatomical investigation exactly the right stage of the disease, and it is harder still to find the histo- logical changes defined exactly and beyond a question. This must always be borne in mind, that we may not suffer ourselves to repose in too great confidence of the value of our knowledge. In the following paragraphs we shall attempt to present a brief summary of what is established in the physiology of the cord, or at least, that which is probable, and capable of beino- used by the pathology of our day. PHYSIOLOGICAL INTRODUCTION. 35 Sensory Conduction in the Spinal Cord. All the impressions received by peripheral sensitive nervesa are conducted to the spinal cord by the posterior roots; they pass first into the gray substance, and thence are conducted into the posterior columns and a part of the lateral columns, in which they ascend to the brain. The principal channel for sensations of touch, pressure, tem- perature, tickling and the like, is to be sought in the white posterior columns. Section of the white posterior columns destroys the sensation of touch perma- nently in the regions situated posteriorly to the section (Schiff); but it does not annihilate every sensation, as a hyperaesthesia, especially in respect to painful impressions, continues for a time, gradually disappearing. It is not yet determined whether there exist separate paths of conduction for the different varieties of the sense of touch, but Brown-Sequard maintains this view and supports it by weighty pathological facts; he supposes these paths to lie mostly in the gray substance. The latest experiments of Woroschiloff (in Ludwig's laboratory) are of great interest; they seem to show that the lateral columns are of far more importance in conduct- ing sensation than has hitherto been supposed. But these experiments are confined to the lumbar cord of the rabbit, and cannot yet be made the basis of more general conclusions. They appear to show that each lateral column contains sensory fibres for both legs ; the more important seem to decussate. The sensation of pain is conducted chiefly or exclusively by the gray substance. Schiff makes section of the posterior columns destroy the sense of touch, but not that of pain ; while section of the entire gray substance, leaving the posterior columns intact, destroys the sense of pain, and leaves that of touch (the condition known in pathology as analgesia). The presence of the network of nerve-fibres shown by histology, hardly permits us to explain these facts by the assumption of separate paths of conduction; hence Wundt (Physiol. Psychologie, p. 117) has proposed the hypothesis of different excitability of white and gray matter; the gray requires, in order to produce a reaction, a much higher and more intense irritation than the white; but when the reaction occurs, its intensity is all the greater, and produces pain. If, therefore, the gray substance alone remains for the purposes of conduction, more powerful irrita- 1 According to Brown-Sequard, the paths for the "muscular sense" lie in the ante- rior roots. 36 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. tions are usually required; and when sensation is produced it is more violent that is, painful; but if the white columns alone are retained, the irritation quickly reaches a degree at which sensation is produced, but never goes so far as to produce pain. The gray matter conducts sensation even after the section of all the white columns ; it does this in its entire section and in every part of it, although it is quite inexcitable under direct irri- tation, and is, therefore, designated as cEsthesodic substance (Schiff). In this sense the white substance, with the exception of the posterior root-fibres which traverse it, was supposed to be also sesthesodic ; the experiments of Engelken, Fick, and Ditt- mar, however, seem to have finally settled that the paths of sen- sation which have once passed through the gray substance of the cord are still excitable. The anterior and the greater part of the lateral columns have nothing whatever to do with the conduction of impressions of sensation. The conduction of sensory impressions decussates in the cord soon after the root-fibres enter it; this decussation seems to be pretty complete in the dorsal and cervical medulla of man (Brown-Sequard, Schiff). The decussation of the sensitive paths is certainly complete in the medulla oblongata. Whether the paths of all the kinds of sensation decussate is not yet fully deter- mined ; according to Schiff's later statements those for the sense of touch do not; according to Brown-S£quard, those for the muscular sense also do not. The latter author also says that the channels for the various kinds of sensation decussate at different heights. Miescher found decussation of the centripetal (sensory) fibres from the sciatic, which produce a reflex increase of the blood-pressure. The fact of the sensory decussation in the cord is established beyond any reasonable doubt by numerous pathological observations. The isolated conduction of the separate sensory impressions can only be explained (in view of the fine network) by supposing that certain tracks in the conductive substance offer less resist- ance than others, and are, therefore, habitually employed. Such tracks are probably constituted by the fibres which pass directly from the network of nerve-fibres into the posterior (lateral) col- umns and pass upward in the latter to the brain; these, under normal circumstances, offer least resistance. The further exten- PHYSIOLOGICAL INTRODUCTION. 37 sion of powerful sensory impressions, or the conduction which continues to take place after interruption of the principal chan- nel, is readily explained by reference to the network. In the same way is explained the transference of powerful irritation to neighboring or distant sensitive tracks, producing the associated sensations; they require only a diminution of resistance in certain channels, or an increase in the strength of the irritation. A retardation of the conduction of sensation occurs when the posterior columns are entirely cut, and only a part of the gray substance remains ; the more the gray substance is diminished, the more distinct is this retardation (Schiff); this fact may very well be used to explain that retardation of the conduction of pain which not infrequently occurs in pathological cases. In regard to the position of definite sensory paths in the cord, physiology informs us that in the case of the lower extrem- ities these paths lie at first in the lateral columns, and do not enter the posterior columns till a higher point; the posterior columns of the lumbar cord are said to contain only the nerves of touch for the pelvic region, sexual organs, perineum, and anal region. Motor Conduction in the Spinal Cord. This subject has by no means been examined in all points. The principal line of conduction for voluntary movements passes from the brain into the cord, through the decussation at the pyramids, and probably to a still greater extent through other routes of decussation in the medulla oblongata and pons. The motor (voluntary) paths do not further decussate in the cord, but remain upon that side which belongs to the half of the body destined to receive the nervous influence. Most of the paths for voluntary motion probably run down in the lateral columns, enter the gray substance at different heights, form connections, through the network of nerve-fibres, with the large multipolar ganglion cells, and pass through their axis-cylinder processes into the anterior roots. The fibres for voluntary motion all lie in the anterior roots; these roots, 38 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. however, contain other fibres which possess a different physio- logical function. Section of the posterior columns and the entire gray substance does not destroy the voluntary movements of the portion of body lying behind the point of section. Section of the antero-lateral columns and the entire gray substance destroys all vol- untary motion in the corresponding parts. Section of the anterior and the lateral column lessens voluntary motion for only a short time, and motion returns the quicker, in proportion as the gray substance is retained. In regard to the function of the anterior columns proper we are still greatly in doubt; they do not seem to aid in voluntary motion; they are supposed to carry fibres, for the most part, whose function is to transmit reflex impulses originating in the brain (Huguenin); they also bear fibres which experience one more decussation in the cord, and pass through the anterior commissure into the gray anterior column of the other side. In" these points, also, Woroschiloff's experiments (upon the lumbar cord) have brought new and unexpected facts to light, which ought, however, to be applied with extreme caution. Motor baths for loth legs are contained in each lateral column; the more important of these, those which produce reflex action, co-ordina- tion, etc., seem not to decussate. Even after section of the antero-lateral columns, a translation of motor impulses to the posterior half of the body is possible through the gray substance, and even through certain limited portions of it. This substance is inexcitable under a great va- riety of stimuli, at the same time that it conducts the impulses of motion ; it is therefore Mnesodic (Schiff). This is by no means true of the longitudinal fibres of the antero-lateral column; they are not kinesodic, as is affirmed by many physiologists, who seek to derive all the phenomena of motion which occur when the antero-lateral columns are irritated, from irritation of the root-fibres which traverse them ; the experiments of En- gelken and Fick leave not the slightest doubt that the anterior (lateral ?) columns of the cord are as truly excitable as any other nerve-fibre. The isolated conduction of individual motor impulses, like that of the sensory excitations, is explained by the supposition that of the many channels which are open some offer less re- sistance, and therefore are usually selected. But even in this region many translations to other tracts (associated movements) occur, either because the normal paths are not sufficiently PHYSIOLOGICAL INTRODUCTION. 39 used, or because the resistance offered by other paths is dimin- ished, or because the irritation is increased in force. As respects the position of certain motor paths in the cord, we will here mention the statements of Schiff, that the lateral columns of the upper cervical portion contain those for the muscles of respiration, and that cutting them destroys perma- nently the movements of respiration on the same side. But this is denied by others. Woroschiloff found in the lumbar cord of the rabbit the motor paths for the foot and leg below the knee lying towards the outer circumference of the lateral col- umn, and those for the thigh more towards the middle. Co-ordination of Movements. The spinal cord plays a considerable part in this important function, and disturbances of co-ordination of movement are not at all rare in spinal disease; for these reasons, and in view of the numerous unsettled controversies connected with the mat- ter, we feel ourselves bound to give a careful statement of the difficulties which surround it. What is meant by co-ordination of movement, is not difficult to define; it consists in the innervation of a large number of muscles simultaneously, each with a different but appropriate degree of force, for the purpose of attaining a given object of motion. A little close inspection will reveal the fact that muscular motions, even those which look simple, as lifting a burden or throwing a stone, are really quite complex, and involve a large number of muscles ; still more is this the case in the more com- plicated acts of writing, piano-playing, gymnastic feats, and the like. The manner in which this wonderful mechanism regulates the co-ordination of movements, and the methods it takes to accomplish its results, can best be seen by observing children or persons who are learning to perform any complex motion, as writing or piano-playing. In the new-born child but few co-ordinate acts seem pre- pared for; the movements of respiration, of sucking, crying, and swallowing, and perhaps those of the eyes, are performed imme- 40 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. diately. All other co-ordinated motions must be learnt with pains and by a thousand attempts, as is the case with standing, walking, running, and especially speaking, and later, writing and all sorts of skill in the use of the hands. The apparatus for co-ordination seems to be ready formed, but not to be in readi- ness for full use ; it attains full development by use and varied practice. It is conceivable and probable that the frequent use of the nervous paths (in the fine network ?) in certain directions by degrees overcomes the resistance along these lines, until at last their employment becomes almost a matter of course. The process which takes place when co-ordinated movements are being learnt, may be somewhat as follows: The will sends down an impulse, and the part of the central apparatus which it first reaches is that which presides over the association and co-ordination of the single impulses of motion. This takes place under the constant supervision of the sight (in the case of speech, of hearing also), and of the peripheral sensations of the skin and muscles ; which convey a conscious impression of the correctness or inaccuracy of the movements, and enable the person to apply to them the proper corrections. By continued exercise and repetition the movements become more and more perfect, and may thus reach a high degree of precision. When co-ordination has once been acquired, and the motor paths concerned have been sufficiently trodden, the complicated movements take place quite automatically, in response to a simple impulse of the will, aided by the apparatus for co-ordination. A supervision by the sight or the sense of touch is then no longer needed. This clearly appears from the fact, that after a little practice we can execute the most complicated motions with a swiftness and sureness which prove that they are not at all con- trolled by any active and defining regulative sensation—as when we grasp at a certain object, throw at a mark, leap over a ditch, play the piano in the most rapid time, etc. We therefore are able so to determine in the central organ the arrangement and force of the various processes of innervation, and by the aid of the will and the co-ordinative apparatus so to bring them to pass, that a completely ordered movement is the result. At any rate, this is the way in which most co ordinate movements are per- PHYSIOLOGICAL INTRODUCTION. 41 formed, when once they have been sufficiently practised and learnt, as walking, running, grasping, writing, speaking, etc. The question as to the anatomical seat of the centres of co-or- dination and the centrifugal paths belonging to it, is not com- pletely settled. According to the latest researches (among which those of Goltz are of especial importance) it appears that the proper centres of co-ordination lie in the brain only. The cor- pora quadrigemina, thalami optici, and cerebellum are the organs which seem to take the most prominent part in the co-ordination of movement. In the spinal cord there seem to be no such centres, although the undoubted fact that orderly reflex movements may be evoked from the cord is sufficient proof that combined movements, serv- ing definite purposes, can be arranged in the cord. But the point we are here interested in is the co-ordination of voluntary movements, which has little to do with the apparatus for these reflex actions. It seems, upon the whole, that the spinal cord contains only those paths of conduction which lead the co-ordinative impulses to the muscles, which, therefore, place the cerebral centres of co-ordination in connection with the anterior roots. In what part of the cord these co-ordinative paths lie, and in what manner they enter into connection with the motor paths, is at present wholly unknown. Pathological facts, to which we shall come later, permit us to suspect that these paths are to be sought in the white posterior columns or in their immediate neighborhood ; and in order to supply the connection with the various nerve paths the fine network of nerve-fibres may also be called in play. But the physiological researches of Woroschiloff—which, how- ever, refer only to the lumbar medulla—show that the co-ordina- tory paths lie in the middle third of the lateral columns, in the hollow between the anterior and posterior cornua. This agrees with a statement by Schiff, that the symptoms of ataxia may be produced in the lumbar cord by lesion of the lateral columns. In the closest connection with the co-ordination of movements we may here speak briefly of the processes which enable us to retain the equilibrium of the body. In the execution of this function a large number of accurately and finely co-ordinated 42 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. muscular contractions are concerned, which continually alter the centre of gravity of the body in such a way that its equipoise is kept and the body remains upright. For this purpose a con- stant oversight by the senses appears to be necessary, to inform us of the position of the body in space and of the posture and position of the parts of the body. The oversight is exercised partly by the sensibility of the soles of the feet, the joints, the muscles, the skin, etc., partly by the sense of sight, and perhaps also by the semicircular canals of the labyrinth of the ear. These centripetal stimuli, constantly in activity, are converted in the central organ into definite co-ordinated movements, which pre- serve the equilibrium of the body. The co-ordinating centre which preserves the balance of the body is supposed to lie in the corpora quadrigemina and the thalami optici. The con- ductive paths appertaining to it lie in the spinal cord, of course, with the exception of those which come from the organs of sight and hearing. The sensory paths for this function are situated, without doubt, in the posterior columns and the gray substance ; the situation of the centrifugal paths is unknown. Vaso-motor Paths and Centres in the Spinal Cord. These have been the object of much and repeated investiga- tion down to the most recent time. Cutting the cord at any point produces a transitory but very considerable dilatation of all the arteries below the point of section ; irritation of the cord, on the contrary, produces a contraction of the arteries below the point of irritation. From this we may infer that vaso-motor paths run in a centrifugal direction in the cord. They are said to be chiefly contained in the lateral columns, and in part, probably in the gray matter also ; they are supposed to decussate for cer- tain parts of the body, especially for the vessels of the thigh and trunk (Schiff). This statement, however, is denied (von Bezold). The centres of vaso-motor innervation certainly lie in the cord and medulla oblongata. It has hitherto been generally assumed that the chief centre lies in the medulla oblongata ; but the researches of Goltz, Schlesinger, Vulpian, and Mor. Nussbaum have now established beyond a doubt that vaso-motor centres are PHYSIOLOGICAL INTRODUCTION. 43 found throughout the length of the cord as far down as the lum- bar region. It is from these centres that the tone of the vessels is re-established when they have been dilated after section of the cord. The wound at first inflicts a shock, with temporary paral- ysis ; hence the dilation which directly follows the section. As soon as the centres have recovered, the vessels return to their normal volume ; every fresh section of the cord at a lower point produces the same series of phenomena. A continued, or even a permanent paralysis of the vessels may occur, but only when the entire cord is destroyed; in this case the irritation of peri- pheral sensory nerves no longer produces a reflex contraction or dilatation of vessels, in the way observed when the lumbar cord, including the vaso-motor centres, is intact. But even when the lumbar cord is totally destroyed, the ves- sels of the posterior half of the body are neither permanently nor wholly paralyzed ; the original dilatation gradually diminishes, and the cutaneous temperature, at first considerably increased, sinks again to the normal point or beneath it. The same is the case after section of the sciatic nerve. These facts have com- pelled us to suppose that the vessels also possess a peripheral gangliar apparatus, like that of the heart, which preserves their tone and keeps them at a certain degree of dilatation, even when they are cut off from all connection with the nerve-centres. Goltz* has recently attempted to refer all the vaso-motor phe- nomena which occur during the various experiments in section of the nerve to irritation of vaso-dilator nerves. These, when irritated by the cut, he supposed to act upon the peripheral ganglia like a sort of nerve of arrest, paralyzing their activity, and thus producing a lax condition of the vessels. According to this view the cord contains only that class of vaso-motor cen- tres which cause dilatation of vessels. In spite of the elaborate defence of this position—which is also held by Vulpian—it has not proved sound, and a further series of researches, made by Putzeys and Tarchanoff in the laboratory of Goltz, has again shaken the theory of vaso-dilator nerves.8 They refer the symp- 1 Pflueger's Archiv. Bd. IX. S. 174. 8 Centralbl. f. d. med. Wissens. 1874. No. 41. 44 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. toms to a great exhaustibility and an excessive stimulation of the vaso-motor paths, which result in immediate dilation of the vessels, preceded regularly by a brief period of contraction. The vascular tonus, therefore, is under the influence of cer- tain very complicated sets of apparatus; those of the peripheral nerves come first, but are subordinated to the centres in the spinal cord, so that when the latter are excluded, the former require some time to develop their entire activity and to restore the tone of the vessels. This increase of the activity of the peri- pheral ganglionic apparatus is perhaps favored by the increased influx of blood which occurs after the spinal centres have been excluded. A similar relation may exist between the spinal centres and the vaso-motor centres in the medulla oblongata. It is not known where the vaso-motor centres in the spinal cord are situated: probably in the gray anterior pillars. The vaso-motor nerves which come from these centres mostly lie in the lateral columns ; they leave the cord in the anterior roots ; those destined for the head come from the cervical cord, those for the upper extremities from the upper dorsal, those for the pelvis and lower extremities from the lower dorsal and the lum- bar cord ; the abdominal viscera receive their vaso-motor nerves through the splanchnic, and the uro-genital apparatus from the lumbar nerves. Trophic Centres and Paths in the Spinal Cord. Physiology is entirely in doubt respecting the existence and the mode of action of trophic nerves. Pathological facts, in numbers, have continually pointed to the existence of some such trophic influence, coming from the nervous centres ; but no generally accepted basis for a doctrine of the trophic nerves and their functions has ever been established. We may therefore confine ourselves to a few remarks, and avoid a close discussion of this section of the general pathology of the spinal cord. The influence of the nervous system upon the processes of secretion is probably no longer doubted, in view of what we really know concerning the secretion of saliva. It is palpable that these processes have the very closest analogy with processes PHYSIOLOGICAL INTRODUCTION. 45 of nutrition. That the nutrition of most of the peripheral parts, the nerves, muscles, bones, joints, skin, hair, nails, etc., depends in many respects upon the spinal cord seems to follow from numerous pathological facts which have been collected by Charcot.1 These observations show that many and various trophic disturbances—both those of an inflammatory and gan- grenous nature, and also simple atrophy and degeneration— occur in all the parts named when their nervous connection with the spinal cord is cut off, or when the latter itself is affected in certain ways and in certain regions. The nature of these trophic influences and the routes which conduct them are in most points problematic. The proper cen- tres for these influences are probably the ganglion-cells, espe- cially those of the gray anterior pillars. The routes over which the trophic influences are conveyed to the periphery run in the motor and sensory nerves ; but it is questionable whether there exist for the purpose special trophic nerve-fibres, or whether the motor and sensory fibres themselves assist in con- veying trophic influences. At all events, no special trophic nerves are anatomically demonstrated at present. Respecting the position of the trophic centres for special tissues, something is known, but most is obscure. Those for sensitive nerves seem to lie in the spinal ganglia, as found by Waller and confirmed by Schiff. There are numerous and well- established pathological facts in favor of this view, as degenera- tion of the posterior roots, with unimpaired nutrition of the peripheral sensitive nerves, in cases by Charcot, Vulpian, Schueppel, and others. The trophic centres for motor nerves and muscles doubtless lie in the anterior cornua, and are usually supposed to exist in the large multipolar ganglion-cells. In the same situation, according to pathological facts, the centres of nutrition for bone and joints are probably to be found (see Infantile Spinal Paraly- sis). But the centres of nutrition for the skin and its adnexa are probably elsewhere ; they are apparently to be sought in the central gray substance or the posterior columns, their nerve- 1 Clinical Lectures on Diseases of the Nervous System. 46 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. fibres leaving the cord with the posterior roots ; perhaps they exist in the spinal ganglia also. Further research is required in order to determine all this. The experiments of Eichhorst and Naunyn' have lately shown that the spinal cord contains the means of self-maintenance and self-nutrition. Pefiex Action of the Spinal Cord. The production of reflex movements—i. e., the direct trans- ference of sensory excitation to motor paths, unassisted by the intelligence and the will—may be assigned without contradiction to the gray substance. All spinal reflex acts—i. e., all reflex acts which occur after the brain has been severed from the spinal cord—require, without doubt, the aid of the gray substance of the cord to produce them. These results are confirmed by a great variety of physiological experiments and by numberless pathological facts. In spite of this, we are not yet entirely clear in regard to the reflex apparatus, and the precise course taken by the excitation which produces the reflex action ; yet it is pretty certain that ganglion-cells constitute the proper apparatus for producing reflex action, and that it is in them that the transference of centripetal sensory excitation to centrifugal motor paths takes place ; experiments show, further, that the entering root-fibres must connect with ganglion-cells very soon after passing into the gray substance. The centripetal paths, which convey a stimulus inward, lie beyond a doubt in the posterior roots ; those which convey forth a stimulus, the centrifugal, or motor, lie in the anterior roots ; but of that which lies between these two routes, and its histo- logical structure, we are not well informed. We may, however, guess that there are branch conductors given off both from the sensory and from the motor paths at various points within the spinal cord, which meet each other at certain ganglia and groups of ganglia (reflex centres), and enter into conductive communica- 1 Arch. f. experiment. Path. u. Pharmak. II. p. 242. PHYSIOLOGICAL INTRODUCTION. 47 tion with each other ; but these conductors may be supposed to be connected by means of the fine network of nerves with all other possible paths in the gray matter, up to a great distance from their proper seat, so that a reflex motor excitation, origi- nating from a single point, may be diffused more or less exten- sively. The reflex excitation may therefore pass to many or even all of the motor paths ; but, as a rule, it passes to but a few, and often to but a single one. There exist numberless paths, with very various resistances to conduction ; those which present the least resistance are first occupied. If the strength of the irritation is increased, or the resistance within the reflex paths is diminished,, the reflex movements are correspondingly increased in extent. In harmony with this complication is the fact, that the time required to carry out the reflex conduction is many times (according to Helmholtz 11-14 times) greater than that required for simple motor conduction. The degree of reflex irritability differs very much in different persons ; in many, all possible reflex acts can be produced with the greatest ease, while in others this is very difficult, or impos- sible. Various physiological conditions, many poisons, and espe- cially pathological conditions, have the power to modify the reflex irritability to a considerable extent. The first and ordinary consequence of a brief sensory irrita- tion is a simple brief contraction of the muscles, or a more prolonged tetanic contraction ; subsequently repeated convulsive jerks also occur; Freusberg' and Goltz2 have lately observed reflex actions that intermitted rhythmically, following a single or continued irritation; in the higher degrees of excitation the muscular contractions become more and more extended, and almost the entire musculature may at last take part in the reflex action, as occurs in many forms of general spasm. The way in which the reflected actions increase in extent, while the irritation is increased, has been carefully studied by Pflueger, who found the following results : The excitation, pass- 1 Reflexbewegungen beim Hunde. Pflueger's Archiv. IX. p. 358. * Ueber die Functionen des Lendenmarks des Hundes. Ibid. VIII. p. 460. 48 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. ing from a sensory fibre, is first transferred to motor fibres on the same side and the same level of the cord ; next it passes to the symmetrically situated fibres of the other side, but in a some- what weaker degree; then motor fibres in other sections of the cord are attacked, first those lying above toward the medulla oblongata, and afterwards those situated lower down; finally, general reflex contractions of the great part of the muscular system occur. The reflex actions are not always simple movements; more or less complicated movements occur, which may even have the appearance of adaptation to a certain end (movements of self- defence, of flight, and the like), in which cases there doubtless exists a simultaneous excitation of several motor paths, which are associated in the cord for certain purposes, or are united by habit. There are, however, actual series of motions, motions with a proper sequence, which serve a given purpose ; such are, for instance, the rhythmic twitching of the hind legs, described by Freusberg, the processes concerned in defecation, etc. These cases are sometimes instances of a stimulus to new motion, originating in the first reflex action; or they are cases of the stimulation of entire centres, which govern various physiological acts at once. Reflex actions may be originated by stimulus applied to any sensitive part of the body. Cutaneous reflex actions are the best known, originating in stimulation of the skin ; the most sensitive regions in this respect are the sole of the foot, the face, the front of the belly, the inner surface of the thigh. Irritation of the skin excites in different persons more or less generalized reflex actions, which are strictly obedient to Pflueger's laws of reflexion. The tendinous reflexions, lately described by Westphal1 and myself,2 are of great importance in pathology. The tendon of the quadriceps and the ligamentum patellae, the tendo-Achillis, and the triceps tendon in the upper arm, are the best points for demonstrating these reflex actions, as yet only observed in man. They are caused only by mechanical irritation (light tapping 1 Ueber einige Bswegungserscheinungen an gelahmten Gliedern. Arch, fur Psych. u. Nervenkrankh. V. p. 803. 1875. ! Ueb. Sehnenreflexe bei Gesunden und bei R .-M.-Kranken. Ibid. V. p. 792. PHYSIOLOGICAL INTRODUCTION. 49 with the finger or the percussion hammer), are very easily dis- tinguished from the cutaneous reflex actions, and are strictly confined to the muscles and groups of muscles belonging to these tendons. Similar reflex actions can be originated, at least in cases of pathological increase of excitability, from the peri- osteum of many bones, from fasciae and articular ligaments. Westphal's article, containing a great quantity of interesting and valuable mate- rial bearing on the phenomena in question, appealed after I had written the above. He gives the name of "lower leg phenomena" to that which I denominated the tendo-patellse reflex action, and the name of "foot phenomenon" to the reflex clo- nus which occurs when the foot is passively moved in dorsal flexion (to be described in the section on general symptomatology under "Increase in Reflex Activity"). The article shows that Westphal does not consider these as reflex acts, but believes that the muscular contractions are produced directly by mechanical stretching and shock of the muscular substance. The fact that this is most easily produced at the tendon depends on the facility with which the fibres of the muscle can be mechani- cally irritated all at once, by pulling the tendon. Westphal, therefore, considers the phenomenon as due to a direct irritation of muscle, and compares it in patho- logical cases with abnormal states of muscular tension and contraction. We ought, I think, to have very convincing grounds for abandoning the theory which lies next at hand, with its numerous physiological analogies, especially when the positive reasons for the alternative theory are so very few. I can by no means admit the existence of such reasons, as opposed to the reflex theory of these pheno- mena. Moreover, a great number of positive facts, which I have since collected, and which can easily be proved, even upon many well persons, are so decidedly in favor of the reflex theory, and against the theory of direct muscular irritation, that all my doubts are completely put to rest. I will mention only a few of these briefly. In many patients, the quadriceps reflex action can be produced by moderate tap- ping on a large part of the free surface of the tibia. Tapping on tendons in places where firm substance underlies them (e. g., tendon of the tibialis posticus under the malleolus) produces the reflex action. In both these cases, all mechanical action upon the muscle is avoided. We can produce the effect upon the biceps femoris (in patients) by taking up the tendon in our fingers, in an entirely relaxed condition, and pinching it a little while; this succeeds, even if the tendon just above the pinched part is held firmly with the other hand. The reflex action of the supinator longus can be produced from the lower end of the radius. I saw in one case a reflex contraction produced in the deltoid when the capitulum ulnae was lightly tapped, and one in the triceps biachii when a spot near the c. ulnae was tapped. In all these cases the experiments were carefully repeated, to show that the reflex action did not originate in the skin, and that no mechanical shock, transferred to the dis- tant muscle, could have been the cause. In hemiplegic patients, when the patellar tendon of one side is tapped, we often see twitching of the adductors of the other VOL. XIII.—4 50 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. side. In a case of compression of the lumbar cord the tendo-patelloo reflex action was absent; when the motility returned, the reflex action also appeared—a proof that the integrity of the conduction to the central organ is requisite. In tabes we often find the tendo-patelloe reflex action wholly absent, while the mechanical excitability of the quadriceps is retained or even exaggerated. But the question has since been attacked experimentally, and, as it seems to me, has been decided beyond a doubt. F. Schultze and P. Fuerbringer ! have made a series of experiments, all favorable to the reflex theory. It appeared, first, that in rabbits and dogs the phenomenon of the tendo-patellae is a quite constant occur- rence, and has remained unknown to physiology only because it has never been looked into; the reflex act can be produced with especial ease and distinctness from the exposed tendon. The experiments were associated in some instances with section of the spinal cord, in others not; they were modified in the greatest variety of ways by section of the nerves and muscles, poisoning with curare, etc., and their uniform testimony was to the effect that the muscular phenomena in question cannot be due to a direct action through the tendon, but depend on a reflex operation, the mechanism for which, in the case of the lower extremity, is situated in the lower segments of the spinal cord; and lastly, that a reflex act originating in the skin can- not possibly be the cause. The last statement leads by anticipation to the observation of Joffroy2 that these phenomena, at least in pathological cases, are essentially due to irritation of the skin, while the irritation of the tendon plays only a subordinate part. Joffroy brings many instances in which irritation of the skin produced the phenomenon of reflex clonus of the muscles of the calf, to be described below. I have repeatedly saen this. I have, however, convinced myself that this also is due simply to a sec- ondary irritation of the tendon. In such cases, every cutaneous irritation of the foot produces a reflex dorsal flexion of the member, and this suffices to originate a reflex clonus, exactly as passive dorsal flexion would produce it. Whether or not there are cases in which the spasmodic tremor can be originated directly from the skin, I must for the present leave undecided. It remains to be said, that O. Barger is decidedly in favor of the reflex theory, upon the ground of such facts as I have mentioned.3 We may therefore with propriety introduce the name of "tendinous reflexion" for this phenomenon. Our view is decidedly supported by C. Sachs' very recent demonstration of nerves in the tendons, which can hardly have any other than a sensitive function.4 It is also known, and has lately been confirmed by Freus- berg's data, that numerous reflex actions may originate from the 1 Centralbl. f. d. med. Wiss. 1875. No. LIV. 2 De la trepidation epileptoide du membre infer., etc. Gaz. med. de Paris. 1875 No. 33 et 35. 3 Schles. Gesellsch. f. vat. Cult. Medic. Sect. Sitzg. v. 23. Juli, 1875. 4 Die Nerven der Sehnen. Reichert und Du Bois1 Archiv. 1875. p. 402. PHYSIOLOGICAL INTRODUCTION. 51 viscera, as the bladder, rectum, anus, the intestines (dependent on their degree of fulness), etc. Freusberg has, finally, tried to show the probability that reflex actions may also be originated from sensitive nerves in muscles, by twitching and stretching them. All these matters find their parallel in human pathology. We have hitherto spoken almost exclusively of reflex actions which affect the voluntary striped muscle. But it is easy to show that reflex actions may extend to. all the centrifugal phe- nomena, and that such actions play a most prominent part in the occurrence of many phenomena of movement; we would call to mind the reflex processes which are so essential to the discharge of fasces and urine, to the movements of the stomach and intes- tine, to erection and ejaculation, to the movements of the uterus ; the reflex production of the secretion ; and lastly, the important reflex processes which occur in the blood-vessels, and are carried out through the vaso-motor paths. Inhibition of Reflex Action. The experiments upon reflex action have also shown that the irritation of certain parts may give rise to an inhibition or sup- pression of spinal reflex acts. And it appears that this effect may be produced as follows : First, a powerful arresting influence proceeds from the brain (Setchenow). Daily experience shows that we can suppress many reflex acts by the aid of the will; but this relates only to such acts as stand under the general control of the will, and can be performed by a voluntary effort. Experiments show that separation of the brain from the cord considerably increases the spinal reflex actions ; such a separation is in fact always made when the reflex processes have to be studied. It is further shown that irritation of certain parts of the brain (in frogs, the so-called optic lobes) lessens the spinal reflex acts, and retards them, or entirely puts an end to them. The paths of conduction for these inhibitory influences from the brain are thought to lie in the white anterior columns. Inhibition of reflex acts can also be produced from the peri- phery. Numerous physiological experiments within the last few 52 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. years have shown that the spinal reflexions can be arrested and completely suppressed by irritation of sensitive nerves (Lewis- son, Setchenow, Nothnagel, Goltz, Freusberg). A great variety of sensitive paths may be used by this function ; the inhibition takes place with most certainty from the skin, whether by power- ful irritation of a limited spot, or by slight irritation of large surfaces; it may also be originated by irritation of the sensory nerve-trunks, of the sensitive muscular nerves, or of the viscera {e. g., by distention of the intestines and stomach). The paths used in the production of these processes of inhibition lie, with- out doubt, in the posterior roots. We have, however, nothing but conjecture to aid us in form- ing an idea as to how these acts of inhibition come to pass in the cord itself. We know that the reflex acts are arrested when the sensory cells of the reflex arc receive impressions simultaneously from other sensory districts—central or peripheral. '' The sus- ceptibility of certain centres to impressions which give rise to the reflex act is lessened, when these centres receive impressions from other nerves at the same time" (Goltz). It is quite obvious that this statement is not an adequate explanation. Perhaps there exists a special inhibitory apparatus in the cord. Centres and Paths for the Innervation of the Viscera. The innervation of the heart, apart from the centres situated within itself, is dependent on certain centres in the medulla oblongata. As regards the part taken by the cord in the ex- tremely complicated innervation of the heart, there still exists a difference of opinion. It is thought that the exciting centre for the movements of the heart is situated, partly or wholly, in the upper cervical region, and that the paths which lead from it run downward for some distance in the cord, after which they reach the sympathetic by various routes, thence passing to the heart. Irritation of the paths in the cervical cord is said to accelerate the activity of the heart. As regards those roots of the accessorius, which originate low down in the cervical cord, it is not yet clear how important they may be in the innervation of the heart. But the cord possesses PHYSIOLOGICAL INTRODUCTION. 53 a powerful influence on the movements of the heart, through the vaso-motor innervation ; it is well known that irritation or paral- ysis of the vaso-motor nerves exercises a great influence upon the rate and the force of the heart's action. The activity of the organs of respiration is also dependent on the respiratory centres in the medulla oblongata. Recent investigations by P. Rokitanskyx seem to show that there exist respiratory centres, analogous to the vaso-motor, in the upper part of the cord, whose function becomes more distinct after the cord is severed from the medulla oblongata. The paths which conduct the excitation from the centres of respiration to the muscles of respiration are said to be all con- tained in the lateral columns of the cervical cord and upper dor- sal cord. This view has lately been maintained by Schiff against the attacks of Brown- Sequard and others. The cord seems to have a great influence upon the movements of the digestive tract. All these movements (swallowing, peris- tole of the stomach and intestine) are reflex in their nature, and are probably produced by centres situated in the cord. On the other hand, the cord has also a reflex inhibitory power over these movements. Thus Goltz8 has demonstrated an inhibitory influ- ence exercised by the cord upon the movements of the oesophagus and the stomach, and states further, that destruction of the cord produces extensive and active peristaltic action of the bowel, and causes diarrhoea. It is much to be wished that we possessed more accurate investigations into these relationships, and into the seat of the centres and paths. The evacuation of the rectum is produced by a more compli- cated mechanism, as follows : The contents of the intestine enter the rectum, producing a reflex peristaltic action of the latter; the centre for this reflex act is situated in the lumbar cord. The pressure of the contents against the place of exit probably at first excites the tonicity of the sphincters by reflex action, and interferes with evacuation. At the same time the sensitive nerves give notice to the consciousness of the approach of an evacuation, 1 Untersuch. iib. d. Athemnervencentra. Wien. med. Jahrb. 1874. I. S. 30. 2 Pfl tiger's Archiv. VI. 1872. 54 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. and the influence of the will can be invoked to strengthen the contraction of the sphincter and prevent the occurrence of dis- charge for a while. If the reflex contraction becomes stronger, or if the sphincter is voluntarily relaxed, the discharge takes place. It is aided by the action of the abdominal compression (straining), which is either voluntary, or, in case of severe irri- tation of the mucous membrane of the rectum (tenesmus), is directly reflex. The passage of the masses of fseces through the anus provokes those rhythmic reflex contractions which Goltz * has described, the reflex centres for which must also be sought in the lumbar cord. These contractions close up the rectum. The centres for all these processes lie in the lumbar cord; the paths from the centres to the rectum lie in the sacral nerves and the sympathetic plexuses. And as the sensory and motor paths which ascend from the rectum through the cord to the brain (the position of which in the transverse section is not yet exactly known), are also concerned in the process of faecal evacuation, it is easy to see how many points there are whence pathological disturbances in the process of evacuation may originate. Quite analogous conditions are found in the evacuation of urine, the disturbances of which are so extremely common in diseases of the cord. According to Goltz' new and admirable investigations,3 the normal process is as follows : the increasing fullness of the bladder produces an increasing irritation of the walls ; by this sensory irritation a reflex contraction of the detru- sor is occasioned through the agency of a centre located in the lumbar medulla ; at the same time the impulse to urinate reaches the consciousness, when the evacuation may be prevented by voluntary contraction of the sphincter vesicse, or of the urethral muscles which act as sphincters, until the vesical muscles become fatigued and the impulse to urinate diminishes. The tonus of the sphincter may also, perhaps, be increased reflexly by the entrance of the first drops of urine into the urethra. After some time fresh and more powerful contractions of the detrusor occur, until at last the sphincter is overpowered, or is voluntarily 1 Pfliiger's Archiv. VIII. 1873. 2 Ueber die Functionen des Lendenmarks des Hundes. Ibid. VIII. p. 474. PHYSIOLOGICAL INTRODUCTION. 55 relaxed, when the evacuation takes place ; it can be hastened by the action of abdominal straining, either voluntary, or, if the impulse to urinate is very strong, of a reflex sort; and is con- cluded by a few rhythmic contractions of the urethral muscles. The act of evacuating the bladder is, therefore, purely reflex in its nature ; the centre for its accomplishment lies in the lum- bar medulla. After section of the dorsal medulla the evacuation takes place in a perfectly regular way, whenever the bladder has reached its normal point of fullness, or the wall of the bladder is irritated in some other way. The complete paralysis and cessation of evacuation which appears to occur during the first days after the operation, depends on the concussion (Erschiitterung) of the lumbar medulla and paralysis of its centres which the operation brings about. These centres usually recover in a short time, and resume their functions. The evacuation is excited by sensory irritations, the most active of which is irritation of the wall of the bladder itself by distention and pressure from its contents ; but irritation of the anal region may also provoke the discharge. The sensory and motor nerves of the bladder, which form the paths for this reflex process, leave the lumbar medulla along with the roots of the sacral nerves (probably the third, fourth, and fifth), and pass with them, either directly or through the sympathetic plexuses, to the mucous membrane and the muscles of the bladder and the urethra. There are, however, other motor and sensory paths, which lead upwards in the spinal cord from the bladder to the brain. Budge has succeeded in producing contractions of the bladder by stimu- lating the cord as high up as the pedunculi cerebri; the paths are supposed to lie in the anterior columns of the cord. It requires no proof to show that the routes for the voluntary exci- tation of the sphincter and the urethral muscles also run through the cord to the brain. In spite of this, the will seems to exercise no direct influence upon the contraction of the detrusor. The voluntary discharge which we can produce without the presence of the impulse to urinate, is probably brought about by relaxing the sphincter, and bringing a powerful abdominal pressure to bear upon the walls of the bladder, which gives rise to a reflex contraction of 56 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. the detrusor (Goltz). But that by an involuntary reflex action originating in the brain the reflex mechanism of the lumbar medulla may be brought into activity, and an evacuation pro- duced, is shown by the cases in which psychical impressions are followed by sudden discharge of urine ; also by the fact that certain ideas are capable of calling out the desire to urinate, or of increasing it considerably. The paths in the spinal cord which serve for the propagation of this class of impressions may be excited by irritating the cord itself, and contractions of the bladder produced. It is a matter of daily observation, and hardly needs to be mentioned, that inhibitory processes exist in the case of the mechanism of urination, as of all other reflex actions. The correctness of the above statements can easily be shown by careful observation of one's own person, and is fully con- firmed by pathological facts. We should, however, be careful to observe that disturbances in the function may originate, not only in the centre in the lumbar cord, but also in the sensory and motor paths which unite the bladder with this centre on the one hand, and with the brain on the other. The relations may certainly be very complicated. Very similar conditions are met with in the processes of erec- tion and ejaculation, which also depend mostly upon the spinal cord, and which have received fresh light from the observations of Goltz (1. a). The erection of the penis is brought about, according to Eckhard's investigations,1 by direct irritation of the so-called nervi erigentes, which originate in the sacral plexus and are dis- tributed in the corpora cavernosa. The process is now universally regarded as an act of inhibition, exercised by the nervi erigentes upon the ganglionic apparatus of the vessels of the penis (Loven); this causes a relaxation of the vascular tone, and a powerful influx of blood into the corpora cavernosa, which produces the erection. This irritation of the nervi erigentes occurs in the reflex way also ; the centre for this reflex act lies in the lumbar cord (Goltz), 1 Beitr. z. Anatomie und Physiologic Giessen. Bd. III. IV. und VII. PHYSIOLOGICAL INTRODUCTION. 57 for it is very easy to produce reflex erections in dogs after section of the dorsal medulla. This reflex act is produced with most certainty by irritation (slight friction) of the skin of the penis and glans, or of the skin of the lower abdomen and perineum; by irritating the bladder or rectum, by introducing the catheter, and probably also by irritation of the testes, by over-fullness of the seminal vesicles, etc. The reflex act can be arrested or suppressed, either by power- ful peripheral irritations or by cerebral influence. Complete destruction of the lumbar cord renders it impossible. The brain also possesses a certain influence upon the occur- rence of erections ; but this is not a direct influence of the will, for erections cannot be thus produced. But erections can be produced by loose thoughts, by stimulation of the fancy, by looking at things which excite sexual appetite. This appetite is known to be located in the brain ; from the cerebral centre, the mechanical reflex centre in the lumbar cord may receive the excit- ing impulse. The paths which convey this excitation from the brain to the lumbar cord must lie in the spinal cord. In fact, Eckhard has succeeded in producing erections by irritation of the spinal cord, as high as the pons and pedunculi. The same is the case in many diseases of the spinal cord. The portion of the transverse section of the cord which contains these paths is not yet known. Quite the same processes are passed through in ejaculation; for this also is a simple reflex act having its centre in the lumbar cord. It seems, however, to require for its production a some- what longer and more powerful irritation. The nerve-paths probably lie chiefly in the sacral plexus. The spinal cord has also an influence upon the uterine con- tractions. The motor nerves of the uterus lie in the spinal cord, and may be followed, by irritating them, up into the medulla oblongata (W. Schlesinger *). Uterine movements may also be provoked reflexly from the sciatic nerve. The centre for these movements does not lie exclusively in the medulla oblongata, as was formerly thought, but such centres may be demonstrated in 1 Ueb. d. Centra der Gefiiss- u. Uterusnerven. Wien. med. Jahrb. 1874. I. p. 1. 58 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. the whole length of the cord (Schlesinger). The chief centre for the production of labor-pains lies in the lumbar cord, according to Goltz.1 After division of the dorsal medulla the reflex acts proper to copulation, and those of labor and birth take place in a normal manner. The processes of ovulation, of development of the pregnant uterus and the lacteal glands, the development of the impulses which are associated with reproduction, suffer no visible impairment from this operation. Nasse has observed in the human subject, after crushing of the cervical medulla, a normal performance of the act of partu- rition. The innervation of the iris is also in part dependent on the spinal cord. The motor-paths for the dilatator pupillse lie in the cervical and upper dorsal cord. Irritation of this region produces dilatation of the pupil; it has therefore received from Budge the name of centrum cilio-spinale. According to Salkow- ski (Dissert. Konigsb. 1867), this centre lies much higher up, namely, in the medulla oblongata. The motor-fibres which pass from it run downwards in the cord without decussating, pass out with the anterior roots of the lower cervical and upper dorsal nerves, go thence into the cervical sympathetic, and then to the eye. Section of these fibres causes contraction of the pupil. The same route is taken by the vaso-motor paths for the head and external ear. The influence of the cord upon the various processes of secre- tion in the body has been very little studied. It is probable that there exists such an influence upon the secretion of sweat and saliva, and doubtless also upon the production of semen and ovulation, the secretion of the digestive fluids, etc. But at pres- ent we are not in possession of exact knowledge in respect to these points. The only positive facts of this sort that we possess are those furnished by Eckharda in regard to the secretion of urine, who says that section of the cervical cord produces a complete and » Pfliiger's Archiv. Bd. IX. p. 552. 2 Untersuchungen iiber Hydrurie. Beitr. zur Anatomie und Physiologic Bd. V. p. 147. 1870. PHYSIOLOGICAL INTRODUCTION. 59 permanent arrest of this secretion. Eckhard infers from his experiments the existence of a centre for exciting the secretion • of urine, situated at the level of the rhomboid fossa ; the excitor paths which pass downwards from this centre leave the cord by the upper dorsal nerves ; there are also inhibitory paths for the secretion of the urine, located in the splanchnic nerve. The qualitative changes in the urine, which are so common in affec- tions of the spinal cord, are probably due in great part to stag- nation of the urine in the paralyzed bladder, and to the decom- posing influences of secondary disease of the bladder. The theory of muscular tonicity needs only a very short mention. It has called forth a great deal of investigation, but can hardly be applied in pathology. We understand by the term muscular tonus, a constant mild innervation of the striped muscles by a stimulant influence proceeding from the spinal cord. Later investigations have shown that this is probably in substance nothing more than a weak reflex excitement, which originates in sensory stimulation of the skin, muscles, joints, and other parts, and is chiefly produced by the action of chang- ing the position of the members of the body. In connection with this point stands the much discussed question of the influence of the posterior roots on the excitabil- ity of the anterior. While some physiologists (Harless, Cyon, Steinmann, etc.) state with perfect confidence that the excitabil- ity of the anterior roots is depressed after section of the pos- terior, other observers (v. Bezold, Uspensky, G. Heidenhain, and others) have denied the statement with equal confidence. But even if the fact were proved, it does not possess the great importance claimed for it in pathology. A tonus of the vascular muscles seems proved. The vaso- motor nerves are its conducting paths ; they are kept in con- stant slight excitement by the centres demonstrated in the medulla oblongata and the spinal cord, and, after these are removed, by peripheral ganglionic apparatuses, which also have the power of keeping up the tone of the vessels. The tone of the sphincters of the bladder and rectum is cer- tainly of a reflex character, and principally depends on the lumbar cord. GO ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. The application of physiological data to pathology is cer- tainly of the greatest importance; it is the source of the only light that has been cast on a great number of pathological pro- cesses and their connection. It must be admitted, however, that physiology is far from explaining everything, and that many points can only be made clear by pathological observations and experiments. Physiological experiments very often produce a pathological state (section, compression, irritation, etc.); similar states are occasionally produced in man by a great variety of agencies, including disease; and these are the cases in which a direct appli- cation of physiological laws to pathology will prove most fruit- ful of results. But the states produced in physiological experiments are far from being so various and general, and are seldom so exactly localized, as are pathological conditions. From the nature of the case they must be very limited in extent; the usual lesions consist of severance of continuity, very small, and with hardly any extension in the direction of the long axis of the cord. Simple sections have hitherto formed almost our entire founda- tion for the experimental pathology of the cord ; and it is time that the method of Nothnagel and Fournie, applied with such success to the brain, were extended to the spinal cord. A brief consideration shows that the experiments of physi- ology and pathology can imitate neither those anomalies which are widely distributed along the length of the cord, yet localized in particular spots ; nor the slowly progressive conditions of irri- tation and paralysis; nor the moderate and gradually increasing and varying degrees of pressure; nor the various finer disturb- ances of nutrition in fibres and cells. In particular, it must be noted that possibly, even probably, the properties of irritability inherent in the cord may be essen- tially changed by pathological processes, so that, for instance, the kinesodic substance becomes motor, the sesthesodic sensitive. Thus conclusions, drawn from the healthy cord, cannot be trans- ferred to the same organ in a morbid state, without certain reserves. These reasons may justify the objections which have been PHYSIOLOGICAL INTRODUCTION. 61 made to a direct transference of physiological principles (in many respects poorly founded) to the pathology of the cord. Nevertheless, we think it not unsuitable to collect in this place some of the principles deduced from physiological and patho- logical experience, so far as they seem applicable to practical needs, as a sort of clew to the interpretation and recognition of complicated pathological processes.1 1. Section or limited affection of the posterior columns de- stroys the sense of touch in parts situated behind the point of injury, but leaves the sense of pain. 2. Disturbance of the conductive power of the gray substance for a limited longitudinal extent suspends the sense of pain, but leaves that of touch (analgesia). 3. Disease or destruction of the entering posterior root-fibres (or of the network of fibres directly formed by them) must impair the sense of touch equally with that of pain and the other classes of sensation. 4. Injury or disease of the posterior columns at the level of the lumbar cord leads to a diminution of the sense of touch at the anus, perineum, etc., while the sensibility and motility of the lower extremities remain unimpaired; the same lesions in the lateral columns of the lumbar cord have the same effect upon the lower extremities as those of the posterior columns in the dorsal and cervical medulla. 5. When the gray substance is partially destroyed in the transverse direction, and the posterior columns are also affected, the conduction of sensory impressions is retarded, in a degree proportional to the smallness of the transverse piece of gray mat- ter that remains. But if the conductive power of the posterior columns is retained, this retardation appears to extend only to the sensation of pain, while the conduction of the sensation of touch takes places with normal rapidity. 6. Destruction of the entire extent of the posterior columns (inclusive of the sensitive root-fibres passing through them) must be followed by anaesthesia of a corresponding extent. 'Compare the " Corollarien fur die Pathologie," given by Schiff (Physiologie, p. 292), and Broicn-Sequard's statements in his Course of Lectures on the Physiology and Pathology of the Central Nervous System. 1860. 62 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 7. Limited destruction of the entire transverse extent of the posterior columns and of the gray substance is followed by com- plete anaesthesia of the portions of the body lying posteriorly, and weakness of motion or partial paralysis. 8. An irritation affecting a limited longitudinal extent of the posterior columns (inflammation, hyperaemia, etc.), produces a spontaneous pain in only those roots which traverse the diseased spot (girdle-pain); subjective sensations of touch (formication, prickling, numbness, sensation of heat and cold) and some de- gree of hyperaesthesia occur in the parts situated posteriorly. 9. A lesion producing paralysis, affecting the posterior columns in the same way, gives rise to a girdle of complete insensibility, corresponding to the district supplied by the para- lyzed nerve-roots ; below this girdle the so-called sensations of touch are absent, or greatly impaired ; the sensation of pain is retained, but is badly localized. 10. If an affection which at first irritates, and afterwards paralyzes, progresses upwards, the painful girdle travels up- wards, and leaves behind it a girdle of anaesthesia which gradu- ally increases in width; in the parts situated behind this the sense of touch is gone, but subjective impressions of touch (for- mication, numbness, etc.) may be present. 11. When the power of movement is unimpaired, and a girdle •of pain without aberration of the sense of touch is present, then only the nerve-roots, within or without the cord, are affected. 12. In diseases of the posterior columns and the gray sub- stance, the parts behind the diseased portion may experience only changes in the sense of touch, without any excentric pains. (?) If the latter occur, they point to an implication of those nerve- roots which are situated further back. 13. Disorganization of an anterior and a lateral column and of the greatest part of the gray substance produces paralysis of the same side. 14. Destruction of the anterior (and lateral) columns in their entire transverse section (inclusive of the motor nerve-roots pass- ing through them) is followed by a paralysis of corresponding extent. 15. Limited destruction of the entire transverse section of the PHYSIOLOGICAL INTRODUCTION. 63 anterior (and lateral) columns and of the gray substance is fol- lowed by complete paralysis, also analgesia, but retention of the sense of touch. 16. Disease of the antero-lateral columns and the kinesodic substance alone produces paralysis without lesion of sensibility. 17. Disease of the motor ganglia, into which the motor roots first enter, produces paralysis in the region of the related nerves, without disturbance of sensibility, but with trophic disturbances. 18. Affections of the antero-lateral columns and the corre- sponding gray substance produce contracture or convulsions only in the muscles immediately dependent on the diseased spot and its motor roots ; but contractures of muscles supplied by the roots given off behind the affected spot are not produced (?). 19. Slight pressure on the cord may bring on paralysis of the extensors and secondary contractures in flexion, but this is never severe. 20. Contractures and convulsions of the lower extremities also occur in affections of the segments of the cord above the lumbar region ; they are then a consequence of an implication of the posterior columns, and arise reflexly. In the same way, in diseases of the posterior columns, spasmodic symptoms occur in the parts situated nearer the head. 21. Disorganization of the entire gray substance to a consider- able distance must be followed by anaesthesia and paralysis in the posterior part of the body; if the lesion is limited to one place, the sensory and motor paralysis may be partial. 22. If the movements of respiration are entirely intact in an affection of the cervical cord which paralyzes the extremities and trunk, then the lateral columns are not involved. 23. Conditions of irritation in the cervical medulla will pro- duce dilatation of the pupil; paralytic conditions, contraction. 24. Unilateral lesion of the cord is followed by almost total paralysis and increased sensory excitability on the injured side, with very slight disturbances of motion and loss of sensibility on the opposite side. 25. Complete compression or division of the spinal cord ex- aggerates the reflex acts in the region lying posteriorly to the lesion. 64 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 26. In limited destruction of the dorsal medulla, the reflex acts which are performed through the lumbar cord (evacuation of urine and faeces, vascular tonus, etc.) go on with very little alteration ; only they can no longer be modified by the will. 27. The nutrition of peripheral parts (muscles, nerves, bones, joints, skin, etc.) remains intact in the various diseases of the spinal cord, in proportion as the gray substance remains normal. The doctrine of the functional reparation (Ausgleichung) of partial lesions of the cord, stated by Schiff, is of great import- ance in pathology; the fact, namely, that while these lesions are not anatomically made good, an apparently complete restoration of function follows. Schiffx affirms that in injury of almost any part of the cord, the consequent functional disturbances may be compensated for by an intact portion of the cord assuming the function of the injured portion; the lesion of the posterior columns alone leads to a permanent loss of the sense of touch, which cannot be repaired. The chief element in this functional restoration is of course a vicarious assumption of the processes of conduction by intact portions of the cord. This fact is not of itself strange, for we can observe in the fine network of nerves what seems to be the anatomical provision for such exigencies. It is not yet settled how far such a vicarious substitution may go in human pathology; but it is clear how wide must be its significance in relation to the prognosis and cure of partial lesions of the cord. It will be proper to introduce here a few remarks on the ana- tomical restoration of partial lesions of the cord. Daily expe- rience shows that this happens very often, and may be quite considerable in amount; it is not rare for apparently very severe injuries of the cord to recover. But the exact histological pro- cesses are not known; it is not yet well ascertained how a chronic inflammation, or the various degenerative processes, scleroses 1 Centralbl. f. d. med. Wiss. 1872. No 49. PHYSIOLOGICAL INTRODUCTION. 65 softening, hemorrhage, etc., are repaired, nor to what extent this takes place. Experimentally, this question has been very little examined, although the physiologists have had material enough. A few positive facts were ascertained by Flourens, Brown-Sequard, H. Mueller; but in recent years Masius and Vanlair : have been the first to institute thorough experiments upon frogs, showing after a lapse of at least six months a great progress in restoration of excised segments of the spinal cord. Motility and sensibility were restored, and nerve-cells and fibres were found in the cica- trix. In the higher order of animals, especially the mammalia, the restoration seems to be less easy and perfect. The same result appears from the latest experiments of Eichhorst and Naunyn 2 upon very young dogs. After section or crushing of the lower dorsal cord, the first occurrence is a complete degene- ration and fluidification of the parts directly attacked ; after- wards an intermediate substance, composed of a tissue like neuroglia, rich in cells, is developed, which incloses a central cavity. Subsequently the double-contoured nerve-fibres are re- generated, and a limited number are seen to traverse the inter- mediate substance. Regeneration of the ganglion cells was never observed. Corresponding with these conditions, a partial res- toration of function appears after many weeks (eight or ten, at least); voluntary, but incomplete and "atactic," movements are the first to appear, and sensibility returns later. But the ani- mals die subsequently, probably in consequence of a secondary hydromyelus. On the other hand, Goltz and Freusberg have never seen a regeneration and restoration of function in their numerous ex- periments upon dogs, although some were kept living for an extremely long time. For this reason Freusberg cannot avoid expressing a suspicion of the correctness of the results, as. re- gards restoration of function, obtained by Naunyn and Eich- horst.3 1 Centralbl. f. d. med. Wiss. 1869. No. 39; and Arch, de Physiol, norm, et path. IV. p. 268. 'L Arch. f. experim. Pathol, und Pharmacol. Bd. II. p. 225. 1874. s Pflueger'a Arch. Bd. IX. p. 390. VOL. XIII.—5 66 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. It certainly follows from these experiments that in the higher animals, and probably in man also, the regeneration of the spi- nal cord, when once completely destroyed, will always remain very imperfect, even if it takes place to any extent. III. General Pathology of the Spinal Cord. In this section we design to give a short account of the facts and observations, but only as far as they seem to possess a pres- ent interest and importance in relation to practice. We shall lay the chief weight upon general symptomatology and thera- peutics, and shall take leave to pass over the general patholo- gical anatomy, which at present is not in a condition to be made useful to the practitioner. General etiology and diagnosis will be but briefly touched, in view of their present condition. A. General Symptoms of Diseases of the Spinal Cord. This involves a systematic enumeration of the several dis- turbances which occur in diseases of the cord, partly in order to explain their significance and names, partly to reduce them to their immediate causes and develop their pathology, partly to point out somewhat in anticipation the more usual groupings of symptoms. We shall thus be enabled to save many repeti- tions and details in the special part. 1. Disturbances of Sensibility. These are very frequent, and their form and grouping is often very characteristic. They are very important in diagnosticating and estimating diseased processes in the cord ; for these reasons they must be stated with great fulness. In examining sensory disturbances, the several qualities of sensation must be strictly distinguished. Let the sensations of touch, temperature, and tickling, of pressure, of space, and of pain be tested. As regards the best methods of doing GENERAL SYMPTOMATOLOGY. 67 this, compare Vol. XI. of this Cyclopaedia, p. 212 [American ed.]. The qualities of perception which are classed together under the name of muscular sensation, or sense, should also be tested. Besides the methods given in the same volume, p. 234, there is a good method given by Leyden' for the exact testing of the sensation of passive motions. No extensive apparatus is required for this; the same exact results are obtained when the leg is suspended in a broad cloth, and by means of the cloth is made to move in various directions, upwards, downwards, outwards, or inwards—its position being either extended (for testing the hip-joint) or semi-flexed (for the knee-joint). The patient is required to state the extent and direction of the movements. In testing the passive movements of the ankle-joint, the front part of the foot is grasped carefully with the hand, and is moved passively. This method is quite sufficient, as the cutaneous sensibility of the patient is usually impaired. a. Diminution of Sensory Action—Anaesthesia. All the sensations which originate in the skin, the muscles, and other more deeply-seated parts may be diminished in dis- eases of the spinal cord; and the diminution may increase, even to the extent of total loss of sensation. They may be extin- guished all at once, or some may be lost and the rest retained. The disturbance of sensibility usually appears first in the lower extremities, ascending by degrees until it reaches the upper extremities. But often the latter are the first attacked, and the anaesthesia extends downwards. Anaesthesia is very commonly attended by various subjective sensations, as the furry sensation (Pelzigsein) or numbness, un- certainty in feeling the ground, sensation of walking on cotton wadding, or on a bladder full of water, etc. In general, the occurrence of anaesthesia permits us to infer an implication of the posterior half of the cord. A widely diffused, total paralysis of sensation (total = af- fecting all the qualities) occurs only when the entire transverse section of the posterior columns and the gray substance is de- stroyed ; that is, chiefly in affections which are diffused over the entire section, extending to a variable distance in the longitudi- nal direction. It also accompanies a complete severance, crush- ing, or compression of the cord at any point; in which case the 1 Ueber Muskelsinn und Ataxic Virch. Arch. Bd. 47. 1869. 6S ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. anaesthesia occupies all portions of the body which derive their nerve-supply from behind the point of lesion. Total paralysis of sensation, of a more limited extent, may occur in various ways, viz.: As unilateral anaesthesia, localized in one leg, or a leg and the corresponding half of the trunk, or finally, in these parts and the corresponding arm. This occurs in traumatic or spontaneous unilateral lesion of the cord, and the loss of sensation takes place on the side of the body opposite to the spinal lesion, owing to the decussation of the sensory paths in the cord. The muscular sense, however, usually remains unimpaired, because the fibres for it cross at a higher point. As anaesthesia in the form of a girdle—a zone of varying width, deprived of sensation, which surrounds at various levels the pelvis, the abdomen, the thorax, or even the region of the shoulder or neck on one or both sides. It is due to a local dis- ease of the posterior roots within or without the medulla, which extends over but a limited length of the cord ; or to a circum- scribed affection of the gray posterior cornua, embracing the net- work of nerve-fibre which is formed by the entering root-fibres, and the paths which traverse the gray substance before re-enter- ing the posterior columns. Finally, as circumscript anaesthesia, limited to certain ex- tremities or parts of extremities, or to the district supplied by certain nerve-trunks. The most frequent cause of this lies prob- ably in affections of single bundles of roots ; it may be produced by local affections, limited to portions of the transverse section of the spinal cord, and affecting only certain of the longitudinal fibres, but this lesion would be more likely to produce a partial paralysis of sensation. It is probable that the sensitive paths for the upper and lower extremities, the anterior and posterior surfaces of the body, etc., have a distinct arrangement in the spinal cord; and it may easily be imagined how many forms may be taken by such circumscript anaesthesia, according to the horizontal or vertical distribution of the morbid change. Partial paralyses of sensation, however (limited to certain of the qualities of sensation), also occur, and nowhere more fre- quently than in diseases of the cord ; the history of tabes dorsa- GENERAL SYMPTOMATOLOGY. C9 lis gives the most numerous examples of this. They occur in all possible combinations, as indicated in Vol. XL, p. 201. The form most likely to attract notice, and perhaps the most fre- quent, is analgesia; but, as remarked, the greatest variety of cases of partial anaesthesia occur. Each sort of sensation may alone be lost or weakened ; and, on the other hand, several may suffer the same change, while only a single one exists in partial or complete integrity. In view of these facts, we can hardly avoid the conclusion that the various sensations traverse distinct paths of conduction in the cord, and that, according to the local distribution of the morbid change in transverse section, sometimes one and some- times another path is specially affected. Nothing exact is known, however, in respect to this. It seems probable that the sense of pain is conducted by the gray substance only, and impressions of touch by the posterior columns only (Schiff). In opposition to this view Brown-Sequard asserts that all sensations are chiefly conveyed through the gray substance, and he even names distinct regions of the latter, which are supposed to contain the respec- tive groups of fibres. The result, therefore, will differ in each case, according to the manner in which the disease is distributed over the various parts of the transverse section of the cord. But little of practical value can be drawn from these scanty and uncertain facts. If disturbances of sensation are present, the physician will have to put to himself the questions—whether there is an affection of the posterior roots within or without the cord, or whether there is an impediment to conduction within the gray substance, or whether certain sensory paths have been injured at a higher point, after leaving the gray substance. The data which are given here and in the physiological introduction will show the points which aid us in making these distinctions ; but they will also show how few and unsatisfactory these points are. What is true of cutaneous sensation may be likewise affirmed of the so-called muscular sensation; both the muscular sense and that which is called the muscular sensibility1 may be reduced ' Compare Volume XI. p. 233. 70 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. or suspended in spinal diseases. The patients lose the sensation of pain in the muscles, produced by various external agencies ; they lose the sense of fatigue ; they are not certain of the posi- tion of their limbs in the dark, or when their eyes are closed ; they have lost the feeling of passive movement of the limbs, their ability to retain their equilibrium is diminished, etc. Regarding the position of the routes which transmit these im- pressions in the spinal cord, we know very little. According to Brown-Sequard, at least a part of them remain on the same side of the cord, and do not decussate till they reach the medulla ob- longata. The application to pathology is evident. A symptom which is not very rare under physiological con- ditions is the retardation of the conduction of sensory impres- sions. This remarkable fact was first mentioned by Cruveilhier' without accounts of special cases; since then, although often observed, it has never been closely studied until very lately, and even now the investigation is far from complete. This retardation is very noticeable and measurable. While in ordinary circumstances sensation follows directly upon the application of the stimulus, in cases like this it is separated from the latter by a noticeable interval of time, which is frequently a fractional part of a second, but not rarely amounts to one or several seconds ; cases have even been observed where the sensa- tion came from fifteen to twenty seconds later than the stimula- tion (Cruveilhier), thirty seconds (Topinard), and even several minutes. In such cases the phenomenon is of course very easily observed ; in less marked cases the existence and the degree of retardation can be determined by exact measurements, such as have been made by Leyden and Goltz.4 The more powerful the stimulus, the shorter the interval. It has been repeatedly observed, and very recently established with exactness, that this retardation relates only to a few of the qualities of sensation, chiefly to that of pain. E. Remak3 has published a case in which pricking with a needle provoked in every instance an immediate sensation of touch, which was fol- 1 Anatom. pathol. Livrais. XXXVIII. p. 9. 3 Leyden, Klinik der Riickenmarkskrankheiten. I. p. 146. 3 Arch, f. Psych, u. Nervenkr. Bd. IV. p. 763. 1S74. GENERAL SYMPTOMATOLOGY. 71 lowed in three seconds by the retarded perception of pain. In such cases every powerful impression gives rise to a double sen- sation, first, one of touch, perceived with normal quickness, and then a retarded sensation of pain. The case published by Nau- nyn in the same journal1 seems on some accounts to belong here; it included retardation of the sensation of pain, associated with hyperesthesia, while the sensation of touch remained normal. Vulpian2 observed a similar state in a case of tabes ending in apoplexy; the prick of a pin was rapidly followed by a slight reflex action, and two or three seconds later by a very full and continued movement of defence. I have under my observation at present a tabetic patient, in whom I have been able to demon- strate this double sensation, not only as regards needle-pricks and pinching, but also under the painful faradic current. E. Remak has treated very thoroughly of the question, whether this retardation of conduction is always limited to the sense of pain, and never affects that of touch. The observations hitherto made seem almost to show that such is the case; but the question needs further careful study, and it is hard to give a reason why the sense of touch should not in some cases be affected. The cases commonly tested are those of tabes dorsalis, in which the sense of touch is more or less weakened, while that of pain is retained ; if both are retained, the double sensation may occur. Topinard also states that the retardation affects chiefly the senses of pain and of temperature.3 It has been made known through the physiological researches of Schiff, that a transverse narrowing of the gray substance (whether the posterior columns are cut or no) produces a corres- ponding retardation of the conduction of sensation, which is marked in inverse proportion to the amount of gray matter re- maining.4 Schiff has even been enabled by his experience to 1 Archiv f. Psych, u. Nrevenkr. Bd. IV. p. 760. 2 Arch, de Physiol, norm, et path. I. p. 405. 3 Ilertzberg (Beitr. zur Kenntniss der Sensibilitatsstorungen bei Tabes. Diss. Jena. 187.")) has lately demonstrated, in some very carefully examined cases, that the most frequent occurrence is that of retardation of the sense of pain alone, but that the sen- sations of touch and temperature also are not rarely retarded, though to a less degree. 4 See Schiff's Physiologie. p. 245. 72 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. predict the existence of double sensation in man, which has lately been confirmed by the beautiful observation of E. Remak; he looks for the appearance of this symptom in eve^ case where the transverse dimensions of the gray substance have been di- minished by pathological processes, while the posterior columns have remained intact.1 It may be assumed, on the strength of these facts, that wher- ever retarded sensation exists, there is an alteration of the gray substance; and it would be entirely consistent with this assump- tion, if it should be found that the retardation always affects the sensation of pain only, and never that of touch. It would then, according to Schiff, depend on the condition of the posterior columns, whether the sensation of touch is absolutely wanting, or appears in reduced amount, but with the normal rapidity. The investigations of Burckhardt,2 who has tried to measure the sensory conduction of the cord in an isolated form, are of great interest. He found that the cord conducts impressions of pain decidedly more slowly than those of touch, and suspects for this reason that the gray substance in general conducts more slowly than the white. The retardation of tactile conduction under pathological circumstances is referred by him directly to a loss of white substance (degeneration of the posterior columns); the more the gray substance is called upon to perform the func- tion of conduction, the more slowly is the function performed. He thinks, also, that every narrowing of the gray substance—■ which is naturally a slow conductor—must still further retard the conduction ; the examination with the second-hand of a watch will not bring out the fact of retardation until such narrowing has taken place. As long as the gray substance is intact, the retardation can only be demonstrated by the aid of fine physio- logical apparatus for measurement. The retardation of the conduction of sensation is perhaps con- nected with another phenomenon, usually observed in the same patients—namely, the inability to count correctly several impres- sions of sensation which follow rapidly {e. g., pricks of a needle). 1 See Physiol, p. 294. Coroll. 3. c. 2 Physiolog. Diagnostik der Nervenkrankheiten. Leipzig. 1875. GENERAL SYMPTOMATOLOGY. 73 Persons in health are able to state without fail the number of pricks (from two to six), even when they come very close togeth- er, while patients cannot do this unless the individual impres- sions follow at considerable intervals. These intervals are sup- posed to bear a direct ratio to the degree of retardation of the conduction of sensation. This symptom would therefore seem to be also dependent on a change in the gray substance. Nor is it easy to see why the impressions are not perceived as separate, since each impression must have precisely the same obstacles to surmount. It is more probable that this phenomenon is connected with another disturbance, which commonly accompanies it—namely, remarkably persistent after-sensations, following impressions of pain. The patients, when their skin is pinched or pierced with a needle, give expression to a much longer and severer pain than is usually felt by well persons. Rapidly succeeding impressions of sensation run together into one, therefore, because the new sensation coincides with the after-sensation of the one before it. The change in the cord upon which this depends cannot at pres- ent be stated with certainty. We may suppose that there are coincident changes in the posterior columns and the gray sub- stance. b. Exaggeration of Sensory Action. This is one of the commonest symptoms in diseases of the cord, and may appear in various forms, viz.: 1. As simple hyperaesthesia; more or less increase of sensi- tiveness to all possible kinds of sensory impressions, which di- rectly increase to pain. This hyperaesthesia not seldom resembles anaesthesia in its manner of appearance and distribution—in fact, it often precedes anaesthesia ; thus, a hyperaesthesia in the form of a girdle may be observed above or below an anaesthetic zone, and may gradually move its position on the body, in company with the latter. Hyperesthesia may also be confined to single denominations of sensibility (pain, sense of temperature, espe- cially sense of cold), and may occur in connection with partial paralysis of sensation. 74 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. It is known from physiological experiments that section of the posterior columns is followed by a hyperaesthesia of the pos- terior half of the body, which at first increases rapidly and con- siderably, and afterwards very gradually diminishes and disap- pears ; x and that when only one posterior column is cut, the hyperaesthesia remains confined to the same side. The hyperaes- thesia increases, if the cut is carried into the lateral columns, and a part of the gray substance (Brown-Sequard) ; it is much less marked when the lateral or anterior columns are cut, and the posterior are left intact. It is hard to give a decided interpretation of these facts. Tuerck and Schiff think them due to a state of irritation of the cut parts and the adjoining regions, especially the posterior col- umns. But the finer mechanism of the process is still uncertain, and the conducting paths are unknown. May it not be that the narrowing of the sensory conductors, produced by the section, has something to do with this result, by increasing the excite- ment of such conductors as remain intact % At all events, Schiff's assumption of an irritative condition in the posterior columns is in satisfactory agreement with the fact that these hyperaesthesiae are by far the most common in such forms of disease as we have been accustomed to ascribe to de- generation of the posterior columns. Nevertheless, it is not unlikely that there are other processes capable of occasioning hyperaesthesia, e. g., implications of the nerve-roots in meningi- tis, etc. 2. As paresthesia. Nothing is commoner than to hear pa- tients with disease of the cord complain of abnormal sensations, which are best called subjective sensations of touch. Thus the feeling of furriness (Pelzigsein), numbness, crawling, tingling, etc. These sensations are referred by Schiff to a moderate excitation of the paths for the sensation of touch, lying in the posterior columns—an hypothesis which seems a little bold, in view of the fact that the posterior columns, with the exception of the root-fibres crossing them,, are stated to be inexcitable. The hypothesis would have to be supported by the further one, that 1 See Schiff, Physiol, p. 274. GENERAL SYMPTOMATOLOGY. 75 pathological processes are able so to change the excitability of the posterior columns that pathological stimuli will arouse sensa- tions. It is certainly possible that excitation of the posterior roots at their entrance may assist in producing such changes in the sensation of touch ; and that a part of these modifications may depend simply upon a dulling of the sensibility (as regards touch), produced by various diseases of the cord. Subjective sensations of temperature also occur, a feeling of burning or cold that may become very intense. These sensations are in part referred by Brown-Sequard to direct excitation of the fibres in the gray matter which conduct the sensations of tem- perature. Schiff, however, believes that changes in the amount of blood circulating in the skin, due to vaso-motor disturbances, may so act upon parts which are already hyperaesthetic as to produce a sensation of increase or diminution in the warmth of the skin. But this explanation can hardly suffice for all cases. This is the place to speak of the girdle-sensation, that pecu- liar modification of subjective perception which produces the impression of having a girdle or a broad bandage tied about the trunk or limbs. This feeling, when situated at the upper part of the thorax, may be accompanied with a severe sense of pressure, and is always very troublesome to the patient. Cruveilhier described it. It may occupy various levels on the trunk, but may also attack various parts of the lower extremities, particu- larly in the region of the ankle and knee of one or both sides. This sensation is probably produced by a slight excitation of the entering posterior roots in cases where the spinal affection is limited in its longitudinal extension. It usually accompanies inflammatory or other irritative conditions of the cord, and origi- nates with the root-fibres which occupy the upper limit of the disease. But any sort of local disease of the cord and its neigh- boring parts, which irritates the posterior roots to a moderate extent, may produce the symptom. 3. As pain. This is seldom quite absent in diseases of the cord ; it varies extremely in form and distribution. Among the most characteristic are the so-called lancinating or neuralgiform pains, which are almost pathognomonic of the 76 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. early stage of tabes dorsalis. These pains are usually very se- vere; they are either continuous, or appear periodically and under certain provocations (especially change of weather, rain, storm, snow-squalls), and are localized in a certain nerve or certain fibres of it, or certain regions of skin ; they rage for a time in one place, and then leap suddenly to another, seldom remaining long in one spot. They are described as tearing, shooting, or going through like lightning ; the patient feels as if a knife or a red-hot wire were thrust into his flesh, or as if cer- tain portions of his limbs were screwed up in a vice ; often the pains are localized in deep parts, as the bones, but they often invade the skin, where they are frequently connected with cir- cumscribed hyperaesthesia. They prefer the night, and are not rarely connected with circumscript vaso-motor disturbances, or even with reflex muscular jerkings. They may occur in any nerve-region whatever, though they are certainly most common in the lower limbs and the trunk, where they often simulate intercostal neuralgia very closely ; they may appear in the upper extremities, and even in the region of the trigeminus. The origin of these pains is almost universally referred to irri- tation of the posterior root-fibres; their extent and location de- pend on the extent to which the latter are implicated. The cases of which they form a symptom are almost exclusively those of degeneration and sclerosis of the posterior columns, and, according to Charcot, of the so-called external bands solely, which contain the inner root-fibres. It is, however, also possible that irritation of the longitudinal fibres of the posterior columns, or of the gray substance, may lead to such excentric1 pains, under pathological conditions ; though usually the gray sub- stance is only aesthesodic. The localization of these and similar pains in the dorsal nerves and a part of the lumbar nerves produces the girdle-pain. This is a neuralgic pain, which may take the form of a bilateral neu- ralgia of the intercostal or lumbo-abdominal nerves, at various levels on the trunk, but is often confined to one side. It oc- curs in cases of limited irritation of the dorsal cord, and still i. e., originating in a central organ. GENERAL SYMPTOMATOLOGY. i i oftener in diseases which directly irritate the sensitive roots, as especially in inflammation, caries, carcinoma of the vertebrae, etc.; it is a valuable sign of the presence of the latter, and often be- trays at a very early period the beginning and the location of a severe disease, which by degrees leads to compression of the cord. Generalized pains are not infrequently met with in the lower extremities, and in the portions of the trunk situated below the point of disease. These pains may differ greatly in degree, and are described by the patient as a more or less extensive sen- sation of pain, hard to describe, but exceedingly unpleasant, which is usually continuous, but from time to time undergoes exacerbations. In some the feet and lower half of the legs are the chief seat of these pains ; others complain more of the back, the loins, or the thigh ; very often the pains are excited or in- creased by spontaneous or reflex twitchings and spasms in the lower (paralyzed) extremities, or by efforts to walk. They occur in all sorts of diffuse, transverse myelitis, in compression of the cord followed by myelitis, in acute and chronic spinal meningitis, etc. The source of these pains is not yet fully clear. The original explanation referred them to a direct irritation of the root-fibres within or without the cord ; but it is probable that an irritation of the aesthesodic paths in the cord may have the same effect. Schiff, however, denies the possibility of this, believing that, in such cases, the disease always extends to the root-fibres. Many facts render it probable that pathological conditions may con- siderabty alter the excitabilit.y of the aesthesodic substance, and it is possible that pathological irritations act differently from our coarse mechanical or electrical stimulations. Hyperaesthesia, when present, may also assist in the production of such pains. Special notice is due to the pain in the back, so common in diseases of the spinal cord. It accompanies a great number of spinal diseases, assumes a great variety of forms, and is referable to a variety of causes. Thus rheumatic or rheumatoid pains, which are most frequent; they are localized in single, distinct muscles, are excited by certain movements, respiration, or pres- sure, and are almost always referable to the influence of cold. 78 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Although they occur at times in well persons, they are very especially common in spinal patients, who, as a class, are very sensitive to cold, and in the latter may be excited in similar ways by a variety of influences which weaken or irritate the spi- nal cord, as excesses in the use of alcoholic drink or in sexual indulgence. Hyper aesthetic pains in the back also occur, consisting of burning, tearing, or duller sensations in the skin of the back, especially between the shoulder-blades, or at certain spinous processes, which, in these cases, become extremely sensitive (spi- nal irritation). This pain indicates abnormal conditions of irrita- tion and hyperaesthesia in the posterior roots and columns, and may be more or less diffuse, according to the extension of these processes. The excentric neuralgiform pains, which have been already mentioned, may of course also occur in the back. They are very violent, tearing, boring, localized in various spots, ac- cording to the seat of lesion, but preferring the region of the nape or the loins. Inflammations, haemorrhages, tumors, degen- erations of the cord, etc., produce these pains, and they probably point, in most cases, to pathological irritation of the root-fibres. The pain is often of much significance in affections of the verte- brae ; it is localized in one or several spinous processes, is espe- cially felt when pressure is made upon them, or when the spine is moved, is usually associated with excentric girdle-pains, and with a very rigid position of the spine ; but the latter circum- stance occurs in some other kinds of spinal pain, without lesion of the vertebrae.' Pains localized in the vertebral column are best examined by pressure on the spinous processes, or by tapping them with the percussion hammer or fist, or by vigorous flexion of the spinal column, a forcible push of the head or the shoulders, etc.; the hyperaesthetic portions may also be very well ascertained by passing over them a sponge dipped in cold or hot water, or by electrical examination. A brief notice of headache is necessary, which, not including accidental complications (fever, cerebral disease), is not a rare 1 Compare also A. Mayer, Die Bedeutung des Riickenschmerzes bei Erkrankungen des Riickenmarks und der umgebenden Theile. Arch, der Heilk. I. p. 349. 1860. GENERAL SYMPTOMATOLOGY. 79 accompaniment of spinal diseases. A direct involvement of the sensitive fibres of the cervical plexus in the lesion of the cord may give rise to (occipital) pain ; in like manner the trigeminus, which receives an ascending root from the cervical cord, may sympathize; finally, headaches are not seldom observed, which resemble hemicrania, and are perhaps referable to an implication of the conductors which lie in the cervical sympathetic and originate in the cervical medulla. It follows that any sort of continued and violent pain of the head is generally to be as- cribed to an affection of the cervical medulla. Such pains occur in tabes, in local sclerosis, in bulbar paralysis, tumors of the cervical medulla, etc. {i. e., in cases of disease of the cord). 2. Disturbances of Motility. These are the most common, and in many cases the predomi- nant and most troublesome symptoms of spinal cord diseases. They deserve a most attentive study in all cases. The proper methods for examining the motor apparatus have been fully explained by me in Vol. XI. of this Cyclopaedia, p. 267, and I would refer to the statement there made. It cannot too often be repeated, that the examination of these points should be as thorough and general as possible in all cases ; in many cases of diffi- cult diagnosis this furnishes the only possible means of attaining an exact idea of the disease, and it is only by this path that we can ever hope to reach a clearer definition of diseases than we now possess. a. Diminution of Motility— Weakness and Paralysis. All degrees of "palsy," from the slightest paresis to complete paralysis, occur in diseases of the cord; and as to the situation any part may be affected, though by no means with equal fre- quency. In the earlier stages the patients complain of being quickly fatigued, of diminished power of performance and endurance in their limbs, then of a slight weakness and incertitude in execut- ing certain movements, perceived only by themselves, and at last a slight dragging of the legs is observed. In these early 80 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. stages it is often especially striking to observe the inability to Stand still for any long time. By degrees the symptoms of weakness become plainer; it becomes harder and harder for patients to mount on a chair or ascend stairs ; every little impediment in their way annoys them and detains them ; their powers grow continually weaker, short distances exhaust them completely, they have to stop or sit down at every other step. Thus it goes on till palsy is complete, with absolute inability to move the muscles ; it may be weeks, months, and years before this point is reached. But, on the other hand, the paralysis may occur almost sud- denly, becoming complete in a few minutes or hours ; bed-ridden patients often observe, at the moment when they wish to make use of their limbs, that they are more or less completely para- lyzed, so stealthily and rapidly may the palsy develop itself. This point depends on the nature of the disease of the cord which causes the paralysis. Our observations upon this matter are defective enough ; but as far as they go, they allow us to associate spinal paralytic symptoms in the first place with affections of the anterior half of the cord ; it seems from pathological observation that the worst disturbances of voluntary motion originate in the lateral columns and the anterior cornua. We are not yet certain as to the part played in man by the anterior columns proper. It is clear that the causal lesion of paralysis may have various locations ; in the anterior roots, within or without the cord, in the large (motor) ganglion cells of the anterior cornua and their immediate off- shoots, or finally, in the paths which lead up in the antero- lateral columns to the brain. The lesion may, further, be cir- cumscript, or may extend over a great part of the length of the cord. The nature and the distribution of the palsy are not very characteristic by themselves, but their combinations with other symptoms give many points which assist in an accurate localiza- tion. Thus the presence or absence of reflex actions, secondary muscular atrophy, muscular tension and contracture, changes in electrical excitability, etc., furnish very important landmarks of GENERAL SYMPTOMATOLOGY. 81 the seat of disease, and it will be proper here to mention briefly some of these points. Paralysis rapidly followed by a marked degree of atrophy and by the reaction characteristic of degeneration (Entartungs- reaction)' points to disease of the anterior roots (rarely), or of the gray anterior cornua (more frequently). In this case all reflex actions are absent. Paralysis with tension and contracture of muscles, without atrophy, is very probably due to an affection of the lateral columns. Paralysis without loss of reflex function and without atrophy points to an affection of the paths which ascend to the brain, outside of the gray substance, or at least outside of the ganglia of the anterior cornua. Such are mostly cases of circumscript disturbances of conduction, the end of the cord below the lesion remaining intact. Paralysis with trophic disturbances gives room for suspecting an affection of the gray substance, since primary affections of the roots are very rare. Very extensive palsy with much atrophy, the reaction of degeneration, absence of reflex acts, points to a widely diffused lesion of the anterior gray substance. Paralysis in the districts of certain pairs of roots {e. g., in those of the upper extremities alone, or both crural nerves, etc.), points to a strictly localized affection of roots or lesion of the gray anterior cornua. Of course these statements are not by any means exhaustive, and give only general assistance ; the difficulty of making the distinctions is at present very great; in many cases a variety of other circumstances (spasms, anaesthesia, pains, palsy of the bladder, etc.) may assist the judgment, but in other cases they only add to the difficulty. Such combinations are very common, and are extremely various, especially in the different forms of myelitis. The conclusions which are formed regarding the nature of the lesion in the cord are far less certain than those relating to Volume XI. p. 426. VOL. XIII.—6 82 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. its place. The diagnosis is commonly established by a considera- tion of the symptoms as a total. In respect to the extension of the disease, a few remarks remain to be made. By far the commonest case is that in which the lower extrem- ities, usually both together or nearly so, are attacked by the paresis or paralysis, which gradually ascends, reaching succes- sively the trunk and the upper limbs. In fact, paraplegia is so characteristic a form of spinal palsy, that when it occurs we always think first of a spinal affection. (A paresis occurring in this form may be designated as paraparesis.) Paralysis of both lower extremities and the trunk to various heights, accom- panied by disturbances of sensibility, palsy of the bladder and rectum, and bed-sores—such is the usual form ; but the latter symptoms may be entirely wanting. The most frequent causes of paraplegia are affections which involve the thickness of the cord, or complete compression from vertebral caries, tumors, etc. ; but paraplegia occurs also in affec- tions which are strictly localized in the motor apparatus, such as spinal palsy of children, hemorrhage in the gray anterior cor- nua, etc. If the upper extremities, and finally the muscles of respira- tion, are also invaded, the affection takes the form of universal spinal paralysis, which is observed in various spinal affections, described in the special part of this work. If only the two upper extremities are attacked by palsy, the legs remaining free, we have paraplegia brachialis or cervicalis; a rather rare form. It occurs in connection with processes which affect in an isolated manner the anterior roots of the cervical enlargement, or in strictly circumscribed lesions of the anterior cornua in the cervical enlargement (as in spinal palsy of children, progressive muscular atrophy, perhaps also lead palsy [?]). In disease of the white columns it is rare that an isolated affection of the paths for the upper extremities occurs. Hemiplegia spinalis (Brown-Sequard) is the name given to palsy of an arm and a leg of the same side, originating in a spi- nal affection ; the face is not attacked. It occurs in unilateral disease or injury of the cord, in which case the motor palsy is on GENERAL SYMPTOMATOLOGY. S3 the same side as the lesion of the cord, while sensory palsy exists on the other side. If this palsy is confined to one lower extrem- ity, it is called hemiparaplegia spinalis. For further remarks see below, in the section upon Unilateral Lesion of the Cord. Finally, partial paralyses of spinal origin are frequent. They may be limited to a single extremity, single groups of muscles and nerve-territories, or even single muscles; this de- pends entirely on the nature and distribution of the lesion in the cord. Such partial palsies are usually due to quite circum- scribed local lesions, which show little tendency to spread ; small hemorrhages in the medulla, circumscribed myelitic foci in the gray substance, little islands of sclerosis, etc. It is often hard, or even impossible, to distinguish these from circumscript affec- tions of the roots or other peripheral palsies. b. Imperfect Co-ordination of Movements—Ataxia. This peculiar and frequent disturbance of movement has been made the subject of numerous debates within the past ten or twenty years, since Duchenne introduced the term " ataxie loco- motrice " into nosology. Ataxia is characterized by inability to make combined or com- plicated movements with certainty and exactitude, or even (in advanced cases) to make them at all, while the simple individual motions and the gross force of the muscles are normal, or but lit- tle impaired. This disturbance is most marked in standing and walking. A patient who presents the characteristic signs cannot perform these acts with security ; in walking, he brings his foot down with a stamp, the motions of his legs are exaggerated, wild, jerk- ing, the movements are various, impulsive, often made in the wrong direction and with an unsuitable degree of force. It soon becomes necessary to exercise an increased control with the eyes over the movements. The patient has to keep his eyes on his feet and on the ground while walking; in the dark, or with closed eyes, his uncertainty increases considerably, espe- cially when there exists an impairment of the sensibility of the legs. It soon becomes impossible to walk without the aid of a 84 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. cane, or a pair of sticks ; finally this also, and even standing, is beyond his power. While lying down, all the simple movements are at first per- formed with ease and certainty, and even with normal force; but a distinct failure of force, and, still more, of endurance, is usu- ally seen at an early stage. All complicated movements, on the contrary (describing a circle or other figure with the tip of the toes, touching objects with the toes, etc.), are more or less inter- fered with, even in the lying posture, by the zigzag movements of the leg. This at last extends to the simple movements ; the leg is jerked hither and thither, away from the intended line of action, or it falls back upon the bed in a spot different from that intended. In the severest forms of ataxia, every attempt at innervation puts a great number of muscles in action ; the limbs are thrown about irregularly, and perform clonic shaking motions which are beyond the control of the will. These motions may ex- tend from one to the other leg, and in severe cases even to the trunk and arms ; they cease as soon as voluntary acts are not attempted. In the arms and hands we observe the same order of progress ; all the finer complicated movements become uncertain, clumsy, sprawling, and at last quite beyond the power of the patient to execute. When he tries to seize an object, he passes by it, spreads his fingers at the moment when he should grasp, moves his hand forwards in irregular zig-zags, and reaches his object with difficulty and after many efforts. He cannot carry his food to his mouth, spills the contents of his spoon and glass, thrusts these objects into his face, etc. Buttoning the clothes, sewing, writing, playing the piano, soon become impossible from the interference of the involuntary motions ; in severe cases a shak- ing and sprawling accompany every attempt to move, and put the patient in a condition of complete helplessness. But the gross force is very often retained to a great extent and for a long time in the arms, the simple movements of exten- sion and flexion being performed quite well; if a hand is offered, the patient presses it powerfully, and is able to make very ener- getic resistance to passive movements. GENERAL SYMPTOMATOLOGY. 85 In rare cases the same disturbance of movement seems to extend to the speech, and even to the motions of the eyes. If the phenomenon is closely examined, it is at once evident that the motor disturbance is of a peculiar kind. The simple motor conduction is not disturbed ; it is entirely possible to per- form any simple motion; the force of the muscles is often re- tained for a long time, or only a little diminished ; the case can- not, therefore, be one of real palsy, however helpless the patient may often be made by these disturbances. There is rather a deficient harmony among the impulses to motion which are requi- site for every combined and associated movement. We may therefore give the following definition : Ataxia is the disturb- ance of movement, produced by defective co-ordination of the latter. Wherever a co-ordination of several muscles is requisite to the production of a certain movement, this symptom appears, and is distinct in proportion as the desired movement is compli- cated. The manner in which ataxia may be produced appears from that which has already been stated (see p. 39 et seq.) concerning the co-ordination of movements—namely, a. By abnormal extension of the motor innervation to too many or too few muscles, so that in some cases more, in others fewer than are normally required, are put in use for the attain- ment of a definite object of motion. b. By abnormal strength of the innervation sent to each muscle in the case of a complicated movement. A division of these disturbances into ataxia proper (cases under a) and disturb- ances of innervation (under b), as proposed by Cyon,1 is impracticable. The effect of both disturbances upon the visible movement is plainly the same. And since, at any rate, the two functions—the choice of the muscles to be innervated, and the strength of the single innervations—are simultaneously executed by the same apparatus (that for co-ordination), the disturbances of this apparatus will always affect both functions more or less. Exactly how these disturbances come to pass is hard to say ; irritative and inflammatory processes in the apparatus for co- ordination may sometimes be the cause. 1 Zur Lehre von der Tabes dorsualis. Berlin. 1867. 86 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. It has been stated above, that the proper centres of co-ordina- tion do not lie in the spinal cord ; that at all events they are by no means to be demonstrated in it. By this one fact, the hypothesis of Brown-Sequard, Jaccoud, Cyon, and others is rendered very improbable ; these authors believe that in spinal affections ataxia originates in a disturbance of the reflex function, because, under normal circum- stances, co-ordination is effected reflexly within the cord, in the gray substance. Although there are a few motor acts, such as standing and walking, in which it is impossible entirely to deny the co-operation of reflex processes; although, more- over, the absence of the tendon-reflex in tabes (recently discovered by Westphal, and confirmed by myself) might be employed to assist this position, yet a closer consideration shows that it is entirely untenable. The subject cannot be further discussed here. In ataxias originating in spinal disease only those conductors can be disturbed whose assistance is required in producing co- ordination. Such paths are either Sensory paths (for the cutaneous or muscular sensation, etc.), which are of use in superintending the movements and in main- taining the equilibrium of the body ; or Those motor paths which convey the impulses from the cen- tres of co-ordination to the motor roots; these paths are prob- ably distinct from the simple paths for motor conduction, which furnish a direct connection between the voluntary centres and the muscles ; they form a sort of side-channel. Ataxia in diseases of the spinal cord must therefore be either sensory (caused by disturbance of the centripetal paths) or motor (caused by disturbance of the centrifugal paths"). The existence of these two forms, and the evidences for sup- posing their existence in various spinal diseases, form the nucleus for the recent theoretic dispute about the existence of spinal ataxia of movement. A very exquisite ataxia is found in various spinal diseases, as sclerose en plaques, and more especially in tabes dorsalis (ataxie locomotrice progressive, gray degeneration of the pos- terior columns). The strife is very hot upon the latter point. While authors like Friedreich, Spaeth, Niemeyer, Topinard 1 Central ataxia, caused by disease of the centres of co-ordination, may be placed in a class distinct from these forms. GENERAL SYMPTOMATOLOGY. 87 Finkelnburg, and others, have supported the theory of motor ataxia, others, as Axenfeld, Landry, Leyden, Ruehle, Clifford Allbutt, have tried to base ataxia upon sensory disturbances. The view of Leyden is at first very plausible ; it has been thor- oughly stated in several works,1 and has gained a very large number of supporters. We will briefly inquire whether the rea- sons brought forward in support of this view are sufficient or not. Leyden's theory of ataxia may be stated as follows: Co- ordination of movements is rendered possible, and is effected through sensibility; suspension of the sensibility (of the skin, joints, muscles, etc.) suspends co-ordination; gray degeneration of the posterior columns is accompanied by disturbance of sensi- bility, along with the ataxia ; we are acquainted with no other than sensory functions in the posterior columns; consequently, ataxia is a result of disturbance of sensibility. First, we cannot consider the experimental proof of this the- ory as very fortunate ; we do not wish to endorse Cyon's violent criticism, but we are forced with him to draw from Leyden's first series of experiments the conclusion, "that the disturbance in muscular function which follows section of the posterior roots has nothing in common with what we are accustomed to call disturbance of co-ordination." And the second series of experi- ments on frogs,2 with section of the posterior regions of the cord, cannot prove anything in regard to the present question, not to speak of the great complication of the circumstances ; it proves at most that when certain portions of the cord are cut, disturb- ances of sensibility and of co-ordination appear simultaneously. It is impossible to draw from these experiments a conclusion as to the dependence of the latter upon the former. The demonstration from pathological cases is based on the fact that in not a few cases of ataxia there exist various degrees of disturbance of sensibility, and especially disturbance of the so-called muscular sense. This also proves nothing of itself ; it 1 Die graue Degeneration der Hinterstrange des R.-M. 1863.—Zur grauen Degenera- tion der hinteren Ruckenmarksstrange. Virch. Arch. Bd. 40. 1867.—Ueber Muskelsinn und Ataxie. Virch. Arch. Bd. 47. p. 321. 1869. 2 Virchow's Arch. Bd. 40. p. 198. 88 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. shows, at the most, that in gray degeneration of the posterior columns sensory and co-ordinatory paths are attacked together. A positive argument against this view is, however, found in the disproportion between the intensity of the sensory disturb- ance and the ataxia; there are cases of severe ataxia with slight disturbance of sensibility, and of severe disturbance of sensibility with slight ataxia; they are not rare in any considerable series of cases. Again, the existence of ataxia in a high degree without any disturbance of sensibility militates against this view. Fried- reich ' has published such cases. Leyden does not fully admit their existence. I nryself, however, have very recently examined two cases of this sort most carefully in regard to this point, and have found severe ataxia associated with a sensibility completely intact in every point (touch, temperature, pressure, pain, sense of tickling, muscular feeling, feeling of position of limbs, of passive movements, etc.), so that the existence of such cases is proved to my mind beyond the possibility of doubt. Again, the occurrence of severe anaesthesia without ataxia does not harmonize with such a view. Literature is not want- ing in cases in which there was anaesthesia of the legs, without ataxia, from one or another cause. In the printed accounts of cases of unilateral lesion, moreover, I have found that ataxia has never been observed in the anaesthetic leg. These cases, however, may be met with the statement that only cutaneous anaesthesia was present, while the muscular sense was intact. The only decisive case would be that of complete spinal anoes- thesia (involving the skin, joints, muscles, etc.) without ataxia. Such a case exists. It was repeatedly examined by various trustworthy observers, with special regard to the question in hand; an autopsy was had, and the state of the cord was given with great accuracy. This is the case of Remigius Leins, first published in Spaeth's work;* the autopsy was fully de- scribed by Schueppel.3 Its importance obliges us to give a brief account of it. 1 Virchow's Arch. Bd. 26 and 27. 1863. 2 Beitr. zur Lehre von der Tabes dorsualis. Tubingen. 1864. 3 Ueber einen Fall von allgemeiner Anasthesie. Arch. d. Heilk. XV. 1874. p. 44. GENERAL SYMPTOMATOLOGY. 89 Remigius L^ins, aged forty-two, in the year 1862, has suffered for twenty years with anaesthesia of the hands and arms, which rapidly became severe ; for six years similar troubles have existed in the lower extremities. Present condition: upper extremities wholly anaesthetic ; on the soles of the feet the sensations of touch, pres- sure, and pain are entirely extinct, and in the legs considerably diminished. He falls when his eyes are closed. In the dark, when in bed, he feels as if floating in the air, as the anaesthesia extends to the trunk. March, 1864.—Sense of pressure in the upper extremity, and the sense of force, entirely extinct. Sense of position of the upper extremity and of passive movements of the latter completely extinct. Movements of the upper extremities powerful and. per- fectly correct; the patient eats alone, dresses himself, etc., as far as he can direct his acts with his sight. "When the eyes are closed the arms are moved nearly like those of a blind man. In the lower extremity, besides the cutaneous anaesthesia, there is complete loss of the sense of passive movements and of the position of limbs. In spite of this the patient can walk without support, quite fast and securely, for a good distance. If he is asked to raise his foot to a given height while his eyes are shut, he accomplishes the act by a perfectly quiet and suitable motion. June, 1872.—Sensibility continues the same. When the eyes are shut he has no idea at all of the position of his limbs, and, if standing, falls. He can still walk, clumsily, but not atactically. He can perform all desired actions with his arms, as long as he can see them. Death, May, 1873. Autopsy.—A cavity in the entire length of the cord, from the level of the first cervical nerve to the first lumbar. Posterior columns in the lower half of the cer- vical medulla wholly destroyed and gone ; above, gray degeneration ; in the dorsal part slight atrophy and increase of connective tissue; the lumbar part normal. Anterior columns everywhere quite uninjured and normal. Anterior commissure, from the second cervical to the twelfth dorsal nerve, completely destroyed. Lat- eral columns in the same regions sclerotic in the neighborhood of the posterior cornua. Gray substance mostly implicated in the cavity; gray commissure and posterior cornua almost wholly destroyed in the entire cervical and dorsal medulla; anterior cornua almost entire, and only in the cervical region reduced to a small size; a lateral strip of gray substance is also retained everywhere. Anterior roots normal. Posterior roots, from the third to the eighth cervical nerves, in a state of complete connective-tissue degeneration,1 and, to the end of the dorsal medulla, more or less atrophied. Lumbar part, with its roots, normal; etc. This case is perfectly clear and convincing ; in my opinion it entirely overthrows Leyden's theory. If the maintenance of sensibility were a necessary condition of co-ordination of move- ments, the extreme of ataxia ought to have accompanied this absolute anaesthesia ; but there was no trace of ataxia. 1 This fact is also very decisive against the reflex theory of Brown-Sequard and Cyon. 90 EKB.— DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. It results without question from this, that the retention of sensibility is not necessary, in order tfcat co-ordinate movements shall be performed ; it may be necessary in acquiring the faculty of doing them, and without doubt it is of great importance in maintaining equilibrium, but it is not indispensable in perform- ing co-ordinate movements which have been learnt. Loss of sen- sibility, therefore, can in no way interfere with these movements, when once acquired by practice. It seems to us, therefore, quite unjustifiable, upon scientific grounds, to make a disturbance of sensibility responsible for ataxia, when both occur together. It must rather be believed, that there exist special co-ordinatory paths in the cord, which are attacked in tabes dorsalis and cognate affections, when the symp- toms, of ataxia appear. In the present state of our knowledge, therefore, we have no right to assume any other than a motor ataxia in tabes. In examining the question whether a motor ataxia can be objectively distinguished from the sensory form, this will become still plainer; it will also be seen whether, and how far, the assumption of a sensory ataxia is justified. A purely motor form of ataxia is to be assumed when the sen- sory apparatus is entirely normal (sensibility, muscular sensa- tion, vision). If sensibility (in its widest sense) is perfect, and the movements are still atactic, it must be that the cause lies only in the apparatus for co-ordination, and not in the accessory sensory apparatus. We have above shown that such cases exist beyond a doubt. We know further, from two series of observations, mutually confirmatory, that the retention of a single sensory control- apparatus is sufficient to render possible a perfect co-ordination of movements, if only the apparatus for co-ordination is itself normal. For (1) blind persons, or well persons with shut eyes, show no trace of ataxia, and (2) anaesthetic patients, even when the cutaneous and the muscular sensibility, etc., are completely extinct, show no trace of ataxia as long as their eyes are open and they can control their movements by vision; this is an in- controvertible inference from the Spaeth-Schueppel case. Hence we may conclude that a case of ataxia, even when only GENERAL SYMPTOMATOLOGY. 91 one sensory control-apparatus remains in activity, must be of a purely motor nature. This is the case when an anaesthetic patient makes atactic movements with open eyes, or when, with normal sensibility, the eyes being blind or shut, ataxia is present. Such cases are indeed not wanting; they form the great majority of tabetic diseases ; they must, therefore, be instances of motor ataxia. It is harder to characterize sensory ataxia; and it is ques- tionable whether that which is commonly called ataxia ever origi- nates in disturbance of the sensory control. If, in spinal affections, all voluntary, complex movements, such as are acquired by practice, are well performed, and if no disturbances occur until movements are attempted, for which a sensory control is indispensable {e. g., maintaining equilibrium, standing upright, etc.), then there will be a certain propriety in speaking of sensory ataxia. It will be recognized by observing that disturbances of motion are absent, so long as even one sen- sory control-apparatus is in action, but make their appearance when, one apparatus being already impaired, the other (intact) apparatus is excluded; thus, when a blind man becomes anaes- thetic, or—to choose a more likely example—when an anaesthetic patient closes his eyes. In these cases, considerable disturbances of motion will inevitably occur. It seems to us, however, ex- tremely questionable whether these disturbances show an agree- ment with or even a resemblance to that which we call ataxia. When a patient whose hands are anaesthetic shuts his eyes, he can no longer hold firmly a needle, a button, or similar ob- jects ; he cannot fasten his clothes, etc.; the things fall from his hand, he does not complete the motions, he performs them falsely —but he does not become atactic. The movements are correctly willed, and probably also correctly executed ; but the patient is no longer able to judge whether the end is attained ; the move- ments are therefore often carried beyond the point desired, or they fail to reach it—but they do not become properly atactic. It is the same as when an object is held before a blindfolded per- son, and he is asked to seize it; he will make the most unsuita- ble movements, but they will not be atactic. If the feet are anaesthetic, and the patient shuts his eyes while 92 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. standing, he will fall immediately, because he has no oversight (" Controle") as to whether the voluntary efforts for the purpose of retaining the equilibrium are sufficient or insufficient. In lesser degrees of anaesthesia, tottering, at least, will occur, because an adequately strong sensory impression is not made by any minute deflection of the body. Walking with closed eyes be- comes uncertain, tottering, even impossible ; but it is not at all necessary that a proper ataxia should exist. This also results from the case of Spaeth and Schueppel. The intentions of the will may be formed and executed quite properly, but they are incorrect with respect to the desired ob- ject, being too great or too small, because the patient is deprived of a standard by which to measure them. In this case, there- fore, the purposes of the will and the voluntary impulses to movement are false, but they are correctly carried out, while in ataxia proper the purposes of the will are correct, but are falsely carried out. The notion of sensory ataxia is, therefore, only admissible in case the motor impulses which maintain the equilibrium are pro- duced quite involuntarily by the action of centripetal excitement on motor paths (in the thalamus opticus, the corpora quadrige- mina, or the cerebellum), that is, in apparatus which is usually called co-ordinatory. But the sj^mptoms of such cases are cer- tainly essentially different from those of motor ataxia. It seems to me, however, much more desirable to separate the processes which serve to maintain the equilibrium and position in space from the processes of co-ordination proper of the {volun- tary) movements ; this wTill certainly conduce to clearness in the question of ataxia. The discovery by Groltz of the different cen- tres for equilibrium (lobi optici) and for locomotion of the body (cerebellum) is a weighty argument for this separation. Of course, the processes of movement which contribute to the main- tenance of equilibrium, etc., equally require the apparatus of co-ordination in order to act normally, and this is put in action by impulses from the centres for equilibrium, as it is by the centres of volition in voluntary actions. The centres of equi- librium, therefore, and those of volition may be considered as standing in' a similar relation to the apparatus for co-ordination. GENERAL SYMPTOMATOLOGY. 93 It follows directly that a disturbance of the centres of equilib- rium does not at all necessitate a disturbance of co-ordination of voluntary movements ; also that a disturbance of the sensory excitations which put the centre of equilibrium in action is not necessarily followed by a disturbance of co-ordination, but that, on the other hand, every disturbance of the apparatus of co-ordi- nation will more or less impair the performance of the move- ments necessary for equilibrium. It will be well in future to apply the test separately in both directions in these cases of spi- nal disease. This brings before us the consideration of another motor symptom, which is usually placed in the most intimate connec- tion with ataxia, namely, tottering and falling when the eyes are shut, a symptom to which, under the name of the Brach-Rom- berg symptom, too much importance has certainly been at- tached. It is easy to prove that many patients with disease of the cord (especially tabetic patients, with a more or less marked ataxia and disturbance of sensibility), who are still able to walk and stand quite tolerably with open eyes, begin immediately to totter as soon as their eyes are shut; the tottering becomes worse and worse, and in severe cases the patient presently falls. This tot- tering is most plain wThen the eyes are closed, and the patient is made to stand with his feet together. The intensity of this dis- turbance usually seems to be directly proportionate to the de- gree of ataxia, but this is only apparently true. This phenomenon is evidently due to a disturbance of equilib- rium and of the power of maintaining position in space. We have already shown that these cannot be maintained without a continued sensory control (principally furnished by the sensory impressions in the lower limbs and by the sense of sight). If one part of this sensory control be taken away by shutting the eyes, the maintenance of equilibrium and position in space will be dif- ficult, in proportion as the other factor is already impaired, that is, corresponding with the existing disturbance of sensibility. In fact, this symptom also is found chiefly or exclusively in cases of marked disturbance of sensibility of the lower limbs; in complete anaesthesia the patients fall quickly when their eyes 94 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. are closed. This phenomenon, therefore, is simply an indica- tion that the sensory control exercised by the soles of the feet, the joints, and the muscles is insufficient. This is in harmony with Benedikt's statement, that in a great many instances of difficulty in standing with closed eyes, he has never seen one where there was not a disturbance of the muscular conscious- ness. But, on the other hand, there are some quite severe cases of ataxy (as I have seen most clearly demonstrated), in which the tottering with closed eyes is absent or scarcely exists, when the sensory control from the skin, the muscles, etc., is perfectly intact, i. e., when there is no disturbance of sensibility. It is well, however, to remember that in atactic persons this symptom must be more marked, since the movements which serve to main- tain equilibrium are inco-ordinate, so that they usually totter very perceptibly, even when their eyes are open. It should here be added, that in many atactic patients the want of co-ordination increases decidedly, the movements become much more excessive and ungovernable, when the eyes are shut. This proves no more than that the control by the eyes may fur- nish a means of partially compensating for the disturbance of co-ordination, so that, as in the process of learning how to co- ordinate, a continuous influence upon the centres for this func- tion may be exercised; if this influence ceases (when the eyes are shut) the disturbance of co-ordination returns in its full foree. This may be the reason why atactic patients, without disturb- ance of sensibility, occasionally totter a little wdien their eyes are shut, because the muscular actions that are called into use in supporting the equilibrium, already atactic, are no longer under the direction and control of the sense of sight. These symptoms, however, are always much more marked in cases where there is impairment of the sensibility, especially of the so-called muscular sense ; in this case the movements become excessive and entirely irregular, because when the eyes are closed the sensory control entirely ceases, and to the existent disturb- ance of co-ordination there is added an uncertainty respecting the extent of the voluntary impulse required, the standard for estimating which has been lost. In such cases the ataxia in- creases considerably when the eyes are shut, while in atactic per- GENERAL SYMPTOMATOLOGY. 95 sons who retain their sensibility perfectly no increase of ataxia worth mentioning occurs, the sensory control afforded by the skin and muscles being complete and adequate. This entire series of symptoms is only a proof that the dis- turbance of co-ordination may be partially made good by sen- sory control exercised through the vision. We have to add, finally, that in a few cases it has been ob- served that atactic persons who were completely blind, but were able to stand, also experienced a distinct increase of tottering when they shut their eyes. It is clear that this cannot be due to any further diminution of the sensory control of the eyes; but it is hard to find any explanation for this singular phenomenon. The most obvious conclusion is, that the phenomenon is a psy- chical one. Might a sudden calling off of the attention cause an increase of uncertainty in the legs ? Or may it be that a new act of motor innervation can send impulses to the co-ordinatory apparatus, which increase the existent disturbances in the lat- ter ? At present we do not know. The preceding appears to furnish a sufficient demonstration of the fact that the chief form of ataxia in spinal affections is of a motor nature. There must, therefore, exist in the spinal cord special centrifugal fibres, employed for co-ordination (Spaeth), and ataxia in a spinal affection occurs only when these fibres are attacked. Their site is entirely unknown. Most observers place them in the white posterior columns, because the autopsy of atactic patients usually shows gray degen- eration of the posterior columns. If it were proved to a cer- tainty that in such patients the posterior columns were exclu- sively attacked, we might regard this as demonstrated. But this is not yet proved ; it is even probable that in such patients there is a more or less considerable implication of the gray sub- stance and the lateral columns, as a rule. Further, the case of Spaeth and Schueppel is rather decisive against the localization of the co-ordinatory paths in the pos- terior columns, although the duration of the case was such that a compensatory conduction might be thought possible. Where, then, are wre to look for these co-ordinatory paths? In the gray substance? In the antero-lateral columns? The 96 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. experiments of Brown-Sequard, who was enabled to produce ataxia in birds by lesion of the gray substance of the ventriculus lumbalis, point rather to the gray substance. On the other hand, according to the experiments of Woroschiloff, the co-ordinatory paths lie (in rabbits) in the lateral columns, in their innermost part, in the sinus between the anterior and posterior columns. At present the question is not settled in the case of man; further exact investigations are necessary to bring it to a solution ; per- haps we may gradually approach a conclusion by careful com- parisons of suitable cases of spinal sclerosis in patches. Till then, our first thought in ataxia will be of a disease of the pos- terior columns, and especially (as would appear from Charcot's latest statements!) the lateral portions of these columns, adja- cent to the gray substance, called the "region des bandelettes externes," region of the inner bundles of root-fibres. c. Various Characteristic Gaits in Spinal Disease. The form of the lesion may often be recognized by the patient's characteristic gait, as soon as he enters the room. I believe that for practical purposes it is sufficient to distinguish the following leading varieties, which may be distinctly sepa- rated : 1. The paretic and paralytic gait—caused by a more or less extensive palsy of the lower extremities. The gait is shuffling, the tip of the foot drags on the ground, the fore-part of the foot hangs down, the sole is planted awkwardly, usually with the outer edge first; the knee is raised high, or is drawn after the patient in an extended position ; a certain stiffness of the legs is often remarked. The patient walks with one or two canes, or is supported by crutches or guides; he totters but little, stands quietly and securely, and when left alone simply sinks to the ground, in most cases. The manner of walking differs some- what, according to the distribution of the palsy among the groups of muscles; if the whole leg is palsied, it is different from 1 Charcot, Lecons sur les maladies du systeme nerveux. II. Serie. 1. fasc. Paris. 1873. GENERAL SYMPTOMATOLOGY. 97 what it is in palsy of the lower half of the leg ; in the latter case it is waddling, and especially characteristic. 2. The atactic walk—caused by disturbance of co-ordination in the legs. It is characterized by irregular hurling movements ; the point of the foot is thrown forward and outward with force ; the heel is brought down with a stamp, the leg stiff at the knee. The patient's eyes are continually on the ground. The gait is tottering, staggering, or even reeling from side to side; the move- ments are hasty, spasmodic, quite unequal; in turning about, especially, there is great uncertainty, and danger of falling. In severe cases the patient falls after a few steps. 3. The stiff, spastic walk—caused by reflex muscular contrac- tions or tension associated with paresis of the leg. This gives rise to a very peculiar and characteristic walk ; the legs are somewhat dragged, the feet seem to cleave to the ground, the tips of the feet find an obstacle in every inequality of the ground ; every step is accompanied by a peculiar hopping eleva- tion of the whole body, dependent on a reflex contraction of the calf ; the patient immediately gets upon his toes, and slips forward on them, showing a tendency to fall forward. The legs are close together, held stiffly, the knees somewhat depressed forward, the upper part of the body slightly bent forward. There is no throwing about of the feet. This gait depends on muscular tension and reflex contractions in the various groups of muscles, which are set in activity during the process of walk- ing. These forms may be more or less distinct; there occur transi- tional forms of a mixed character; but not every patient with spinal cord disease has a characteristic gait. d. Increase of Motility—Spasm. Motor symptoms of irritation are among the commonest of spinal symptoms ; they occur in a great variety of forms. The simplest form is without doubt the so-called muscular tension. In this case the muscles (which are usually in a con- dition of greater or less paresis) are in a state of moderate tension or contracture, which makes the execution of passive movements VOL. XIII.—7 98 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. quite difficult. This tension often occurs at the moment when a passive movement is being performed, especially if it is done rather quickly ; there then follows a jerking, impulsive resist- ance, which enables us to recognize with ease the slighter forms of the disturbance. The voluntary movements, also, are more or less obstructed and clumsy, are performed as if the patient were in a semi-fluid medium, and require the expenditure of an ab- normal amount of force. It is easy to show that these tensions in passive motion occur chiefly in the muscles which are stretched and pulled on by the movement; thus, in passive extension, the flexors, and vice versa. The tension seems here to be reflex in character, and is probably connected with the abnormal tendon-reflex action, to be men- tioned later. In severer cases the movements grow more and more stiff, the resistances greater, and a condition may finally exist which resembles the flexibilitas cerea of catalepsy. The contraction is not always equally distributed through the entire muscle; in some muscles it may be only partial, forming knots or lumps. A simple exaggeration of this state doubtless constitutes what is called stiffness of the muscles, rigor. The muscles are stiff and stark, much swollen, and firmly resistant to the touch; on pressure, they are usually very painful; both active and pas- sive movements are extremely difficult. The extensor muscles are usually the principal ones affected ; very often also the mus- cles of the nape and back (torticollis). In the worst cases, decided contractures occur, which may be limited to a few muscles or groups of muscles, but often attack many in a variety of places. Sometimes the flexors, and some- times the extensors are more affected, hence the difference of posture in the different cases. I do not now refer to the so-called paralytic contractures,1 which are certainly nothing uncommon, even in spinal diseases, but exclusively to neuropathic contractures, which owe their origin to abnormal states of irritation in the cord. The muscles are much shortened, their tendons quite prominent, and passive 1 Vol. XI. p. 379. GENERAL SYMPTOMATOLOGY. 99 movements are entirely impracticable. If energetic attempts to perform them are made, vigorous clonic contractions of the muscles manipulated are often produced, or the contracture is increased, leading to a momentary tetanic stiffness of the whole limb. It would be very difficult, at the present time, to refer all these conditions of irritation to pathological changes in certain portions of the cord. But there is no doubt that there are two ways in which muscular tension and contractures may come to pass ; first, a reflex origin may be conceived, which is doubtless the chief element in cases where sensory phenomena are promi- nent, in diseases of the meninges, the posterior roots, the poste- rior columns, the reflective gray matter, etc.; such reflex mus- cular contractions are said to attack by preference the flexors. On the other hand, these symptoms may originate through direct irritation of the motor parts of the cord. The seat and the character of this irritation are hardly known ; a direct irrita- tion of the anterior roots is possible ; according to Charcot's later observations, sclerosis of the lateral columns is a very common cause of such motor symptoms of irritation ; it is not at all known how far the gray substance might produce them. In such cases of direct irritation, at least in the lower extremities, the extensors are said to be principally affected. In respect to the exact pathogenesis of these motor symptoms of irritation, we know only this, that they chiefly occur in acute or chronic inflammatory conditions of the cord and its mem- branes, in the various forms of meningitis and myelitis, in many cases of multiple sclerosis, paraplegia after acute sickness, etc. We know still less about one of the severest forms of spinal spasm, namely, tetanus, and its pathogenesis. This is a power- ful tonic spasm of almost the entire muscular system; the spasm occurs in paroxysms, which are brought on, or increased, by reflex action, but continues in the intervals in the form of a moderate degree of rigidity. Tetanus is probably caused by an (inflam- matory or toxic) affection of the gray substance, which enor- mously increases the reflex excitability. A like condition exists in meningitis spinalis.1 1 See Volume XII. 100 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. The attacks of so-called tetany have a remote resemblance to tetanus. By this we understand attacks of tonic spasms, occur- ring in regular paroxysms, and affecting the extremities chiefly. It is probably of spinal origin.1 Among the forms of clonic spasm, in spinal disease, tremor, in the first place, is not rare; either permanent or transitory, accompanying certain movements, following exhaustion, etc. Its manner of origin is as yet quite unknown ; one is naturally in- clined to refer it to the gray substance. A higher degree of tremor is present in shaking, which accom- panies and disturbs all voluntary movements in multiple spinal sclerosis; a sort of greater tremor, which begins whenever a voluntary innervation occurs, and may perhaps be regarded as a very severe degree of ataxia, although, as it appears, it is essen- tially distinct from the latter. We have not yet succeeded in forming an exact pathogenesis of this sj^mptom ; and we may say the same of that characteristic form of tremor, most marked during repose, which is the essential feature of paralysis agitans. Few of the other clonic spasms can be referred with probabil- ity to the cord; those of single muscles, or groups of muscles, have seldom been derived from the cord, and general convul- sions, as occurring in epilepsy, eclampsia, uraemia, etc., have commonly been ascribed to the medulla oblongata. A few special cases remain to be described. Among these is a peculiar form of clonic spasm in the lower extremity, which appears in various lesions of the cord, and runs an extremely characteristic course. In its lightest form, it consists of that clonus of the foot and lower leg which appears when the attempt is made to bring the foot quickly into dorsal flexion by pressure upon the sole; a rhythmic, clonic jerking of the foot begins, which ceases as soon as the foot is let go and brought back into plantar flexion. I have demonstrated that this symptom, described by Brown-Sequard2 and Charcot, most probably originates in the reflex manner, through irritation of the tendo Achillis.3 In se- 1 Volume XI. p. 368. 2 Journ. de la Physiol, de l'homme et des anira. I. 1858. p. 472. 3 Ueber Sehnenreflexe bei Gesunden und Riickenmarkskranken. Arch. f. Psych, u. Nervenkr. V. Heft 3. p. 792. GENERAL SYMPTOMATOLOGY. 101 verer cases a very slight pressure on the sole or the toes suffices to produce the phenomenon ; for which reason it seems often to arise spontaneously. Then the spasm extends to other parts; the whole leg falls to trembling convulsively, and the other leg soon does the like. When the evil is at its worst, any irritation whatsoever, originating in the skin or the intestines, and acting reflexly, is followed by a tetanic stiffness, together with convul- sive tremor, of one or both legs, lasting several minutes. This severest degree of reflex convulsion, which is hardly found except in entirely palsied, paraplegic limbs, is what Brown- Sequard (loc. cit.), and after him Charcot,1 have rather unsuita- bly termed tonic spinal epilepsy. This phenomenon is especially observed in cases of compression of the cord, or circumscript affections of its entire transverse dimensions, if the reflex excita- bility is also much increased by an accompanying state of irrita- tion. The slighter degrees of this phenomenon seem also to occur in sclerosis of the lateral columns,2 while in severer cases we should always think of an implication of the gray substance. The so-called saltatory spasms, recently described by Bamberger, Guttmann, and Frey, would seem to belong to this category, and to present a specially marked modification of these reflex cramps. It is evident at a glance that this phenomenon has nothing whatever to do with epilepsy proper. But doubtless there are certain relations between epilepsy and spinal disease, which we must briefly speak of in this place. Brown-Sequard 3 made the remarkable discovery, and studied it with the greatest thoroughness, that in guinea-pigs and other mammalia epilepsy appears in four or five weeks after uni- lateral section of the lumbar or dorsal cord; an attack may be produced at any moment by irritating an epileptogenic zone, 1 Clinical Lectures on Diseases of the Nervous System. 1872-3. p. 216. a JErb, Ueber einen wenig bekannten spinalen Symptomencomplex. Berl. klin. Wochenschr. 1875. No. 26. 3 Compt. rend, de la Soc. de Biolog. 1850. Vol. II.; Arch, de Medic. Fevr. 1856; Researches on Epilepsy. Boston, 1856-57; Lectures on the Physiol, and Pathol, of the Central Nervous System. Phila. 1860. p. 178 ; Arch, de Physiol, norm, et path. I. 1868. p. 317; II. 1869. pp. 211, 422, 496; IV. 1872. p. 116. 102 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. comprising portions of the region of distribution of the trigemi- nus and the two or three upper cervical nerves. We need not give all the details of Brown-Sequard's experiments, though they are extremely interesting ; they have, at all events, demon- strated a fact which has since received confirmation from other sources, namely, that, after unilateral injury of the cord, a dis- eased condition develops in a few weeks, which presents an un- mistakable likeness to epilepsy. We are, however, still in uncer- tainty regarding the interior relations and mechanism of these processes. Brown-Sequard found also that section of one sciatic nerve produces, after a few weeks, exactly the same epileptiform accidents as the section of the cord. Finally, Westphall found that simple tapping on the heads of guinea-pigs would give rise to an exactly identical form of epilepsy with epileptogenic zone, etc.; he found, in every instance, small hemorrhages, irregularly distributed, in the medulla oblongata and the upper part of the cervical cord, and very often further down, even in the dorsal cord. Westphal is inclined to regard the hemorrhages in the cord as furnishing the cause for the subsequent development of epilepsy. It therefore appears to be proved with sufficient certainty that, in animals at least, certain injuries of the cord—as small hemorrhages, and probably other lesions—are capable of giving rise to epilepsy in a manner hitherto unknown. But the ques- tion whether such a thing occurs in the human subject is not yet decided with certainty. It is true there are several cases in which epilepsy appeared after lesion of the sciatic nerve, just as in animals; and Leyden2 has published a case in which epilepsy occurred after an injury of the head, and which seems to resem- ble Westphal's experiments ; but in the case of diseases or inju- ries of the cord the demonstration of secondary epilepsy has been much less clear. Brown-Sequard quotes some cases from older accounts, which he believes establish this point. Charcot3 mentions periodic epileptic attacks among the symptoms of com- 1 Ueber kiinstl. Erregung von Epilepsie bei Meerschweinchen. Berl. klin. Wochen- schr. 1871. No. 38. J Virchow's Archiv. Bd. 55. 3 Lecons sur les malad. du syst. nerv. II. Ser. 2. fasc. p. 137. GENERAL SYMPTOMATOLOGY. 103 pression of the spinal cord, and cites a series of cases in proof of it; a case by Dumenil1 seems especially convincing; andOppler3 has quite lately published the case of a young, powerful soldier who had never suffered from epileptic spasms, but had several attacks during the convalescence from a traumatic spinal menin- gitis. In spite of this, it would be desirable to have more obser- vations upon the human subject. Considering the very great frequency of lesions of the cord, the occurrence of epilepsy as caused by such lesions is extremely rare, and therefore of little practical consequence. It would be of great interest, if cases should be observed, to demonstrate the existence of an epileptogenous zone. A less common series of spinal symptoms is furnished by the associated move- ments, by which we mean involuntary, often spasmodic actions, which, making their appearance when any voluntary movements are to be executed, complicate and disturb them. The region of their origin seems to be usually the brain, and especially the centres of co-ordination in the brain. No doubt many symptoms in diseases of the cord belong to this class ; thus we cannot altogether refuse to regard the atactic movements, the shaking in local sclerosis, etc., as associated movements, although they are decidedly of spinal origin. In the same class are the movements of antagonists, which accompany the effort to innervate palsied or paretic muscles; these, however, are not a true spinal symptom, but simply express the fact that a large number of muscles receive a common co-ordinated innervation, some of which have become insufficient to perform their functions, thereby permitting the action of their antagonists to appear more distinctly ; this occurs in all palsies. It is not certain to our mind whether the spasmodic and wholly uncontrolled movements which often occur in paraplegic extremities when a powerful act of the will is directed to them, are to be considered as belonging to this class. They seem to depend rather on an abnormal diffusion of the process of excitation among the motor paths, when pathologically irritated—a diffusion which might be explained by reference to the structure of the nervous network in the inflamed gray substance, and by supposing an interruption of the chief paths to have taken place. Probably, however, a part is owing to the presence of reflex actions, the stimu- lus to which originates in the skin of the palsied parts, under the influence of the motions of the trunk and arms; this symptom is almost always associated with an excessive increase of reflex excitability. It is quite certain that the reflex process is concerned in those tonic or clonic contractions of paraplegic legs, which are often 1 Gaz. des hopit. 1862. p. 470. 2 Riickenmarksepilepsie ? Archiv fur Psychiatrie u. Nervenkrankheiten. Bd. IV. p. 784. 104 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. associated with the act of evacuating the urine or faeces. The same have been observed by Freusberg in dogs whose spinal cord had been cut. It is hardly necessary to repeat, that in all the above symp- toms of motor irritation our first thought should be of an affec- tion of the gray substance and the antero-lateral columns. We are at present unable, or at best are able in but a few cases, to define the point where the implication of either terminates, or the general pathogenesis of the spasms. It should not be for- gotten that an affection of the sensory portions of the cord may give rise to reflex symptoms of spasm. e. Alterations in the Velocity of the Motor Conduction. Recent observations have made us aware that this class of alterations is by no means infrequent; but at present they have been little observed. Retardation of the motor conduction, long known by physiologists, was first observed under pathological conditions by Leyden and von Wittich,1 who made careful esti- mates of its extent. Their three cases, however, are probably not affections of the spinal cord proper, but of the pons and medulla oblongata. The rate of conduction was reduced to one-third of the normal speed, and in correspondence with this, the move- ments of locomotion, speech, and so forth, were greatly retarded, and the patients were unable to execute the same movement several times in rapid succession. The principal attention was directed to measuring the motor conduction as a whole. Burckhardt5 has lately undertaken to measure the spinal motor conduction alone, by the aid of a vari- ety of physiological methods, and has reached very remarkable results. He found that under normal circumstances the spinal motor conduction takes place from two to three times as slowly as the peripheral, and he suspects that the reason lies in the in- tercalation of ganglion cells in the motor conductive path. But under pathological conditions he found sometimes an accelera- tion of spinal conduction (as in writers' cramp, in spinal palsy of 1 Virch. Arch. Bd. 46. p. 476, and Bd. 55. p. 1. 8 Die physiol. Diagnostik der Nervenkrankheiten. Leipzig. 1875. GENERAL SYMPTOMATOLOGY. 105 children, in central myelitis, in some cases of tabes, etc.), and sometimes a more or less considerable retardation (as in myelitis of the white substance, in diffuse sclerosis of the cord, in certain cases of tabes, etc.). He concludes that the anatomical basis of central retardation probably lies in the white substance, and that of central acceleration in the gray. Retardation of motor con- duction in the cord gives ground, therefore, for inferring a dis- ease of the white substance, and acceleration for inferring disease of the gray. It scarcely need be said that these theories are greatly in need of more exact establishment and elaboration. f Electric Reaction of the Motor Apparatus. The labors of Marshall Hall, Todd, Duchenne, and others gave rise to great expectations of improvement in the diagnosis of spinal diseases through the use of electricity; but these expec- tations have not been fulfilled. In fact, the electrical examination seldom gives decisive evi- dence, to enable us to place the seat of a disease in the cord, or brain, or peripheral nerves ; this can be done only under special conditions. In many cases, however, valuable information is given as to the state of nutrition of the nerves and muscles, and thereby indirectly as to the nature and probable location of the disease. (Compare the full statements of this matter made in Vol. XL, p. 423 et seq.) A practically useful general statement of the changes in elec- trical excitability which occur in diseases of the cord cannot be given at present; the investigations hitherto made are few, and not free from objections. The most frequent, and probably the most important, forms of alteration—namely, the slight quantita- tive changes in electrical excitability—suffer from a serious want of observations; the results have in almost all cases been ren- dered untrustworthy by defective methods of investigation. I have shownl the method wdiich should be observed in seeking 1 Erb, Zur Lehre von der Tetanie, nebst Bemerkungen iiber die Priifung der elektr. Erregbarkeit motorischer Nerven. Arch. f. Psych, und Nervenkr. IV. p. 271. 106 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. (particularly in spinal diseases) for certain and exact results. I give here a few points briefly. In diseases of the spinal cord the electrical reaction of the nerves and muscles, under the faradic and galvanic currents, may be increased or diminished; the degree of alteration is usually slight. The diminution may amount to a complete extinction of electrical excitability, but this is usually preceded by the change denominated the reaction of degeneration (Entartungsreaction). Distinct pathological conclusions cannot be drawn at present from the slighter degrees of quantitative change. The reaction of degenerationl is by no means rare; it is more frequent than has been supposed. It is not yet known whether it takes the same strongly-marked course as in traumatic lesions of peripheral nerves; from certain observations, which, however, are not conclusive, it seems to me that the increase in the suscep- tibility to galvanic currents is not quite so marked as in peri- pheral palsies, or perhaps that it passes off more quickly. It is, however, certain that the qualitative change of galvanic excita- bility occurs in a perfectly characteristic form, with a contrac- tion at anodic-closure which is stronger than that at cathodic- closure (AnSZ >KaSZ), and with a sluggish and protracted con- traction. The inferences we are permitted to make in respect to the histological changes in nerves and muscles, which exhibit such reactions, are the same that may be made in peripheral palsies. They are of a good deal of importance, and the changes they indicate are of the most striking character. By patient care a great number of facts have been collected, of which mention will be made further on, and in the special portion of this work (see " Trophic Disturbances " and the chapter on " Spinal Paralysis of Children"); we have learnt that identical histological changes may originate from direct lesions of the gray substance of the anterior cornua (spinal origin), and from an impediment to con- duction between that gray substance and the peripheral parts (peripheral origin). When, therefore, in a disease which can be demonstrated to be of spinal origin, we find the reaction of degen- 1 See Volume XI. p. 427. GENERAL SYMPTOMATOLOGY. 107 eration, we may infer a lesion of certain parts (anterior cornua) of the gray matter, provided, however, that a peripheral origin can be disproved. On the other hand, when the electrical exci- tability is retained in its normal form in a spinal disease, it is allowable to infer that these portions of the anterior gray sub- stance are not involved in the lesion.1 As a very general rule, it may be stated that the results of electrical examination cannot safely be applied to the diagnosis of spinal disease, except in the closest connection with the other symptoms. We shall give a more detailed presentation of the known facts in connection with the respective diseases. 3. Disturbances of Reflex Activity. It is of the greatest importance to test the reflex activity in spinal diseases ; the most valuable information in respect to the disease may often be thus had. Diminution or suspension of the reflex actions is usually recognized with ease ; it is shown by the partial or complete fail- ure of the ordinary means of stimulation, as applied to the skin or to the tendons and other parts from which we expect reflex results. It is necessary to remember that many persons have normally a very slight reflex reaction; but this will be easily recognized, as a pathological diminution is usually limited to a portion of the body. It may be produced— a. By disease (arrest of conduction) of the entering sensory root-fibres ; in which case there must be more or less anaesthesia in the regions supplied by these root-fibres. b. By disease (arrest of conduction) of the departing motor root-fibres ; in which case there must be a more or less complete paralysis of corresponding extent. c. By disease of the gray substance of the reflex apparatus itself, when both sensibility and motility may be present, or 1 Compare the observations of Burckhardt in Physiolog. Diagnostik der Nerven- krankheiten. pp. 264 and 270. 108 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. one or both of them may be altered to a greater or less extent, according to the extension of the disease in the gray substance. Examples of all these forms are furnished by pathology. d. Finally, it is permissible to entertain the case of reflex arrest, in accordance with known physiological facts (see above, p. 51) ; but we have at present no pathological facts. The decision between these various possibilities will be facili- tated by an exact estimation of the weight of each element in the problem. A retardation of reflex actions has been found in pathological cases under the same circumstances as retardation of sensory conduction. We have mentioned this fact previously (p. 70). A more frequent and interesting circumstance is the increase of reflex actions. It makes its first and its most conspicuous appearance in the voluntary muscles. They twitch at the lightest irritation; often the movements are slight and imperfect, but more often they are very powerful, complete, or violent; the legs and arms are thrown about forcibly in all directions, twitch frequently, or enter into a clonic tremor or a fully developed tetanus; the motions are almost always unsuitable and disorderly; flexion and extension of the joints alternate, giving rise to irregular sprawling move- ments; the patient's leg can often be placed at will in reflex extension or flexion by a definite localization and intensity of irritation;x orderly and fitting movements are rarer; thus Mc- Donnel * reports that a patient, who suffered with compression of the cervical cord, continually moved his paralyzed left hand to his genitals during catheterization. Such reflex acts are usually produced with most ease by ir- ritating the skin; tickling, pricking and pinching, or stroking the skin, especially that of the soles, the inner surface of the thighs, the toes and fingers, and the palm, produce them ; Pflue- ger's law of extension of reflex phenomena can often be con- firmed in such patients. Reflex acts are also excited from the intestines ; in certain spinal affections nothing is more common 1 Virchow, Gesammte Abhandl. p. 683. 2 See Virchow-Hirsch's Jahresber. 1871. Bd. II. p. 7. GENERAL SYMPTOMATOLOGY. 109 than to find full, powerful, and very troublesome reflex actions taking place in the legs during evacuation of faeces or urine, in consequence of colic pains, or during catheterization ; they often continue for a considerable time in a semi-rhythmic manner. The reflex actions which originate in tendons, fasciae, and articular ligaments are also very important. We have given above (see p. 48 et seq.) a brief account of their physiological occurrence ; in pathological cases they often increase to such a degree that the lightest tapping on the tendons leads to the most vigorous jerk- ing ; in this case the phenomenon can be produced from many more tendons than usual; thus, I have seen them originate from the ligamentum patellae, the tendo Achillis, the tendons of the adductors, gracilis, biceps femoris, tibialis anticus and posticus; in the arm, from those of the triceps, supinator longus, radial ex- tensors, flexors of the fingers, biceps, flexor radialis, etc. Their relation to the reflex actions of the skin is very variable ; some- times both are present and are exaggerated, sometimes those of the tendons are absent while those of the skin are present, and sometimes those of the tendons are enormously increased while those of the skin are normal or diminished. These circumstances are probably of great importance in a diagnostic point of view, but this requires further observation. The class of tendon-reflexions ought, in our opinion, to in- clude a reflex phenomenon which has long ago been described by French authors (Brown-Sequard, Charcot, Vulpian, Dubois, and others)—namely, the reflex clonus which appears in the foot and lower leg when the foot is rapidly brought into dorsal flexion by another person. If the fore-part of the sole is vigorously pressed up with the flat of the hand, the rhythmic reflex con- tractions of the calf produce a clonic tremor of the foot, which continues as long as the pressure on the sole lasts, and ceases immediately when the pressure is withdrawn or when the foot is brought energetically into plantar flexion. When the reflex excitability is greatly increased, the slightest pressure on the sole is sufficient to set in motion the clonus; the action may extend to the whole leg, and even to the other leg; in its most violent forms, tetanic rigidity of the legs alternates with convul- sive shaking, and we have the phenomenon described by Brown- 110 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Sequard and Charcot as spinal epilepsy (see p. 101). In my arti- cle on Tendinous Reflex Actions1 I have attempted to prove that this reflex clonus is nothing but a tendinous reflexion, produced by the sudden tension of the tendo Achillis, and maintained in a very simple way by the continued pressure against the foot. I have recently succeeded more than once in producing just the same phenomenon from the tendo patellae, and have observed it in the biceps femoris. It also occurs in the foot, when the skin is irritated, if the excitability is very much exalted; I have ex- plained (p. 50) the mechanism of this. It cannot be denied that the phenomenon may possibly be produced directly from the skin in many cases ; but we require more convincing proof than Joffroy2 has brought forward. The increase in reflex activity may manifest itself in the in- testines and the vaso-motor apparatus; but this has been little studied in the human subject. For example, I have observed in paraplegic patients that a sudden discharge of urine can be produced by external pressure upon the bladder, or by introduc- ing the finger into the rectum; I have also seen a mucous fluid evacuation of the bowels occur regularly upon the occasion of dressing and cleansing a large bed-sore ; I also have seen erections produced by irritation of the skin of the penis or perineum, or by introduction of a catheter, etc. It is probable that a closer inspection will frequently discover a reflex action upon the cuta- neous vessels, etc. This excess of reflex action is explained, first by a separation of the reflex apparatus from the brain, wdiich puts a stop to the action of the centres of inhibition. In fact, the highest degree of excess is found in all those affections of the spinal cord which put a complete stop to the transmission of impressions in the cord; in separation or compression, in circumscribed transverse myelitis or softening, in tumors or cavities of the cord, etc. It must be considered an indispensable condition for the production of the reflexions, that the gray substance situated below the point of lesion should be intact; and it is not strange that parts 1 Arch. f. Psych, u. Nervenkr. Bd. V. p. 792. J Gaz. med. de Paris. 1875. Nos. 33, 35. GENERAL SYMPTOMATOLOGY. Ill which have retained their reflex excitability usually possess also their electrical excitability, because the gray substance is the essential factor in the conservation of the nutrition of nerves and muscles. The second cause of increased reflex action is the increased ex- citability of the gray substance—a condition which may certainly be produced by inflammatory and other irritative conditions, by many sorts of disturbance of nutrition, and by certain poisons, as strychnia, opium, belladonna, etc. The greatest increase will be found when both these causes act together, as in the case of myelitis from compression, or when strychnia is acting on the paraplegic parts ; this is confirmed by daily experience. Whether an increase of the excitability of the sensory con- ductors (hyperaesthesia), or of the motor conductors (convulsi- bility) is capable by itself of producing an increase of reflex ac- tivity, is a point which requires closer examination, but is not improbable a priori. 4. Vaso-motor Disturbances. These are very frequent. They consist of the two conditions of spasm and palsy of the vessels, with the consequences. In view of the complicated mechanism for innervation possessed by the vessels, explained on page 42, it is extremely difficult to inter- pret these phenomena, especially as there are many others to be taken into consideration along with them. The following appear to constitute the principal facts: In many cases local hyperemia and fluxion, increased rea- ness, and elevation of temperature occur in the parts affected (usually paralyzed); thus, for example, in complete severance or compression of the cord, of acute origin ; and most distinctly of all, in unilateral lesions, where the difference between the dis- eased and the well side is very striking. If the lesion is entirely local, and the vaso-motor centres situated within the cord are left nearly intact, the normal condition returns after a short time. In such cases the symptoms of vascular paralysis are mostly temporary, and the normal condition returns after some weeks or months; while at a later time paleness, diminution of tempera- 112 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. ture with subjective feeling of cold, and even cyanosis, are very often observed. In other cases, especially in the early stages of tabes or mye- litis, before any symptoms of palsy appear, there is a striking coldness, great paleness, and anaemia of the lower extremities, a tendency to goose-skin, the subjective feeling of icy coldness of the feet and inability to warm them even in bed, a small pulse, excessive sensitiveness to the impressions of cold, etc. It can- not be doubted that these phenomena are due to conditions of abnormal excitability of the vascular nerves, with increased con- traction and excitability of the vessels. Finally, in very severe or old cases (usually of spinal palsy) we observe, in connection with the subjective and objective cold- ness of the parts, a marked lividity, a cyanotic tinge of the skin, puffiness, swollen veins and capillaries, slow and poor circula- tion ; in this case there evidently exists a state of great vascular atony, and a more or less distinct venous stagnation; the arterial pressure is lessened, the venous increased, the circulation re- tarded. These three groups of vaso-motor disturbances may be natu- rally'interpreted by what we know of the laws of vascular inner- vation. In the first group—paralytic hyperaemia—we should recall the hundreds of experiments that have been made upon section of the cord ; every such section produces paralytic hyperaemia in the parts situated behind it. Goltz has shown how, when the spinal centres recover themselves, the circulation may return to nearly its normal point; only when the destruction of these centres is quite extensive (as in spinal apoplexy, haematomyeli- tis, etc.) will the fluxion and elevation of temperature be more permanent, and finally result in atony of the vessels. For the second group — ischaemic pallor and coldness — ab- normal excitement of the vaso-motor centres and conductors is doubtless responsible ; they are most frequently caused by chro- nic inflammatory conditions of the cord, and may be produced either directly or reflexly. In the third group — atonic hyperaemia by stagnation — it is commonly supposed that the absence of muscular action in the GENERAL SYMPTOMATOLOGY. 113 palsied limbs produces disturbances of the venous circulation, and thence gives rise to the other symptoms. It may, however, be easily seen that this cyanosis occurs in parts which are not at all palsied, and may be absent in completely palsied regions. The assigned explanation, therefore, is at least insufficient; the absence of muscular contraction may favor the production of atonic hyperaemia, but cannot by itself produce it. It seems to us that, in order to produce such results, a more or less general palsy of the vaso-motor nerves is required, such as is produced either by destruction of the vaso-motor centres in the gray sub- stance, or by interruption of the vaso-motor conduction in the lateral columns or the anterior roots. The longer this paralysis exists, and the more complete it becomes, the more marked will be the vascular atony. Spinal palsy of children (destruction of ■the vaso-motor centres in the gray substance) is a good example of the former case ; in disease of the lateral columns the question has not been fully studied, but in one case of probable sclerosis of the lateral columns I have observed an exquisite development of the atonic hyperaemia of stagnation. Conditions of great vascular irritability in the skin are oc- casionally observed; sudden blushing or paling of certain por- tions of skin, erythema fugax, etc. They appear most frequent in association with meningitic conditions. It therefore appears plainly that vaso-motor disturbances may afford us some information respecting the nature of the disturbances in the cord, but enable us to draw no certain con- clusions respecting its exact locality. 5. Trophic Disturbances. These constitute one of the most interesting, and also one of the obscurest symptoms of spinal disease, and there is still a great deal of controversy in regard to their interpretation. We must necessarily speak of the different tissues separately, in our enumeration of these symptoms. The trophic disturbances of nerves and muscles have received great attention, especially in spinal diseases; it has very lately VOL. XIII.—8 114 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. been discovered that they may occur apart from palsy, becoming a subsequent cause of palsy, as in the typical form of progres- sive muscular atrophy. But it is not all the forms of spinal paralysis that are accom- panied by considerable trophic disturbances of nerves and mus- cles. In many cases the nutrition and the electrical excitability of these parts suffer not the slightest change ; such cases are always due to circumscribed disease of the entire transverse sec- tion of the cord, or a disease of the white substance, which may be of great extent. The affection of these parts seems, therefore, to have nothing to do with the nutrition of the nerves and mus- cles ; an inference which is certainly correct in regard to the entire posterior columns and the posterior section of the lateral columns, but is still doubtful in respect to the portions of the anterior columns which are traversed by the anterior roots. It seems certain, however, that in all cases of paraplegia without atrophy the gray substance—at least that of the anterior columns —is not altered to any considerable extent. There are also cases in which a simple atrophy of the muscles occurs, which may make great progress, and may even emaciate the legs to the condition of a skeleton ; the histological condition of the muscles remaining for the most part intact, with only a diminution of the breadth of the fibres, and in places a certain increase of interstitial fatty tissue, but without a trace of pro- liferation of interstitial connective tissue, of multiplication of the nuclei in the muscles, etc. In correspondence with this condi- tion, the electrical excitability remains entirely intact, with, at the most, a slight quantitative diminution, and the reflex actions are mostly present. This form of atrophy occurs in the later stages of tabes, in many cases of chronic myelitis, in paralyses due to compression from vertebral caries, etc.; it appears most frequently to attack persons who are debilitated or weakly. This simple atrophy is commonly referred to the palsy, the long - continued disuse of the parts, but we are not content with this explanation in all cases. We cannot but think that certain distinct changes in the spinal cord must exist before this form of atrophy can come to pass. At all events, this question is still in great need of inves- GENERAL SYMPTOMATOLOGY. 115 tigation, both in its histological and its pathogenetic relations. Our present knowledge of it is extremely small. The same is true to a certain point of the most important form of disease of nutrition in nerve and muscle, the degenera- tive atrophy. In certain spinal affections, this is developed very quickly and in a strongly-marked form. Although the histologi- cal account of this disease is in many respects defective, espe- cially in the earlier stages, yet our present knowledge, in connec- tion with the results of electrical examination (which invariably gives the "reaction of degeneration") points with tolerable cer- tainty to the conclusion that the essential histological changes are the same as those which so invariably follow severe traumatic lesions of peripheral nerves—fatty degeneration and atrophy of the nerve-fibres, simultaneously with proliferation of cells and hyperplasia in the neurilemma ; atrophy with increase of nuclei and chemical changes in the muscular fibres, simultaneously with proliferation of the interstitial connective tissue ; and in the last stages excessive loss of muscular substance and transformation into connective tissue with secondary deposition of fat. We would refer the reader to the full description of degenerative atrophy of the nerves and muscles given in Volume XL, p. 411. We are convinced that the changes are essentially the same ; it remains, however, to be decided by more careful examination whether the process in spinal diseases runs its course with the same rapidity and intensity as in traumatic palsies, and whether there are not certain differences in degree, which require further statement. This degenerative atrophy occurs regularly in the so-called spinal palsy of children and the analogous affection of adults ; it is regularly found in the typical form of progressive muscular atrophy (atropine muscul. progress, protopathique of Charcot); it appears to occur also in the sclerose laterale amyotrophique described by Charcot,1 and in many other spinal affections, when- ever they implicate the gray substance of the anterior cornua. The past few years have given us a series of discoveries in relation to the spinal palsy of children and progressive muscular 1 Lecons surles maladies du systeme nerveux. II. Ser. 3. fascic. p. 213 et seq. 1874. 116 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. atrophy (which we may regard as types of the spinal affections here considered), which indicate a great improvement in our knowledge of the trophic functions of the spinal cord. It has been shown that these diseases are uniformly associated with an affection of the anterior cornua, in the former case acute, in the latter chronic, which regularly and in quite a peculiar way involves the great motor ganglion cells. The most recent observations, without ex- ception, state this point, which was formerly almost always overlooked, owing to defective methods of examination. It would lead us too far, if we were to undertake to enumerate and criticise all these observations. We would refer to the memoirs, chiefly published in the Archives de physiol. norm, et pathol., by Charcot, Joffroy, Hayem, Duchenne, Vulpian, Pierret, G-ombault, Troisier, and others, and the experiments of Voisin and Hanot, Lockhart Clarke, Roger and Damaschino, Roth, and others, which are thoroughly convincing. These observations contain in addition a series of facts which decidedly refute the view that the affection is due to an inflammation conducted from the primary focus in the cord to the nerves and muscles ; but further special observations on this point are desirable. Observers are not agreed as to whether the change of the ganglion cells is primary, or whether it is the consequence of an interstitial myelitis. That, however, is a subordinate question, as concerning the object of our study. It appears to be certain, at any rate, that functional injury or destruction of these great ganglion cells of the anterior columns is most closely related to degenerative atrophy of the nerves and muscles. It certainly can hardly be doubted any longer that the trophic centres for the motor nerves and muscles are situated within the gray substance of the cord, very close to the point where the anterior roots of the nerves concerned enter. While this is ren- dered exceedingly probable by the above facts of local destruc- tion of the anterior cornua, it is on the other hand strongly sup- ported by the fact that the degenerative atrophy is absent, even in cases of the severest spinal paraplegia, when the correspond- ing sections of the gray substance are intact. Compare upon this point two cases given by Burckhardt.' 1 Physiol. Diagnostik der Nervenkrankh. p. 264. Beob. 45 und 46. GENERAL SYMPTOMATOLOGY. 117 Of the nature of the connection between these trophic centres and the peripheral parts, of the manner in which, and the chan- nels through which their influence is distributed from the one to the other, we are ignorant; and the boldest hypotheses are allow- able. Anatomy and physiology are not informed of the exist- ence of proper trophic nerve-paths ; but of those who write upon the subject, one party regards them as a physiological postulate, while the other refers the transmission of trophic influences to the motor and sensory fibres. I have attempted to show,' by the comparison of a series of mutually corroborative cases, that the trophic paths cannot be fully identical with the motor. Those facts certainly show that the motor and the trophic paths must be distinct at some points, as they are capable of being diseased independently of each other. Such separation certainly exists in the central organ ; but it is as yet doubtful how far outwards it extends—whether motor and trophic fibres run separately as far as the periphery, or whether the motor fibres are also capable of conducting the excitation from the trophic centres. Burck- hardt2 is of the latter opinion, and claims for the great ganglion cells of the anterior cornua the function of centres of nutrition for the motor fibres which pass from them, and for the muscles. In fact, the recent investigations into the structure of the gan- glion cells furnish a ready and plausible form for conceiving of the double or manifold functions of these great ganglion cells. If the plan which Max Schultze3 gives of the fibrillary structure of the ganglion cells is correct in the case of the human subject — and that can hardly be doubted — it can easily be conceived how such a cell may form the point of union of fibrils of the greatest variety of physiological rank (motor, co-ordinatory, reflectory, etc.), which unite, in part, in the nerve-process, and enter the anterior roots. While thus the cell serves as the point of union for these various fibres, it is also capable of acting as a trophic centre for them, and of sending from its own substance trophic fibrils to the anterior root-fibres. The well-known fibril- 1 Ein Fall von Bleilahmung. Arch. f. Psych, u. Nervenkrankh. Bd. V. 1875. p. 445. 2 Loc. cit. p. 271. 3 Strieker's Handb. der Gewebelehre. p. 130. 11.8 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. lary composition of the axis-cylinder would even permit us to dispense with the hypothesis of trophic nerve-fibres, as the axis- cylinder of the motor nerve may easily be supposed to contain fibrils of very various physiological functions. We will not, however, enter too far into the field of purely hypothetical con- siderations. One last question is still awaiting a decision—the question whether the processes of degenerative atrophy should be referred to an irritation or a palsy of the trophic central apparatus. Charcot * is of the former opinion, thinking that irritation of the trophic ganglion cells and the trophic fibres produces degenera- tive atrophy, while simple paralysis, or separation of the cells from the peripheral parts, leaves the nutrition of the latter intact. He bases his opinion chiefly upon the supposed fact that crush- ing, inflammation, and similar injuries of the peripheral nerves act in a different way from simple section ; in the latter case the characteristic histological changes being supposed not to occur. The incorrectness of this position is sufficiently proved.2 The processes of infantile spinal paralysis also render this assump- tion quite impossible; for, firstly, the initial phenomena, the complete palsy, etc., make an increase of the activity of the ganglion cells very improbable ; and secondly, the complete dis- appearance of the cells, which is demonstrated in the later stages of all such cases, would necessarily (upon Charcot's theory) re- sult in repair of the disturbances of nutrition, so that the nerves and muscles would return to their normal state — which is the contrary of what we know to be the case. We are, therefore, at present of the opinion that a paralysis or destruction of the central trophic apparatus, or a separation from the peripheral parts, produces the symptoms of degenerative atrophy. This may make the matter harder to understand, but we are obliged to take the facts as they are. Upon the whole, we are justified by the present state of our knowledge in assuming a disease of the anterior cornua when the electrical examination shows the existence of the reaction of de- 1 Lecons sur les maladies du systeme nerveux. 1872-3. pp. 19, 23, and ch. 2. 2 Erb, Zur Pathol, und pathol. Anat. peripherer Paralyse. Deutsch. Arch, f. klin. Med. Bd. V. p. 53. GENERAL SYMPTOMATOLOGY. 119 generation, and consequently of degenerative atrophy of nerves and muscles, provided the disease is clearly of spinal origin. It is well known that an increased deposit of fat in the interstitial connective tissue of the atrophied muscles is not rare in the later stages. I have very recently Been a case of palsy from spinal apoplexy, in which the muscles of the calf, at first atrophied, became by degrees excessive in size, probably from deposition of fat, the paralysis continuing.1 This is a kind of pseudo-hypertrophy of the muscle. But it is still a controverted point whether the peculiar disease known by this name (also atrophia musculorum lipomatosa, paralysie musculaire pseudohypertrophique, etc.) is of spinal origin; Charcot, Eulenburg, and Cohnheim are opposed to this view; L. Clarke, O. Barth, and others, are in favor of it; Friedreich considers the disease as a mere progressive muscular atrophy modified by certain peculiarities of infancy; and W. Mueller likewise considers the lipomatosis as a more or less acci- dental complication of the atrophy. At all events, we must wait for further investi- gation of the matter. The same must be said of those cases of true muscular hypertrophy—rare at pres- ent—which have been found sometimes alone (Auerbach, Berger), and sometimes accompanied by progressive muscular atrophy (Friedreich2). The neurotic origin of these cases cannot at present be established. They should not be confounded with the hypertrophy from use, which occurs here and there in muscles which have had to do double duty on behalf of paralyzed ones. A good instance of this is presented by the left sartorius, in the case described by me, as above mentioned.3 Trophic disturbances in the structures of the skin are very common in spinal disorders. Those of the epidermoid structures are of subordinate importance, although their theoretic interest is considerable. For instance, in some cases of spinal palsy an abnormal growth of hair4 has been observed. Closely associated with other disturbances of the skin, with atrophy of the muscles, etc., occur decided alterations of the nails, deformity, increased curvature, and furrowing, clubbed swelling, yellowish or brown- ish discoloration, and the like. The changes of the skin itself are more important.6 First, and not infrequently, erythematous 1 Arch. f. Psych, u. Nervenkrankh. Bd. V. Heft 3. p. 782. 2 Ueber progress. Muskelatrophie, ueber wahre und falsche Muskelhypertrophie. Berlin. 1873. Cap. VI. 3 Loc. cit. Bd. V. p. 780. 4 Jelly, Brit. Med. Jour. 1873. June 14. 5 Compare in particular the beautiful account given by Charcot in his Clinical Lec- tures. 120 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. spots and eruptions, which may appear almost anywhere, and usually are very transient; then lichenoid or papulous erup- tions, extending over greater or smaller portions of the skin, often restricted to the district of a single nerve or to a single limb ; not infrequently wheals of urticaria, of greater or less size and extent, usually accompanied by violent itching; or herpes zoster, in its characteristic mode of appearance ; and finally, in rare cases, pustule-formation, related to pemphigus and ecthyma, and usually leading to ill-looking and badly-heal- ing ulcerations. Besides these alterations, which remind us of the appearances of well-known and typical diseases of the skin, there occur others of a more diffuse sort; uniform thinning of the skin, abnormal smoothness and shining look of the epidermis, connected with more or less livid redness ("glossy skin")—changes of which we have spoken in Vol. XI., p. 409, under Paralyses; on the other hand, there are often abnormal thickening and swelling of the skin and subcutaneous cellular tissue, not seldom connected with oedema, or gradually developed from it. Our knowledge of the theory of all these phenomena and their special connection with the spinal cord and with the dis- eases of certain sections of it, is still very defective. The idea that they may be of neurotic origin is hardly yet familiar, but from what parts they may originate, and how, is still a matter for guesses merely. In some cases they are usually associated with violent sensory phenomena (the lancinating pains of tabes, etc.); hence it has been inferred that they might depend on an irrita- tion of trophic fibres—a position which is strongly supported by the manner in which herpes zoster occurs in neuralgia and after neuritis ; on the other hand, it is not to be denied that another group of these phenomena occurs only under circumstances which almost conclusively point to paralysis of the trophic paths. At present it cannot be decided with certainty what special part the irritation or paralysis of trophic fibres takes in the produc- tion of cutaneous changes. The peripheral channels through which the trophic influence passes to the skin and its adnexa appear beyond a doubt to lie in the sensitive nerves ; this is supported by a large number of GENERAL SYMPTOMATOLOGY. 121 unquestionable facts. But it is still doubtful where the centres for the nutrition of the cutaneous structures are situated. They appear, at all events, not to be in the anterior cornua; this fol- lows from our experience in regard to the spinal paralysis of children. And, as the gray substance is the only probable region, there remain only the posterior cornua, or the spinal ganglia; the latter site has been rendered probable by many facts, and is accepted by several authors. We must leave it for the future to establish the influence of these structures upon the nutrition of the skin. By far the most important trophic disturbance which the skin experiences in spinal disease is gangrene from pressure or bed- sore. Its occurrence is a sign of the greatest danger, and is often decisive of the prognosis. In practice it is well to distinguish two forms : the one is acute, is caused by slight irritation or brief pressure, is preceded by an inflammatory eruption, appears a few days after the beginning of the central lesion and leads rapidly to gangrenous destruction (decubitus acutus of Samuel); the other, more chronic in its origin, accompanies the later course of spinal diseases, is chiefly dependent on prolonged pressure, and takes the form of simple gangrenous death of the skin and the subcutaneous tissue (decubitus chronicus). Decubitus acutus, of which Charcot (1. c.) has given a very vivid picture, usually begins a few days after any severe spinal lesion or after a severe exacerbation of a spinal disease, and is characterized by a very rapid development. Upon a portion of skin which has been exposed to pressure or'to any irritation (and often when no such circumstance has occurred), erythema- tous spots appear, which are soon covered with vesicles, the con- tents of which, at first clear, become rapidly brownish or reddish ; under favorable circumstances these vesicles may dry up, and the spot recovers without further change ; but this is not com- monly the case; the vesicles burst and leave ill-looking ulcera- tions, the basis of which is composed of the skin, infiltrated with blood, and usually in a state of phlegmonous inflammation. The base of the ulcer perishes by gangrene, the neighboring skin is infiltrated with blood, and inflamed to a greater and greater ex- tent, the gangrenous destruction goes deeper and deeper, laying 122 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. bare and including in its destructive operations tendons, fasciae, ligaments, and bones. This entire cycle of processes is complete in a few days, and cannot be avoided by any care or cleanliness ; at the same time, cystitis and haematuria are sometimes observed, or the muscles become the prey of a rapid atrophy. The consequences of such extensive gangrene soon appear; violent fever with severe chills and great variations of tempera- ture, a septicaemic condition, purulent infection, gangrenous thrombosis and embolism occur, and the fatal result is preceded by a general marasmus; or the gangrene extends still further into the interior of the vertebral canal, when a purulent or icho- rous meningitis, rapidly ascending to the cranium, soon closes the painful scene. Simple chronic decubitus usually originates in a somewhat different way. In chronic diseases of the spinal cord, in para- plegias, there is seen a diffuse dark redness of the portions which are most pressed upon in sitting or lying; often mingled with superficial ulcerations. Some day there appears upon this red- dened portion of skin a black spot, which rapidly enlarges if the pressure is continued. The skin dries to a black leathery mass, around which a bounding line of inflammation soon appears, which under proper treatment leads to a throwing off of the gan- grenous layer, and cleaning up of its base, with the formation of granulations. But if the pressure is continued, the ulcerated surface assumes a bad, unwholesome color from infiltration with blood, the inflammation assumes an appearance more like that of a phlegmon, and the gangrene may spread rapidly, deeply, and cause horrible destruction. And then the symptoms above named as characteristic of acute decubitus appear and soon put an end to the patient's life. This form of gangrene may occur at any place which is exposed to a continued pressure, but is far the most common on the coccyx and buttocks, next over the trochanters and ischiatic protuberances, heels, and knees, the spinous processes of the vertebrae, the shoulder-blades, elbows, etc. In severe cases of this sort, the patient, with his numerous large sores, presents the very picture of wretchedness. Nor is the end of this misery GENERAL SYMPTOMATOLOGY. 123 always speedy; if attention and care be given, the sores often clean up, good granulations appear ; but the tendency to heal is very slight, and it is a desperate while before cicatrization occurs. I have seen a patient, who had nine large bed-sores and several small ones, linger along for over a year under faithful care. Though some places may cicatrize, a new sore will appear here or there; the occurrence of bed-sores, therefore, unless they improve rapidly and considerably, must always be considered a very bad omen for the patient. The occurrence of acute decubi- tus renders the prognosis extremely bad in all cases. Very various accounts are given of the way in which bed-sores originate. Continuous pressure is commonly thought to be the chief cause of the bed-sore ; its action is supposed to be considerably favored by the complete immobility of paralyzed patients, by the absence of sensation in some others, by the filth from the bladder and rectum which is liable to accumulate; the more of these causes are present, the more confidently is the occurrence of bed- sores expected. In fact, we may count with certainty on the appearance of bed-sores when all these causes coincide. But this by no means proves that the sores are due to such causes. In acute myelitis of the anterior columns (spinal paralysis of children, etc.), in many forms of hysterical palsy, in fractures of the thigh, and similar cases, we find abundant proof that long-continued pres- sure, palsy, etc., are not by themselves adequate to produce bed- sores. Charcot has seen decubitus acutus occur, even when all pressure and all befouling of the person was avoided. It seems therefore absolutely necessary to seek for another explanation. The vaso-motor paralysis, which is commonly present, and the anaesthesia, have been thought of ; but it is easy to prove that this view is incorrect, and that both these circum- stances act only as facilitating the action of pressure, which itself is not the essential element in the production of bed-sores. It is manifest that there must be some very special changes in the nervous system, special influences added or subtracted, in order to produce such fearful gangrenous destruction in patients whose general health is good, and the action of their hearts 124 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. vigorous. Such influences may most properly be called trophic. In chronic decubitus we may assume that the trophic disturb- ances cause a diminished power of resistance, a lessened vital turgor, on the part of the skin, which, in connection with the weakness of the circulation caused by the vaso-motor paralysis, probably explains the gangrene of pressure ; as to acute decubi- tus, Charcot believes that he has proved that it is caused by a "violent irritation of a more or less extensive district of the spinal cord." Acute decubitus is found associated chiefly with severe trau- matic lesions of the cord (compression and destruction en masse by fractures of the vertebrae, etc.), in acute myelitis, haematomy- elia, and the like ; it has also been observed in unilateral trau- matic lesions of the cord, upon the anaesthetic side only, not on the paralyzed side. Chronic decubitus is found in chronic myeli- tis transversa (affecting the cord diametrally), in the last stages of tabes, in paraplegiae of slow origin, and similarly also in peri- pheral palsies in the district of the cauda equina. If the latter originate acutely, e. g., by fracture of the sacrum, they may themselves be followed by acute decubitus. It seems to us that the one element which the above affections share in common is rather the destruction and paralysis of cer- tain parts than their irritation, and we think it most probable that the chief cause of the decubitus in spinal affections is the paralysis of certain trophic centres in the cord, or their severance from the peripheral parts; in certain cases of acute decubitus, however, it is not yet proved that the disease does not originate in irritation. The exact location of these trophic centres is as little known to us as is the way in which they exercise their trophic influence upon the skin. Many things render it probable that they are to be found in the gray substance, especially in the central portions and the posterior cornua, and that the paths which begin in these parts are situated in the posterior roots. Observations of unilateral lesion of the cord have also made it probable that the trophic fibres for the skin decussate in the cord like the sensory fibres. The relations of the spinal ganglia to these processes are not clear. GENERAL SYMPTOMATOLOGY. 125 The conclusions in regard to the seat and nature of the spinal affection, which are to be drawn from the occurrence of bed- sores, are obvious. The bones often undergo trophic disturbances in spinal dis- ease. One of the commonest symptoms in the spinal paralysis of children is arrest of growth of bones. The bones of the ex- tremities remain short and small, the limbs are shortened, the pelvis displaced, and the spinal cord in consequence curved. If a series of cases be compared, it will plainly appear that this impairment of growth is not always proportional to the muscular atrophy or the degree of palsy ; it is to a certain extent indepen- dent of these circumstances, and in such cases the paralysis and muscular atrophy may be the chief feature in one limb, and the atrophy of the bone in the other. In other cases, on the contrary, a swelling, thickening, hy- pertrophy of the bones is observed ; they become heavier, and are often greatly enlarged, especially at the joints. This condition may coexist with pseudo-hypertrophy of the muscles, or with degenerative atrophy. A closer examination, however, shows that in all such cases the essential element is a hyperplasia of connective substance, both in the bone-tissue and in the muscles. An abnormal brittleness of the bones has been observed in very rare cases. There can be no doubt that the majority of these changes depend on disturbances of the nervous system. The facts of infantile spinal paralysis render it almost certain that the trophic centres for bones are in the anterior cornua, but that they are certainly not identical with those for the muscles. Further exact study of these conditions is needed. Especial attention has been lately given to the trophic dis- turbances of the joints, which occur in many spinal diseases, and are very interesting. It is very common, both in spinal and peripheral palsies, to find slight swelling, stiffness, a little pain, and a moderate amount of ankylosis of the joints. This is probably due in part to long disuse, and occurs in like manner after the long wearing of a plaster of-Paris bandage, but it is partly, no doubt, of ner- vous origin. 126 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Charcot's admirable researches l have very recently placed before us an extremely characteristic affection of the joints, of manifestly nervous origin, chiefly associated with tabes ; its char- acteristic symptoms are an abundant serous discharge, wasting of the cartilages and bones, subluxations, and the like. This is the so-called spinal arthropathy of tabes. This affection of the joints is very strikingly different from the ordinary spontaneous inflammations of a rheumatic or trau- matic origin. It much prefers the knee-joint; after that, in diminishing frequency, the shoulder, elbow, hip, and wrist joints. It begins, usually suddenly and unexpectedly, without any ex- ternal cause, and its first symptom is a large diffuse swelling of the joint, caused by an abundant exudation of serous fluid in its cavity ; fever, redness, and pain are usually altogether want- ing. The adjoining parts are always considerably swollen, which often extends to nearly the entire extremity. This swelling is partly cedematous, and partly of a harder nature. It usually disappears in a few days and the articular effusion likewise, after which the ends of the bones come in contact, are worn away and their cartilages and ligaments destroyed; these changes are indicated by a good deal of cracking and rubbing noise in the joint. Deformities of the joints are the result—sub- luxations, loose joints, and the like. This may continue for months or years and then disappear, but usually the changes which result are incurable. These advanced stages, when examined anatomically, exhibit the marks of arthritis sicca, but with this distinction: that the erosion of the articular extremities is considerably greater than the growth of new bone. This arthropathy is most common in the early stages of tabes, and chiefly in the preliminary period, before the atactic disturb- ances of motion have appeared, and when the lancinating pains constitute the chief feature of the complaint. It has, however, been observed in the same, or nearly the same, form in compres- 1 Cf. Charcot, Arch, de Physiol. 1. 1868; II. 1869; III. 1870 (with Joffroy); and Clinical Lectures on Diseases of the Nervous System. I. and II. series.—Ball, Gaz. des Hop. 1868 and 1869.—Buzzard, Lancet. 1874. Aug. 22.— Weir Mitchell, Amer. Journ. Med. Sci. April. 1875. p. 339.—See also below, section on Tabes Dorsalis. GENERAL SYMPTOMATOLOGY. 127 sion of the cord from vertebral disease, in acute myelitis, progres- sive muscular atrophy, traumatic unilateral lesion of the cord (on the palsied side), etc. It can hardly be doubted that this arthropathy depends on disturbances of the nervous system. Charcot has supposed that they were referable to a pathological irritation of central trophic apparatus, and has, in fact, found in autopsies of tabetic patients suffering from this arthropathy, an atrophy of corresponding portions of the gray anterior pillars and disappearance of their ganglion cells. But in a later case he has failed to find this lesion, in spite of careful search, which discovered marked altera- tions in the spinal ganglia. Further examination is therefore needed to decide this difficult question. The rarity of the arthro- pathy in spinal palsy of children, and its close connection with tabes, certainly require of us great care in forming an opinion. Of trophic disturbances of the intestines in spinal disease we know little, and this little will be set down under the proper heads hereafter. The general nutrition, in most spinal diseases, suffers only in very exceptional conditions, or when the duration is very pro- tracted. It is not rare to see a spinal patient in the most hope- less case—paraplegic, or excessively atactic—confined to his bed or the wheeled chair, who nevertheless looks very well in com- plexion, is muscular and plump, has a good appetite and diges- tion, and for years and tens of years enjoys a tolerable existence. In other cases the nutrition fails fast, the general health is much impaired, the patient sinks rapidly into marasmus. The causes of this loss of health are as follows: continued rest, want of motion and fresh air, poor digestion, severe pain which takes away sleep, fever, malignant new-formations, and, above all, cystitis and bed-sores. We shall see in the course of this account that these causes are very frequent, and accompany all sorts of spinal disease. The state of the general bodily temperature, and the fever of spinal diseases, may here be mentioned. The local changes of temperature, limited to single extremities or parts of bodies, are accounted for by the vaso-motor disturbances 128 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Inflammations of the cord are accompanied by fever, like those of the other organs. Its type and course will be described under the several diseases of the cord, as acute meningitis, acute myelitis, acute spinal paralysis, paralysis ascendens acuta, etc. Fever also occurs in consequence of many complications of spinal dis- ease, as in gangrenous bed-sore, etc. This is of subordinate importance at present. On the other hand, the often enormous rise of temperature which accompanies or closes many severe spinal diseases, and which is of great theoretic interest, deserves a brief mention here. This phenomenon is commonly ascribed to the " neuroparalytic agony," and has been frequently observed and several times criti- cally described in severe disease of the various parts of the nervous system, espe- cially in severe lesions of the cord.1 The chief interest for us lies in those cases where, after crushing and injury of the cervical medulla, the bodily temperature continued to rise, and finally reached an enormous height (42.9-44.0° C.=109° to 111.3° Fahr.), followed by death. The first case of this kind was observed by Brodie; other similar ones are given by Billroth, Simon, Quincke, Fischer, and others. Unusually high temperatures have also been observed in the agony of tetanus (Wunderlich), of meningitis cerebro- spinalis (Erb), etc. Very lately, J. W. Teale2 has published a case of spinal disease, perhaps inflammatory, caused by an injury, in which the axillary temper- ature several times reached the incredible height of over 50° C. (122° F.) ; the case nevertheless recovered. With a view to explaining the connection between this rise of temperature and the spinal lesion, various experimental observations have been made which, how- ever, have not yet furnished conclusive results. It has been found that section of the dorsal cord produced a depression, while section of the cervical cord in the neighborhood of the pons produced a considerable rise of temperature (Tscheschi- chin); that crushing of the cervical cord uniformly raised the temperature, if pe- ripheral cooling was prevented by suitable measures (Naunyn and Quincke); and finally, that an injury of the cervical cord produces no rise of temperature, provided the anterior columns are spared (Fischer). It would lead us too far, to attempt to give the conclusions drawn from these ex- periments in respect to the exciting and moderating influence of the spinal cord upon the development of heat. In doing it we should have to enter upon the theory of fever, which is confessedly one of the most difficult parts of general pathology. 1 For further information see the following : Wunderlich, Archiv der Heilkunde. II. p. 547; and III. p. 175.— Brodie, Med. Chir. Trans. 1837. p. 416.—Billroth, Beo- bachtungsstudien iiber Wundfieber. 1862. p. 158.—Erb, Deutsches Archiv f. klin. Med. I. p. 175. 1865.—Tscheschichin, Reichert und Du Bois' Archiv. 1866. p. 170.—Naunyn and Quincke, Reichert und Du Bois' Archiv. 1869. pp. 174 and 521.—Quincke, Berl. klin. Wochenschr. 1869. No. 29.— II Fischer, Centralbl. f. d. med. Wissensch. 1869. No. 17.— B. Heidenhain, Pflueger's Archiv. 1870. p. 578.— Biegel, Ibid. Bd. V. 1872. p. 629.—Naunyn and Dubczanski, Arch. f. exper. Path. u. Pharmak. I. * Lancet, 1875, March 6, p. 340 (Clinical Society of London). GENERAL SYMPTOMATOLOGY. 129 For the present it seems to us most natural to assume, with Naunyn and Quincke, that in these experimental lesions of the cervical cord, as well as in those of a pathological nature, there is a paralysis of certain paths which serve to restrict the production of heat. At the same time, however, an extensive vascular paralysis takes place, whereby an increased amount of heat is given off, which more or less compensates for the increased production. According to the preponderance of one or the other factor, the rise of temperature will be more or less considerable, or may be absent or even a minus quantity. Here much plainly depends on accidental external circumstances (temperature of the air, covering of the body, proportion of surface to weight of body, etc.). It is found, however, that an increase of the bodily temperature is most prominent in lesions of the cervical cord. The whole question deserves a fresh investigation, in view of the recent discoveries of Goltz respecting the vaso-motor centres in the cord. The experiments cited have shown that in cases of section of the cord a lowering of temperature often occurs, especially where the effect of the vaso-motor paralysis is chiefly directed to the loss of heat from the surface. A similar condition exists in many diseases of the spinal cord; mechanical lesions (Fischer, 1. c, Nieder'), chronic myelitis, the closing stage of tabes, etc. The temperature falls to 35°, 32°, 30° C. (95°, 90°, 86° Fahr.), or even lower ; the patients meanwhile often live on for days and weeks. These are probably sometimes the temperatures characteristic of collapse, but at other times they are doubtless due to excessive loss of heat from vaso-motor paralysis. 6. Disturbances in the Urinary and Sexual Apparatus. These are among the most important symptoms, for they always inflict great discomfort, and often influence the prognosis seriously. Our acquaintance with them, it must be admitted, is in many points defective. a. Disturbance of the Secretion of the Kidneys. But little is known of this at present, in spinal affections. In various spinal lesions, especially the more severe and acute forms, considerable changes in the character of the urine rapidly appear, but it is not yet clearly settled how far the kidneys and their innervation are directly concerned in this. After crushing of the cord by fracture of the vertebrae, after knife-wounds of the cord, after spinal apoplexy, in acute myelitis, etc., we often see 1 Med. Times and Gazette. 1873. No. 1180. VOL. XIII.—9 130 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. the urine becoming turbid and slimy in a few days after the event, with blood and pus, with alkaline decomposition and its inevitable results, triple phosphates, and a horrible smell. It is generally thought that this change is caused in the first place by retention and ammoniacal decomposition of urine in the blad- der, the result of which is a cystitis and an inflammation of the kidneys, secondary to the cystitis. Rosenstein1 believes that he has obtained certain proof of this. But Charcot,2 in view of the very rapid appearance of change in the urine, and the ecchymo- ses and foci of inflammation repeatedly found in the kidneys very soon after the spinal lesion, is forced to the conclusion that the spinal affection may be of itself the cause of the acute inflamma- tion of the kidneys, and he lays special weight upon the element of irritation in these spinal lesions. Whether the case is similar in chronic disease, or whether in the latter the affection of the kidney is always secondary to that of the bladder, is likewise undecided at present. Still less is known about anomalies of secretion, or extensive anatomical changes. The increased excretion of phosphates, observed in many chronic spinal cases, occurs in many other neuroses. In respect to the alteration in the quantity of urine in spinal diseases very little information is furnished by human pathol- ogy. An analogy with the temporary suppression of this secre^ tion, observed by Eckhard after section of the cord, may proba- bly be found in a case of laceration of the cervical cord, observed by Brodie, in which the quantity of urine passed was extremely small. A considerable increase of the secretion sometimes occurs, a literal diabetes insipidus, accompanying spinal diseases (Fried- reich, in degenerative atrophy of the posterior columns); it may be assumed with probability in these cases that the process has extended to the medulla oblongata. 1 Pathol, n. Ther. der Nierenkrankheiten. 2. Aufl. p. 287. 2 Lecons sur les maladies du systeme nerveux. 1872-3. p. 117. GENERAL SYMPTOMATOLOGY. 131 b. Disturbances of the Bladder and Changes in the Charac- ter of the Urine. Spinal patients, without number, are attacked after a longer or shorter time by such disturbances, the occurrence of which always marks an unfavorable phase of the disease, owing to the difficulty of giving relief and the fact that they very often form the starting-point of the most serious complications. These disturbances almost always begin with the paralysis of the bladder, so common in spinal complaints, and the consequent retention and stagnation of urine in the bladder. In the chronic cases, which are the more frequent, and in which there is often no other complication than an incomplete and an infrequent evacuation of the bladder, decomposition of the urine occurs with slight alkalescence and deposition of con- cretions in the bladder; the consequence of this is a catarrhal cystitis, with formation of mucus and pus, abundant develop- ment of vibriones (which increases the facility of decomposition), an alkaline reaction, and a foul ammoniacal smell of the urine. Examination of the turbid urine shows a muco-purulent deposit, a few blood-corpuscles, numerous crystals of triple phosphate, vibriones, etc. The mucous membrane, at first in a state of catar- rhal inflammation, is covered by degrees with erosions, is thick- ened and swelled, contains hemorrhages and pigment-deposits in its substance ; the muscular coat of the bladder is hypertrophied, the wall of the bladder is thickened and retracted, etc. Purulent pyelitis and purulent disseminated nephritis very soon appear. This is the usual condition at the close of chronic spinal diseases (myelitis chronica, tabes dorsalis, etc.). In quite acute cases the affection of the bladder not rarely opens with haematuria, with which are associated acute purulent or even ichorous cystitis, pyelo-nephritis, etc., very quickly lead- ing to the most extensive decomposition of urine with all its con- sequences, high fever, uraemia, etc. It remains to be proved whether the stagnation of the urine, produced by the vesical paralysis, is the sole cause of all these disturbances, or whether, as is extremely probable in acute cases, 132 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. and is certainly possible in chronic cases, the lesion of the cord of itself constitutes a distinct cause of this inflammatory condi- tion of the bladder and all its consequences. We know nothing certainly in respect to the nervous paths and centres in the cord which are concerned in these processes. But it is certain that these conditions of the bladder may lead to the severest disturbance of the whole system, by the fever, the loss of fluids, and the retroaction upon the kidneys, which are associated with them. c. Disturbances of the Function of Urination. This very common and important class of symptoms compre- hends many varieties, differing in their origin and course, as might be expected in the case of such complicated mechanism. In the chronic cases, wirich are by far the most common, the first symptom is frequently a certain difficulty in passing water ; the patient has to wait a longer time than usual, has to press more strongly in order to set the process going, and when the stream comes, it is small and slow, and at the close there is a more or less prolonged dribbling. Later, this increases more and more, and actual retention of urine occurs, which compels the regular use of the catheter, or may produce the "ischuria para- doxa," in which a distended bladder keeps up a constant drib- bling. It is, however, possible that the retention may go on to the production of actual incontinence. But, on the other hand, incontinence of the bladder may be the first s}nnptom ; the patient has to make haste the moment he feels the inclination to pass water ; soon the discharge occurs at the same time with the inclination, and at the last it comes unexpectedly and involuntarily, is often quite unnoticed, and passes into the bed, the clothes, etc., at any time. The discharges may be considerable in quantity, and take place at certain inter- vals, or they may be frequent and small, or the urine may drib- ble constantly. Any of these disturbances may be further com- plicated by the appearance of cystitis. In acute cases (sudden destruction or squeezing of the cord, myelitis acutissima, spinal apoplexy, etc.) complete retention GENERAL SYMPTOMATOLOGY. 133 usually exists from the outset, or within a few days. In many cases, as in experimental section of the cord (Goltz), it is merely the result of concussion of the entire cord, and depends on paral- ysis of the centres in the lumbar cord. Soon, however, the spon- taneous (though not the voluntary) discharge returns, and passes directly into incontinence. The form which is assumed by the incontinence then depends essentially upon the seat of the lesion and the secondary changes in the cord. There either occurs, from time to time, a full, regular discharge of the bladder against the patient's will, and often without his knowledge—a sign that the reflex centre in the cord is in existence and the detrusor is not palsied—or there is ischuria paradoxa, an excessive fulness of the bladder with continual dribbling, in which case either the reflex centre is paralyzed and destroyed, or else the peripheral paths are interrupted. The detrusor is paralyzed together with the sphincter. The bladder is at first excessively distended, often reaching nearly to the navel; but subsequently, owing to catarrh of the bladder and hypertrophy of its wall, its dimen- sions diminish continually, though the incontinence continues unchanged. Subsequently the symptoms may alter as partial improve- ment occurs in one or another of the nerve-paths ; but the above description will be recognized as giving the ordinary traits of spi- nal paralysis of the bladder. With our present knowledge of the mechanism of the evacua- tion of the bladder (see p. 54), it is not difficult to understand how the various forms of paralysis originate. It is, however, in special cases, often extremely difficult to decide which nervous apparatus is involved, as most of the symptoms may originate in more ways than one. The complexity of these conditions will best be shown by a brief mention of the disturbances which may follow lesions of different portions of the paths which convey the innervation to the bladder. The evacuation of the bladder may be interfered with : 1, by lesion of sensory and motor peripheral paths ; 2, by lesion of the reflex centres in the lumbar cord ; and 3, by lesion of the sensory or motor paths which lead to the brain above the lumbar region. 134 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. If the peripheral sensory nerves of the bladder are alone par- alyzed, the patient will probably perceive no further impulse to urinate, but will be able, from time to time, to pass water volun- tarily by the action of the brain upon the centres in the lumbar cord; in this case the patient does not feel the evacuation. If the motor nerves of the bladder are peripherally palsied, the consequence will be retention with incontinence (ischuria para- doxa), in which voluntary urination is impossible. If both sen- sory and motor paths are paralyzed, as in lesions of the cauda equina, ischuria paradoxa, or at least absolute incontinence, will be the unavoidable result. (It is not yet established, whether the bladder, deprived of its spinal innervation, may continue to con- tract independently by virtue of the influence of the ganglionic apparatus situated in its walls.) All this holds good, of course, of the sensory and motor paths within the spinal cord previous to their connection with the reflex centres. If these centres are paralyzed or destroyed, the necessary consequence will be complete retention followed by incontinence (ischuria paradoxa). The utmost that can be accomplished by the patient in such cases will be an incomplete evacuation by the aid of abdominal straining. If the sensory paths on the other side of (/. e., above) the lum- bar cord are alone paralyzed, while the centres in the cord are uninjured, a regular discharge of the bladder will occur from time to time when it has reached the proper fulness; but the patient feels nothing of it, and therefore cannot prevent its occur- rence. If only the motor paths above the lumbar cord are pal- sied, the patient can neither discharge his urine voluntarily, nor arrest, by voluntary contraction of the sphincter, an evacuation which has begun or is threatening; but he feels the inclination to urinate, which immediately excites a reflex evacuation of the bladder, withdrawn as it is from voluntary control. If all the paths above the lumbar cord are paralyzed, the periodical reflex discharges of the bladder take place without the patient's feeling anything of them, and without any power on his part to influ- ence them. In most of the cases of this group the action of ab- dominal straining will not occur; but this does not much alter the symptoms. GENERAL SYMPTOMATOLOGY. 185 We see that all the symptoms that have been described can be thus naturally explained, and it is necessary in each case to examine every circumstance with care, in order to ascertain the precise seat of the lesion. Such experience will soon convince us that the various forms of vesical palsy are very characteristic- ally distinct; it will be easy in particular to decide whether the centres in the cord are in action or not, by irritating the wall of the bladder and producing reflex evacuation. Many cases, how- ever, in which the disturbance is complicated and diffuse or ill- defined, will present insurmountable obstacles to exact diagnosis. The localization of which we have spoken relates rather to ascertaining at what height in the spinal cord the nervous sup- ply for the bladder is intercepted. We know, however, but little of the course taken by the paths concerned within the cord, and therefore are unable to say much about the location of a disease, relatively to the transverse section. The affections of the reflex centres must always be located in the gray substance of the lumbar cord ; yet it should be remembered that a lesion of the root-fibres as they pass out may give rise to just the same disturbances as a lesion of the centres. In the case of the paths which lead to the brain, we must first think of the gray sub- stance ; in that of the motor paths, of the anterior columns also (Budge). Further information can only be given by special in- vestigations. The reflecting reader will find it easy to comprehend the course and the complications of those cases in which the altera- tions begin in a primary focus, and spreading from that gradu- ally include other points in the conductive path; for example, when crushing of the dorsal medulla gives rise to myelitis of the gray substance, which extends downward to the lumbar cord and there paralyzes the centres for the bladder. It will also be easy to form a correct view of the processes of initial or slight dis- turbances of the functions of the bladder.1 1 In these statements we have intentionally avoided making a sharp distinction between palsy of the sphincter and of the detrusor, because, although conceivable theoretically, such a distinction hardly occurs in practice. We have reason to believe that the paths leading to both muscular systems, from the brain as well as from the centres in the lumbar cord, are close together, and therefore, as a rule, are affected 136 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. We have spoken only of spinal paralysis of the bladder ; of its spasmodic affections in spinal disease little is known. As such, we ought perhaps to speak of numerous cases of excessive desire to pass water, or a few cases of ischuria. Nothing precise is known of these cases. d. Disturbances of the Sexual Functions. These have always been considered closely related to the spinal cord, and especially in the causal relation. They form, however, a very prominent portion of the symptoms of spinal troubles, and are much more noticeable in the case of the male sex, owing to the far closer dependence of the function upon the integrity of the cord in this sex than in females. The symptoms in men suffering from spinal disease are: Increased sexual desire and increased sexual excitability; every lustful thought, the sight, or the merest touch of a woman, causes erections. A state of weakness is usually associated with this; in coitus the ejaculation takes place too quickly ; the erec- tions mentioned are often immediately followed by ejaculation; pollutions by day and spermatorrhoea make their appearance. Whether there is really an increased potency, a power to prac- tise coitus normally with unusual frequency, is questionable and is hard to decide, as, even under physiological circumstances, the sexual powers of performance differ extremely in individuals. Far more common is the so-called irritable weakness of the sexual organs, wdiich is especially observed at the beginning of spinal diseases and in functional debility of the cord. In this condition erections easily occur, which are weak, insufficient, and of short duration ; the ejaculation during coitus takes place too soon, occurring before or immediately after intromission of the penis. The sexual sensations during coitus are diminished or quite wanting ; the sexual appetite is lessened ; the performance of the sexual act is followed by great exhaustion—a feeling of weakness, sweating, pain in the back, sleeplessness for several together. It will also be very easy to make out the cases of isolated palsy or weakness of the sphincter, which, properly speaking, is directly subject to the will alone. GENERAL SYMPTOMATOLOGY. 137 hours, etc., and a feeling of great exhaustion usually lasting several days. Repetition of the act is impossible. This condition is followed by diminution and complete loss of potency. The erections become continually rarer and weaker, are confined to the morning when the bladder is full, are usu- ally absent when most wished for, and finally cease altogether. The sexual appetite usually disappears, but pollutions may occur with more or less frequency by day or night with or without sexual feeling ; they may, however, be entirely absent. Priapism is not rare, in the form of frequent and continuous more or less complete erections. The power of copulation may be retained, and the sexual desire increased. Those cases are of more importance in which such pathological erections accom- pany a more or less complete interruption of conduction in the spinal cord; they may originate in apparently a spontaneous manner, when the penis continues for a considerable time in a semi-erected state, more rarely in complete erection; but more usually such erections are reflex, depending on external irrita- tion, introduction of the catheter, friction of the skin of the glans or perineum or of the inner side of the thigh. The investigations of Eckhard and Goltz furnish an easy and plausible theory of the manner in which these various dis- turbances originate under pathological circumstances, of the way in which interruption of the peripheral sensory and motor conduction, paralysis and irritation of the reflex centres in the lumbar cord, or cutting off or irritating the paths which pass from the lumbar cord to the brain, act upon the processes of erection, ejaculation, and copulation. It is not necessary to ex- plain these in detail. It may be added that the present state of our knowledge per- mits us to draw very few conclusions from disturbances of sexual functions, as regards the exact seat and nature of the spinal lesion. As respects the disturbances of sexual function in women who suffer from disease of the cord, little is known. Ovulation, pregnancy, parturition may take place normally, even during severe spinal troubles. In regard to the libido sexualis, and the act of copulation, nothing satisfactory is known. 138 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 7. Disturbances of Digestion and Defecation. Of the chemistry of digestion, the preparation and secretion of the digestive fluid in diseases of the cord, almost nothing is known, though disturbances certainly occur. The secretion of the intestinal juices seems to be impaired in many cases, probably owing to the great tendency to constipation which often exists. The intestinal movements are usually much affected, either in the way of increase or of diminution. The former, of which the symptom is a frequent, watery- slimy diarrhoea, is the less common condition ; it is often capa- ble of being produced reflexly; thus, in a patient with chronic myelitis, I observed the regular evacuation of a mucous fluid mass from the intestine as often as his bed-sores were cleansed, and the like has been seen in dogs whose lumbar cord was cut. Much more commonly there is habitual, often excessively obstinate constipation, of which almost all chronic spinal pa- tients complain. The stool is slowly discharged, dry, and hard, and the evacuation occurs only at considerable intervals, and on application of energetic remedies. Several causes doubtless contribute to this—diminution of the intestinal secretion and of the peristaltic action, and probably also the weakness of the abdominal muscles of compression, which is often present. If there is an extreme degree of weakness, meteorism and accumu- lation of faeces occur, with their consequences. We do not know exactly from what portions of the cord these disturbances proceed. French authors, as Charcot,1 Delamare, Dubois, and others, have described, in connection with tabes and other spinal affections, certain peculiar attacks, to which they gave the name of " crises gastriques," comprising violent pains, radiating from the back to the epigastrium, with uncontrollable vomiting, nausea, vertigo, etc. These attacks may last several hours or days; they recur periodically like the lanci- nating pains in the limbs of tabetic patients, and have manifestly a close analogy with such pains. They unquestionably depend upon transitory states of irritation in certain portions of the cord. I myself have repeatedly seen them in tabes. In like manner, there is occasionally observed (chiefly in tabetic patients) a violent 1 Lecons sur les maladies du syst. nerv. II. Ser. I. f asc. p. 32. GENERAL SYMPTOMATOLOGY. 139 and painful pressure in the rectum, conjoined with acute pains in the perineum, the anus, and the sexual parts. These symptoms also have, probably, a neuralgic character. Of much more importance are the disturbances of evacuation, which accompany many diseases of the cord, and are analogous to a certain extent with the disturbances of the function of urina- tion. These cases are chiefly caused by a paresis or paralysis of the sphincter ani, the consequence of which is a more or less severe incontinentia alvi. In the mildest cases, the patients cannot retain their stool for any length of time, but are forced to yield to the pressure as soon as felt. This weakness may so increase that the discharge occurs at all times, and without obeying the person's will in the least. There may also be present a disturbance of sensibility, which makes the matter still worse ; the patient does not feel the call, and even if he possesses some voluntary control, he is sur- prised by the discharge, of which he feels nothing, and is only in- formed of its occurrence by his nose or eye, or by the sensibility of his legs. This, we hardly need say, is a shocking infliction. This paralysis of the rectum may, in acute cases, attain very rapidly to its fullest development, but in chronic cases it comes on very gradually. It is easy to explain the several disturbances in the func- tion of defecation, and their origin, by reference to the data of physiology (see above, p. 54). In brief, we would refer to what has been said under disturbances of urination, and in this place would only remark .that our attention should be directed partly to the peripheral sensory fibres of the rectum and anus, partly to the motor fibres of the sphincter, and to the reflex cen- tres in the lumbar cord, and the sensory and the motor paths which ascend from them to the brain. The action of abdominal pressure must also be thought of; and the ganglionic apparatus situated in the intestinal wall. The complexity of these points will increase the difficulty of an explanation, but in most cases we shall succeed in obtaining a satisfactory account of the nature, and probably also of the seat of the lesion. The remarks pre- viously made in regard to disturbances of urination may be repeated here. 140 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 8. Disturbances of Respiration and Circulation. Our knowledge of this branch of the subject is confined to isolated points, and is applicable only in a slight degree to the uses of pathology. Disturbances of respiration occur in but few diseases of the cord, and almost exclusively in those of the cervical portion. The cord contains only conductor paths for the respiratory move- ments, situated probably for the most part in the lateral columns, and leaving the cord at various levels. The centres for respira- tion lie higher, in the medulla oblongata. Lesions of the upper dorsal and of the cervical medulla, when they involve the lateral columns, always give rise to a disturbance of inspiration, which is severe in proportion to the height of the lesion. As long as it is confined below the point of exit of the phrenic, there is no danger, for only the intercostals and some auxiliary muscles of respiration are deprived of their function, while the diaphragm—the chief inspiratory muscle—keeps up the process of breathing to a sufficient extent. But, if the lesion seizes upon the roots of the phrenic nerve, the inspiration is always gravely impaired, even if only one side is attacked, wdiile if both sides are affected, a fatal result from insufficiency of aeration is inevitable. Hence the rapidity with which death fol- lows severe injuries of the uppermost part of the cervical cord, as in fracture of the odontoid process of the axis, etc. In strictly unilateral lesions, disturbances of breathing will be seen, limited to the side of the injury in all cases. It is much more usual to see disturbances of expiration in spinal disease, caused by paralysis of the expiratory muscles (of the abdomen and back). If the organs of respiration are sound, this gives rise to no great inconvenience ; at the most, it becomes somewhat difficult to utter loud tones. But if bronchial catarrh and similar troubles exist, for which an energetic expectoration is required, the greatest danger to life may arise from accumula- tion of mucus in the bronchi. Hence the frequent fatal result of bronchitis, pneumonia, etc., in myelitic patients. It is plain what must be the location of the disturbance in GENERAL SYMPTOMATOLOGY. 141 the spinal cord, in order to produce this difficulty in expira- tion. The disturbances of circulation which accompany spinal dis- ease have been very little examined, with the exception of the vaso-motor. They are confined to alterations in the action of the heart, which are seldom very great, as the influence of the spinal cord upon the heart is only subordinate. Nevertheless, changes in the activity of the heart seem not to be rare in spinal diseases, though little noticed. Charcot1 notes a permanent acceleration of the pulse as a frequent symptom in ataxia; he also speaks of a permanent retardationa of the pulse as a note- worthy symptom of compression of the cervical cord, and de- scribes it carefully. The rapidity of the pulse can be influenced to a considerable extent, both by the sympathetic fibres which pass in the cervical medulla and by vaso-motor spasm or paralysis. If we further reflect that the root-fibres of the vagus and the spinal accessory descend to a considerable distance in the cervical cord, it will be clear that alterations of the rate of action of the heart are fre- quent in diseases of the cervical cord. The precise pathogenesis of these alterations must be ascertained in each individual case. 9. Disturbances of the Oculo-pupillary Fibres, the Various Cerebral Nerves, and the Brain itself We will here enumerate briefly a series of disturbances, of which only a part are directly referable to lesions of the cord, the remainder being more or less accidental complications, the connection of which with the spinal lesion is wholly unknown to us, even if it exists. But all these points may acquire such an importance in reference to the diagnosis of cases or varieties of disease, that it is quite worth while to mention them here, although we shall have to defer a minute examination to the special part of this work. The connection between certain oculo-pupillary symptoms 1 Lecons, etc. 2. Ser. 1. fasc. p. 56. 2 Loc. cit. 2. fasc. p. 137. 142 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. and spinal diseases is very clear. The fibres destined for the dilatator pupillae originate in a centre situated in the medulla oblongata ; they descend in the cervical medulla without decussa- tion, and at various levels' make their exit, passing to the cervi- cal sympathetic, and thus to the eye. Irritation of these fibres produces dilatation of the pupil (mydriasis spastica), paralysis of the fibres causes contraction of the pupil (myosis paralytica). These phenomena may be unilateral or bilateral, according to the extent of the lesion in the cervical cord ; in unilateral lesion the alteration occurs on the same side ; the phenomenon is very characteristic, especially in lesions of one-half the cervical cord. Vaso-motor irritation or paralysis in the corresponding half of the face often accompanies the corresponding pupillary phenom- ena. A combination of the two constitutes a valuable symptom in diseases of the cervical cord. It should be added that, accord- ing to Robertson, Knapp and Leber,' the pupil in spinal myosis reacts to impulses of accommodation, but not to changes of light. The hypoglossus nerve is affected only in diseases of the cord which extend to the medulla oblongata ; the resulting symptoms are paralysis of the tongue, disturbance of speech, and atrophy of the tongue. The vagus and the spinal accessory seem not to be often affected; the consequences are spasmodic cough, dyspnoea, and anomalies of the action of the heart. Still less is known of the affections of the glosso-pharyngeus ; the paralysis of swallowing which occurs in many spinal diseases, especially in the later stages, is probably due to an extension of the morbid process to the paths of the glosso-pharyngeus, which lie in the medulla oblongata. The auditory nerve is now and then attacked {e. g., in tabes); the connection between the atrophy of the auditory nerve and the spinal disease is entirely obscure. Nervous deafness, or loss of hearing for high or low notes, is then observed. The facial nerve is very rarely affected in spinal disease ; the lower branches are more liable. The usual cause is extension of disease to the medulla oblongata. 1 Virchow-Hirsch's Jahresbericht fur 1872. II. p. 544. GENERAL SYMPTOMATOLOGY. 143 Symptoms from the trigeminus are much more common ; the sensory fibres are oftener attacked, the motor more rarely. The (symptoms are formication, anaesthesia, pain ; for which the affec- tion of the upper cervical cord is a sufficient explanation. The involvement of the muscular nerves of the eye is very common in spinal diseases, and very hard to explain. It is espe- cially common, in the stage of precursory symptoms in tabes, to observe paralysis of one of these nerves, either in one eye or in both. The oculo-motorius is most often attacked, next the abdu- cens, less frequently the trochlearis. We have at present no right to speak of this disease as depending on the spinal lesion; we know nothing of a trophic action of the spinal cord upon the cerebral nerves ; we are forced to assume that the degenerative atrophy is localized simultaneously in several points of the cere- brospinal axis. The same is true of those extremely common affections of the optic nerve, which, associated with tabes dorsalis, add horrors to a disease already sad enough. These cases are always due to * progressive gray degeneration of the optic nerve, recognizable by the increasing atrophy of the papilla. Amblyopia, color-blind- ness, contraction of the field of vision, are the first symptoms, and lead with frightful rapidity to total amaurosis. Similar affections of the optic nerve, not quite so hopeless as to progno- sis, occur also in multiple sclerosis. The connection between this disturbance and the spinal disease is wholly unexplained; the amaurosis often precedes by many years the first appearance of the tabetic symptoms (lancinating pains, anaesthesia, ataxia). Of affections of the olfactory nerve in spinal diseases, nothing is known at present. A good deal of research will be required in order to establish upon an accurate basis the connection between these diseases of cerebral nerves and spinal disease. If we refuse to localize the disorder in several spots at once, we shall be most likely to as- sume a propagation of the process to the nerve-nuclei in the medulla oblongata, and perhaps a spreading of meningeal pro- cesses at the base of the brain; probably other relations, as yet unknown, will hereafter be discovered. Concerning the disturbances of speech, which are not rare in 144 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. spinal affections, a few words will suffice. These are never psy- chical (aphasia proper), but probably are solely peripheral and motor in character, originating in the muscular apparatus of speech {anarthria). This may be due to paralysis of the hypo- glossus, which will injure the lingual sounds, or of the facialis, which interferes with the labials, or of the velum palati, which gives a nasal tone to the voice, or, finally, of the accessorius, which interferes with the formation of the voice, and may pro- duce aphonia. Not infrequently a sort of ataxia, an inco-ordi- nation of the movements of speech, an irregular stuttering way of speaking, is observed, as in many cases of tabes; and finally, a slow, scanning speech is highly characteristic of multiple scle- rosis. Many other disturbances of speech occur, of more or less importance. The brain itself may be involved in the spinal disease in a great variety of ways and in very various degrees. It is charac- teristic of many cases of spinal disease, that the brain remains intact with its functions of intelligence, memory, capacity for work, etc., and that the cerebral nerves are not in the least af- fected. But in other cases, not less characteristic, we observe a more or less general implication of the brain in the morbid dis- turbance. This may occur in several ways, e. g. : {a) The same process may be localized both in the brain and in the cord, or it may extend from the latter to the former; thus, in multiple sclerosis, there may be sclerotic patches in both brain and cord; in tabes, gray degeneration of the posterior columns of the cord and of the optic or other cerebral nerves ; in dementia paralytica, simultaneous degeneration of the cord ; the same is true, in syphilis of the central nervous system, in meningitis cerebro-spinalis, in meningitis tuberculosa, paralysis ascendens acuta, secondary descending degeneration of the lateral columns in consequence of cerebral affections, etc. In every case the cere- bral symptoms here form important features in the ensemble. {b) Cerebral symptoms may further be caused by the second- ary effects of the spinal disease ; as by uraemia due to cystitis and nephritis, by pyaemia due to decubitus, etc. (c) Finally, severe cerebral symptoms occur in a way not yet understood in the final stages of many spinal disorders ; as delir- GENERAL SYMPTOMATOLOGY. 145 ium, coma, excessive temperature, spasmodic conditions, with which cases of tabes or chronic myelitis often terminate. It is hard to say how these symptoms originate; usually the exces- sive cachexia, due to the spinal disease, may be the proximate cause; but may it not be supposed that vaso-motor actions originating in the cervical medulla may change the circulation and nutrition of the brain, and thus form an intermediate mem- ber between the spinal disease and the cerebral symptoms \ We have now enumerated nearly all the forms of disturbance which occur in connection with the spinal cord, and have endeav- ored to develop their pathogenesis, as far as possible, in order to give the practical physician a scientific view of the connection between apparent diseases and the fundamental lesions in the cord. The coalition and varied grouping of single symptoms consti- tute the characteristic forms of disease which we meet in prac- tice. Daily experience serves to show that the greatest variety exists here ; sometimes we meet with a combination of motor and vaso-motor disturbances, and sometimes one of sensory and motor disorders; to these are superadded in various instances alterations of reflex function, or anomalies of the function of the bladder and sexual organs ; in other cases single cerebral nerves are implicated in the disorder, or the trophic disturbances assume a leading place, etc. This multiplicity of symptoms permits us to divide them into certain groups, many of which are already well-known forms of disease, while others stand in need of a stricter definition. The exact localization of the several disturbances is often significant; for example, when both the lower or only both upper extremities are attacked by palsy, when anaesthesia or pain exists at a certain level in the trunk or limbs, when the motor palsy is confined to one side, and the sensory to the other side of the body, etc. It is the object of clinical study to ascertain what is charac- VOL. XIII.—10 146 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. teristic and common in all these symptoms ; having done which, we are to draw sharply-defined portraits of disease, and to refer the latter to changes in the cord, strictly defined as to locality. In the special part of this work we shall see how far the pathol- ogy of the day has gone in solving this difficult problem. B. General Etiology of Diseases of the Spinal Cord. The etiology of diseases of the cord is not in a very satisfac- tory condition. A great many isolated facts have been recorded, not always sufficiently well founded, but the really scientific re- sults are small, few general points have been established, and the pathogenesis of the forms of disease remains obscure in most cases. We must therefore content ourselves with brief outlines, leav- ing the fuller details to the special part. We will state here only that which is in some degree certain, but the most part of our remarks will relate to defects in our knowledge. First, there is a series of causal agencies and injuries which place the cord in a condition of increased susceptibility to dis- ease ; these may be designated as predisposing causes. They are certainly very prominent in the pathogenesis of spinal dis- eases, but we should not forget that the same injuries may under certain circumstances produce not only the morbid tendency, but also the disease itself; and that, therefore, they may in some cases become direct causes. This depends partly on the intensity with which they act, partly on the accidental combination of favoring circumstances. One of the most powerful predisposing agencies is doubtless the so-called neuropathic disposition, that peculiar disturbance in the nutrition of the nervous apparatus which lessens the re- sistance of the latter to all possible injuries, and increases the tendency to disease in a definite direction. It may exist in the spinal cord, and predispose it to pathological reaction under all kinds of irritation. Numerous spinal diseases are, without doubt, referable to this condition. This neuropathic condition is certainly congenital in most GENERAL ETIOLOGY. 147 cases, and is transferred from parents to children. Whole fami- lies, many generations, may be thus burdened with neuropathy, and cursed with a feeble power to resist, on the part of the ner- vous system. In many cases the effect is seen in a general neuro- pathic disposition ; all possible neuroses (hysteria, tabes, epilep- sy, psychoses, etc.) are at home with the members of a family, and each one is affected in only that portion of his nervous appa- ratus which is accidentally the subject of a special injury. It is not at all necessary that the parents should have suffered from the same disease; the children, in such cases, inherit merely a general disposition of the nervous system to disease, which may be manifested in very various ways, according to the nature of the incidental causes. In other cases a perfectly definite disposition is inherited by the cord, so that children are attacked by the same affection as their parents (direct inheritance), of which progressive muscular atrophy furnishes the best examples; or it may happen that several or all of the children of one couple suffer from the same disease when neither parent has had it, as in the cases of degene- rative atrophy of the posterior columns, published by Fried- reich.1 The way in which this neuropathic disposition is propagated from generation to generation, often with increasing intensity, is entirely obscure; and we are quite ignorant of what the finer changes in the nervous system, and especially in the cord, may be. The exaggerated susceptibility to disease on the part of the nervous system, and especially of the cord, may also be acquired by a variety of circumstances which must be reckoned among the predisposing causes. Of these, sexual excesses and irregularities occupy the first place. Their effects were formerly often overestimated ; but at the present time the tendency of opinion is so strongly in the other direction that an author like Leyden makes no mention of them in his general etiology.a 1 Virch. Arch. Vols. 26 and 27. s Klinik der Riickenmarkskrankheiten. I. p. 170. 148 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. My own opinion, based upon observations which for some time past have been specially directed to this point, is that these causes are decidedly important in the production of numerous spinal diseases—a view which is represented in the writings of many prominent authors (Romberg, Nasse, Hammond, Salomon, M. Rosenthal, and others). I believe we may say that any gratification of the sexual pas- sion, whether natural or unnatural, indulged in to excess and for a long time, forms for many men—not for all—a circum- stance that powerfully depresses the spinal cord, and predis- poses it to disease. The processes which accompany the sexual act, especially ejaculation, are attended with a very violent exaltation and shock of the entire nervous system; and the spinal cord seems to be the organ which suffers most.1 Certainly this element seems to us of far more importance than the comparatively trifling amount of loss of material which occurs in the discharge of semen. The facts may be analyzed as follows : Excessive natural coitus, in many persons, certainly produces sjnnptoms which point to a weakness and a diminished functional capacity on the part of the spinal cord; weakness of the legs, inability to stand for a long time, trembling when forcible move- ments are made, pains in the back, shooting pains in the legs, sleeplessness, etc. This may often be noticed in the newly-mar- ried, or in persons who have indulged in great excess for a short time. If the cause of these symptoms soon disappears, the in- jury may in most cases be quickly repaired ; but if the excesses are continued, further injury, or even positive disease, occurs. Any external injury, exposure to cold, excessive walking, etc., may then bring on the worst results. It is really hard to say at what point excess begins. No number can be given; the disparity in the powers of different men is enormous. While for some men Luther's rule, " die Woche zwier " (twice a week) denotes the limit of their capacity, others can with impunity do four, six, or ten times as much. This seems to depend on congenital differences in the sexual power, such as is found also in animals (stallions, etc.). A slight degree of potency seems to me to be a common circum- stance among numerous members of nervous families. Of course such a weakness 1 Wundt, Physiologic 2d edition, p. G90. GENERAL ETIOLOGY. 149 may be acquired by all sorts of influences which depress the nervous system. In determining the question of excess we must, therefore, take pains to ascertain the powers of the individual. Ill very young people, not fully grown, and in elderly per- sons, the evil effects of excess are more readily perceived than in persons of the vigorous age. If coitus is begun at a very early age, and practised with excessive frequency, its evil consequences follow with more or less rapidity in the form of spinal weakness, general nervousness, etc. Youth has immense power to repair losses, but the consequences of early squandering of power often appear later in life. A specially injurious effect upon the spinal cord is ascribed by many physicians to coitus practised in the erect posture ; it is often given as an occasional cause of acute spinal disease. The effects of unnatural gratification of the sexual appetite —onanism—are exactly the same as those of the natural indul- gence. The consequences are much exaggerated, but neverthe- less they do exist, and are much more pronounced in the case of certain individuals—weakly, irritable, nervous persons—than in that of others. Onanism, commenced early, practised frequently, and continued for years, must be most decidedly injurious. The undue irritation of the nervous system which it causes, occurring in the period of growth and development, is seldom without in- jurious results, of which the most prominent consist in weakness and irritability of the nervous system. It is common to consider onanism much more dangerous than natural coitus. This does not seem credible to us. The effect upon the nervous system of a man must be the same, whether the friction of the glans is effected in the vagina of a female or in some other way; the nervous shock of ejaculation is the same; it might even be naturally supposed that the nervous excitation wrould be greater in case of connection with a woman. But the frequent repetitions of excitement at an early period of life, which are caused by self-abuse, are certainly very dangerous; and it is furthermore quite certain that the feeling of degradation—so commonly felt, and so well grounded—the perpetual struggle between the powerful impulse and the moral duty, must wear and exhaust the nervous system. These circum- stances may increase the evil effects of onanism. But it is only the excess—that which for the individual is excessive—which does harm; if practised to a moderate extent, onanism is no more dangerous than natural coitus. There are not a few men who are unable to obtain the natural indulgence owing to circumstances, or who are 150 ERB,—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. afraid of contagion, or who think onanism less degrading than contact with public prostitutes—who, from time to time, practise onanism, certainly without injury to their health. Of the moral effects of this vice this is not the place to speak. A similar effect is produced by habitual pollutions, if fre- quently repeated for years together. They are especially com- mon in onanists, and are rather to be taken as evidence of an existing disorder, than as liable to become the cause of such. But even in such cases they often aggravate the difficulty. Finally, in delicate and nervous persons, very destructive effects upon the nervous system are produced by long-continued sexual excitement without gratification, such as often occurs in prolonged and very affectionate courtship. All this is applicable only to the male sex. In the female, very little is known of this matter, and it is of course very diffi- cult to obtain information. I have never found that public pros- titutes exhibited any special tendency to spinal diseases. The effects of sexual excesses find a parallel in all sorts of influences which give rise to an undue strain upon the nervous system, and especially the spinal cord. They produce exhaus- tion and over-stimulation more or less quickly, and thereby increase the danger of disease. Among such circumstances may be named excessive bodily efforts, marching, climbing of moun- tains, riding, etc., especially when the supply of nourishment is deficient, and sleep is insufficient; also protracted watching by night, deprivation of sleep, violent and continuous excitement of passions, and, without doubt, also excessive mental efforts, espe- cially when combined with other injurious agencies, such as severe bodily exertion or sexual excesses. To the period of life only a slight predisposing influence upon certain spinal diseases can be assigned; such diseases occur at all ages. In a few, however, there exists a decided preference for childhood, and in others for adult or advanced life. The ten- dency to spinal diseases is certainly greater in adults, as will be shown in the special part of this work. Sex has still less predisposing influence than age. There cer- tainly are diseases which occur much oftener in men than in women, as tabes, but this may be explained by the fact that men are much more exposed than women to certain forms of injury. GENERAL ETIOLOGY. 151 To general disturbances of nutrition, on the other hand, of the greatest variety of character, we may ascribe a decided pre- disposing influence ; all states of anaemia and cachexia depress the nutrition of the cord, simultaneously with that of the gene- ral system, and increase its susceptibility to morbific agencies. Thus may be explained the effect of loss of blood, chronic dis- turbances of digestion, severe and protracted acute diseases, long- continued loss of fluids, etc. Among the incidental causes of spinal disease, the simplest and most direct are without doubt those of traumatic origin. There are numberless ways in which this may take place direct- ly ; cases are known of gunshot, stabbing, incised, and other wounds, crushing and destruction of substance by fractures or dislocations of the vertebrae, shocks from severe falls or railway collisions (railway spine of the English), and so forth. No explanation is needed of their mode of action, or of their conse- quences (inflammation, softening, necrosis, degeneration, etc.). In close relation to these causes stands that of slow compres- sion by pathological growths, by tumors, abscesses, new forma- tions, exudations, curvature of the vertebrae, etc. Inflammation, secondary degeneration, etc., are of frequent occurrence in these cases. Direct propagation of neighboring morbid processes forms an equally evident source of spinal disease. Thus, inflammation and suppuration of the vertebral bones or the adjacent soft parts may extend to the membranes of the cord, or to the cord itself ; new growths may intrude upon it, the gangrenous inflammation of bed-sores may seize upon the contents of the spinal cord, etc. But the effect of exposure to cold, evident as it is in fact, is quite obscure in its nature. Nothing is more certain than that, in a very great number of cases, a sudden or continued cooling of the surface of the body is followed by spinal disease. This has been seen after a fall into the water, after sleeping on the damp ground, sudden drenching of the clothes or exposure to a draft when the body is heated, bivouacking in snow or rain, working in ice, in damp cellars, in cold water, etc. There are several diseases which may be produced in this way, spinal men- ingitis, myelitis, tabes, spinal palsy of children, tetanus, etc. 152 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Of the activity of this cause there cannot be the slightest doubt; its effects seem most decided in nervous, irritable persons with predispositions to spinal disease, or in cases where other injuri- ous agencies, as great bodily exertion, mental excitement, etc. (as in military campaigns), have come into play. But the manner in which these circumstances act is still entirely unknown ; it is probable that the morbific influence con- sists in a reflex action, originating in the skin. But we have only hypotheses as regards the way in which this influence produces inflammations and other disturbances of nutrition in the cord. It is not yet certain whether a cooling of the blood has a share in the result—the lower temperature of the blood being supposed to act as a direct stimulus to the cord. It is hard to conceive how the direct action of cold should affect in any other way an organ so deeply placed as the cord, although myelitis can be pro- duced by the application of severe cold to the exposed cord. We are still wholly in doubt as to the reason why the same cause produces in one person tabes, in another myelitis of the gray anterior cornua, and in a third, meningitis or tetanus. Disturbances of circulation, of very various origin, may cause sundry disturbances of the spinal cord ; hence the effect of sup- pressed menses, of hemorrhoidal disease, of arterial fluxions and venous congestions, of vaso-motor disturbances, of embolism and thrombosis, atheroma of the spinal arteries, etc. A frequent cause of spinal disease consists in excessive exer- tion of any sort, exhausting the cord. In this category are in- cluded sexual excesses, when practised frequently and at short intervals, walking, riding, swimming, or other muscular acts which go beyond the natural powers. All these may become the point of origin for severe spinal disorders, especially when they affect predisposed individuals, or when other agencies coincide— as that of cold; whence the frequency of these affections after laborious campaigns, bivouacs in winter, etc. Psychical influences are a less frequent agency in the produc- tion of spinal disease. Fright, alarm, disgust, etc., seem to have a pretty clear connection with the origin of general and diffused neuroses (epilepsy, chorea, hysteria, and the like); but not to the same extent with that of spinal diseases. But there are some GENERAL ETIOLOGY. 153 cases in which paralyses and other disturbances of a probably spinal nature have been seen to arise from purely psychical states, especially fright and terror. Thus, J. Russell Reynolds' observed the occurrence of paraplegia in a young lady, arising from a fear of the disease ; she was nursing her father, who was paraplegic. Hinea saw an acute and fatal myelitis in a pregnant woman, caused by violent emotion. Leyden reports a case of paraplegia caused by fear at the breaking out of a conflagration, and Kohts3 tells of similar occurrences at the bombardment of Strasburg. It is quite uncertain how we ought to interpret these facts, and whether the psychical emotions act through the vaso- motor paths,4 or whether they may directly produce a disturb- ance of the finer processes of nutrition in the central nervous elements. Certain intoxications present well-known spinal symptoms; such are poisoning with strychnia, arsenic, phosphorus, lead, etc. Some of these poisons seem to have the power, when long continued, to produce marked spinal diseases; for example, lead. The local development of various infectious diseases, acute or chronic, is of great importance in etiology. Syphilis, by becom- ing localized in the vertebral column, the membranes, or the cord itself, may lead to spinal symptoms ; tuberculosis not seldom attacks the cord and its membranes ; and of the acute infectious diseases there is one (meningitis cerebro-spinalis) of which the chief seat is the pia mater cerebro-spinalis. To these must be added the cases, not few in number, of spinal affections follow- ing acute diseases (typhoid, acute exanthemata, intermittent, influenza, pneumonia, etc.), which, as a rule, must be regarded not as a specialized localization of the original process, but rather as somewhat accidental complications of the latter, dependent on a local predisposition established by the acute disease. A very frequent source of spinal disease is found, lastly, in 1 Remarks on Paralysis, etc., Dependent on Idea. Brit. Med. Jour. No. 6. 1869. p. 483. 2 Med. Times. 18G5. Aug. 5. 3 Berl. klin. Wochenschrift. 1873. Nos. 24-26. 4 In the third case of Kohts the menses were instantly suppressed by fright. 154 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. irritation and disease of peripheral organs. Of this we have already numerous proofs. Paraplegia has been seen with espe- cial frequency following severe and obstinate dysenteries and other intestinal diseases, and chronic affections of the kidneys and bladder ; in many cases the autopsy has shown myelitis to be the cause of the paraplegia. Such occurrences have been less frequently observed in uterine disease, which is more commonly followed by hysterical palsies—though the latter also, in some cases, are certainly of spinal origin. Myelitis has also been ob- served to follow peripheral lesions of nerves, diseases of joints, and so forth ; the tetanus which follows injuries of nerves and peripheral lesions certainly belongs to this class. All these processes have long been studied with great zeal; they have, in fact, been made into a special class of reflex disor- ders (usually termed reflex paralyses), because they have been commonly supposed to originate in the reflex way from periphe- ral irritation. But the theory of these reflex diseases is in dis- pute to this day; and the number of works written upon them is very large.1 We have discussed this point in another place;3 the statements there made relate chiefly to reflex paraplegia and the myelitis which causes it, and we may therefore refer to that place, to avoid repetitions. The spinal disturbances which fol- low peripheral irritation or disease cannot, therefore, as a general thing, be referred to a purely reflex disturbance of function ; they must, for the most part, be dependent on coarser changes of nutrition (inflammation, softening, exudation) in the cord. Regarding the connection of the latter with the primary irrita- tion, we are not yet fully in possession of the facts ; it is in part effected by an ascending neuritis, of the existence of which there 1 For more minute information we refer the reader to the following : Leyden, Ueber Reflexlahmung. Volkmann's Sammlung klin. Vortr. No. 2. 1870.—Lewisson, Hemmung der Thatigkeit der motorischen Nervencentren, etc. Reichert u. Du Bois' Archiv. 1869. —Feinberg, Ueber Reflexlahmung. Berl. klin. Wochenschrift. 1871.—Tiesler, Ueber Neuritis. Diss. Konigsberg. 1869.—Brown-Sequard, Lectures on the Diagnosis and Treatment of the Principal Forms of Paralysis of the Lower Extremities. London. 1861.—Jaccoud,hes paraplegies et l'ataxie du mouvement. 1864.— W. Gull, Med.-chir. Transact. Vol. 39. 1856. p. 195. 2 See Vol. XI. p. 399. GENERAL DIAGNOSIS. 155 is no doubt; but in other cases the inflammation is transmitted to the cord in the reflex way. A few attempts have lately been made to settle this question, but without much success. The investigation by Roessingh' threatens to set us back a step, as he has arrived at entirely nega- tive conclusions in his repetition of the experiments of Lewisson and Feinberg. Klemm's2 laborious studies leave room for many questions and doubts. They by no means prove that a direct propagation of the inflammation takes place along the nerve to the central organ : an extension by leaps was all that was proved. In this case, therefore, and especially where inflammation is transmitted to the symmetrically situated nerve of the opposite side of the body, without demonstrable affection of the central organs, the only explanation is that which assumes a sort of reflex transmis- sion. The process may be essentially like that in which ex- posure of the skin to cold produces inflammation of the spinal cord. In so-called "reflex paralysis," the irritation is of an- other sort, and acts upon some other organ than the skin. The question of reflex disease of the cord is certainly still in doubt, and is in great need of further clinical and experimental study. C. General Diagnosis of Diseases of the Spinal Cord. When we encounter a complicated nervous affection, the first step to be taken is a careful enumeration of the existing disturb- ances. The first and most important point is, to test all the de- partments of the nervous system, and thus to ascertain the existence, the grouping, the succession, and the history of each symptom. The diagnosis is made from the total of all these. The next question is always that of the location of the dis- ease; the organ affected; in nervous diseases, the choice lies 1 Bijdrage tot de Theorie der Reflexparalyse. Nederl. Tijdschr. vor Geneesk. 1873. Bd. I. No. 5:5. See Virchow-Hirsch's Jahresb. for 1873. Bd. II. p. 44. 2 Ueber Neuritis migrans. Diss. Strassb. 1874. 156 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. between the brain, the medulla oblongata, the spinal cord, the peripheral nerves, and the sympathetic. The reply to this question, in the case of the spinal cord, often involves great difficulties. We may, it is true, follow the good old rule, to place the point of lesion at a spot where all the affected paths lie nearest together. But this rule often goes but little way with the spinal cord, both because all the paths which it contains pass into the peripheral nerves, and may be diseased in them, and also because a plurality of seats of disease is possible, and, in the case of the central nervous system, is very common. There is no function, quite specifically peculiar to the cord, the impairment of which would lead us at once to recognize an affec- tion of the cord: this statement is true, even in regard to the disturbances of reflex activity. AVhen, therefore, disturbances of the sensory and motor sys- tem, of the vaso-motor and the reflex functions, of the trophic conditions and of the genito-urinary functions, etc., coexist, and in parts which directly depend on the cord for their innervation, then there is a great probability that the cord is affected ; but certainty does not exist until we have excluded the affections of the peripheral paths. This is certainly possible in many cases, but not in all; there are, for instance, diseases of the cauda equina, which cannot be distinguished with certainty from those of the cord, and the same is true of extensive disease of the nerve-roots, etc. In such dubious cases, various means may be employed to confirm the diagnosis, such as the data of the history of the case, or the causal factor, which often give us an opportunity to infer a definite seat of lesion. By far the best aid is that furnished by experience, which teaches us that certain well-characterized groups of symptoms correspond to very definite lesions of the cord. We are in pos- session of a series of groups of this sort, which can without hesitation be recognized as dependent on disease of the spinal cord ; thus, tabes dorsalis, the so-called acute spinal paralysis of children and adults, sclerosis of the lateral columns, progressive muscular atrophy, tetanus, and many others. Experience goes still further; it often gives us notice by a few GENERAL DIAGNOSIS. 157 symptoms, often by a single one, of a threatening or actually present disease of the cord, because the constant or almost con- stant, coincidence between the symptom and the disease has be- come established through observation; thus, for instance, tabes may often be recognized by a precursory atrophy of the optic nerve, or by lancinating pains. It therefore follows that in order to form a correct and sure diagnosis of a spinal disease, we need not only a very careful and comprehensive investigation, not only an accurate statement and estimation of the etiological and other elements, but also an intimate acquaintance with the whole of the pathology of the cord, and a good bit of practical experience. There remain, however, a few cases in which the diagnosis may be difficult, and in which the spinal location of the disease is not quite certain. It then becomes necessary to distinguish the spinal from the peripheral disease, on the one hand, and from the cerebral on the other—which is often very difficult. We must, however, here confine ourselves to naming a few points which will assist diagnosis in given cases. In favor of a peripheral localization, the following circum- stances may be mentioned: Limitation of the disturbances to single nerves or branches of nerves; exact coincidence of the motor, sensory, vaso-motor, and trophic disturbances with the distribution of a peripheral nerve; absence of retarded conduc- tion of sensation ; absence of all reflex action ; absence of weak- ness of the bladder and the sexual functions, etc., in case the sacral nerve itself is not the seat of disease; presence of great disturbance of the trophic function ; certain results of electrical examination ;x the existence of a known local cause of lesion. In favor of a cerebral location we may have the following (among others): hemiplegic distribution of the disturbances, with the sensory and motor disturbances upon the same side ; unequal intensity of the sensory and the motor disturbances ; absence of all trophic disturbance; entirely normal electric reaction; re- tention or exaggeration of all spinal reflex acts ; retention of associate movements and automatic movements, and of the rectal 1 See Vol. XI. p. 445. 158 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. and vesical functions; presence of disturbance of the higher senses, and of various cerebral nerves (except so far as well known to be often involved in spinal disease), of disturbances of speech and of the mental functions; finally, the presence of headache, giddiness, and causeless vomiting. In favor of the spinal seat of disease, the following circum- stances may be used in evidence: the usually paraplegic distri- bution of symptoms; crossing of motor and sensory disturbances in case of hemiplegic symptoms ; sensation of a girdle at the upper limit of the other disturbances ; change in a portion of the spinal reflex acts (exaggeration or weakening); weakness of the genito-urinary functions; paralysis of the rectum ; trophic dis- turbances, bed-sores, etc.; definite paraesthesiee, retardation of the conduction of sensory impressions; disturbance of certain automatic movements ; the peculiar local limitation of spasms of cerebral origin ; absence of psychical changes, and usually, of dis- turbances of the higher organs of sense and the cerebral nerves. It must also be noted that all these points possess by no means an absolute, but only a very conditional value ; that their significance is very often not decisive, except in connection with many other symptoms, so that they cannot be made useful for diagnostic purposes except after a very careful estimation of all circumstances. When we have decided that the cord is the seat of disease, we have to proceed to localize the lesion within the cord. In doing this, the distribution of the symptoms, especially those of paraly- sis, usually furnishes an excellent point: it is often possible to decide within a hair's breadth to what height in the cord a certain affection extends, and the gradually upward progress may often be followed in a very beautiful manner. While thus the upper limit of a lesion is usually very easily recognized, the same is not equally true of the lower limit, and it is often hard to decide whether the lesion is diffuse or circumscribed as respects the longitudinal section of the cord. Yet there are certain points which indicate that the lower portions of the cord are intact; the principal of these (see General Symptoms) are those relating to the reflex function, that of the bladder and rectum, and the nutrition of skin and muscles. GENERAL DIAGNOSIS. 159 This is the case when disease extends over the entire trans- verse diameter of the cord, and to some extent, also, in the longi- tudinal direction of the cord. We are enabled by experience to recognize also diseases con- fined to limited parts of the transverse section ; such may also extend to a greater or less distance in the longitudinal axis. Thus we can distinguish the affections of the separate white col- umns, the anterior and the central gray matter, etc. ; those of the white posterior columns (probably only the outer divisions) furnish the symptoms of tabes dorsalis (see the special part); that of the white lateral columns, the symptoms of Charcot's lateral sclerosis (which see); that of the anterior gray cornua in its acute form, the symptoms of infantile spinal paralysis; in its chronic form, probably those of progressive muscular atrophy ; disease of one lateral half of the cord, symptoms of Brown- Sequard's unilateral lesion ; disease of the central gray substance gives rise to an equally characteristic group, and in general, the implication of the gray substance may be recognized by the dis- turbances of nutrition, of reflex action, of electrical reaction, etc. Thus, in many cases, it is possible to decide very accurately with regard to the seat and location of the lesions in relation to the longitudinal and transverse sections of the cord ; it is certain that the perfection of the methods of anatomical research, recently applied to the diseased cord, will soon add much to our means of diagnosis. And a good deal remains to be done, for there are considerable parts of the transverse section, the lesions of which have never yet been brought into relation with any group of symptoms. It remains for us to decide the nature of the lesion—whether paralysis or irritation, inflammation or degeneration, softening or atrophy and sclerosis, compression or bleeding or other lesions, are present in the cord. It is difficult to establish general diagnostic rules for this; symptoms of irritation (spasm, pain, increased reflex action) will incline us to infer a corresponding pathological state ; symptoms of paralysis will point rather to degenerative processes, softening or compression and destruction of the cord ; but we must be cau- tious in these inferences, since both sorts of symptoms and both 160 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. pathological conditions are very often combined, and the same disease in its progress not seldom leads to a manifold alternation of symptoms. But, as a rule, more and better points can be derived from the results of experience, from the development and order of succes- sion of the symptoms, from the history of the case, the etiology, the objective examination, etc. It would lead us too far to attempt to give and analyze ex- amples of even a portion of the possible cases here alluded to. We shall find opportunity for doing this in the special part of this work. Our present object is confined to indicating the points for diagnosis, and the methods and instruments, the precautions and the care, required in order to render the diagnosis exact. As regards complications, we will only say, in brief, that they must be ascertained and judged according to the usual diagnos- tic rules. IT. General Therapeutics of Diseases of the Spinal Cord. This branch of our subject presents many weak sides. In most diseases of the cord, our success in the use of remedies is rather small. The general opinion regarding spinal diseases, that they are nearly or quite incurable, is but too well founded. It is true that we have recently had to modify this view essentially. A great number of curable diseases have been re- ferred to a spinal origin ; and, on the other hand, the prognosis in many chronic spinal diseases has been much improved by the progress of therapeutics. Yet much remains to be done. And above all, we must learn how to recognize the diseases, before we can treat them ration- ally ; we are still at the threshold of exact knowledge of the pathology of the cord, and the scientific therapeutics of its dis- eases is still in its first stage. The attempt to state the general principles of treatment at this day seems hazardous, so small is the material, and so uncritically reported. The attempt will nevertheless be made to present the GENERAL THERAPEUTICS. 161 remedies which are used in disease of the cord, and especially those which we have reason to suppose exercise a decided in- fluence over that organ. For the present, we must be content with such a mere attempt. The indications in spinal disease are very numerous, consist- ing of, a, the removal of so-called functional disturbances (intan- gible disturbances of nutrition), especially those of a chronic sort; b, alteration of disturbances of circulation (hyperaemia and anaemia); c, the cure of acute anatomical changes (acute inflam- mation, softening, hemorrhage, etc.) ; and, finally, d, the removal of chronic anatomical changes (degeneration, atrophy, sclerosis, induration, new formations, etc.). All the usual methods of treatment are, of course, employed for these objects, with suitable modifications to adapt them to the seat of the disease ; the functional disturbances are remedied by regulation of the function, by slight stimulation of the latter, by alteration and improvement of the nutrition and sanguifica- tion ; for disturbances of circulation, we have a variety of means for acting on the vaso-motor system and the vessels; acute in- flammatory processes are treated by antiphlogistics, derivation, etc.; the chronic alterations are usually attacked by alterative, exciting, and derivative procedures. In the cure of these chronic cases nature has, of course, the chief part to play ; we have only to supply the most favorable conditions for repairing the disor- ders, to excite the desired change in the general nutrition by cer- tain remedies, by promoting the formation of blood and the pro- cesses of nutrition, by stimulating the metamorphosis of tissue, by regulating the function of the diseased parts, and so on. For more particular remarks the reader is referred to the special part of this work. We shall here give the remedies and methods in general, which are adapted to the above indications, and shall attempt to make their mode of action intelligible upon scientific principles. This attempt is made rather in the hope of stimulating exact study than as an exhaustive presentation; such a presentation would be forbidden by the limits of the present work. We shall first devote a section to the very important group of external or physical remedies, then speak of the very scanty list VOL.' XIII.—u 162 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. of internal remedies ; in a third section a series of symptomatic remedies and methods will be mentioned, which may be employed according to occasion in any spinal disease; and in the fourth section the general regimen and diet. 1. Physical Remedies.—External Remedies. Cold. The application of cold to living tissues first depresses their temperature, and lessens the supply of blood b}^ ischaemia ; this retards the processes of metamorphosis, and limits those of exu- dation and emigration; at the same time the excitability and conductibility of the nervous apparatus are depressed. Hence are derived the leading indications for the use of cold in inflammations, hyperaemias, and exudations, and also in cases where there is abnormal excitement in the nervous system, pains, and spasm. In accordance with the latest researches of Riegel' and F. Schultze,2 it can hardly be doubted that the cord can be reached directly by the action of cold, although the thickness of the parts overlying it is so great that a very powerful and continu- ous application of ice along the line of the spine is necessary to produce that effect. The effects of Chapman's well-known vaso- motor therapeutics are also in favor of the possibility of such an action. Chapman,3 by the application of ice or of warmth to the spine, produces a pow- erful action upon the cord and its vessels. He states that the continuous applica- tion of ice produces ischremia of the cord, lessening the reflex irritability and the other functions; alternate application of ice and warmth increases the flow of blood and the manifestation of energy upon the part of the cord ; repeated brief applications of ice at longer intervals produces similar but less marked effects; and, finally, by application of ice to the back we can increase the circulation in those peripheral regions which receive their vaso-motor nerves from the portion of the cord thus treated. 1 Virchow's Archiv. Bd. 59. Heft 1. 2 Locale Einwirkung des Eises auf den thier. Organismus. Deutsch. Arch. klin. Med. XIII. p. 500. 1874. 3 Med. Times and Gaz. July 18, 1863. GENERAL THERAPEUTICS. 163 Besides this direct action, a reflex influence may be exerted by the cutaneous nerves, as excited or depressed by the stimulus of cold; this has not yet been carefully studied. The application of cold to the spinal cord may be made either by a common ice-bag or by several, if required, or (better) by Chapman's bags ; the complicated apparatus of Koopman ' does not seem to be required. Less energetic and more transitory ef- fects can be obtained by cold irrigation or cold affusion of the back. Warmth. The effects of warmth are in many respects the opposite to those of cold ; it raises the temperature of the tissues, increases the flow of blood towards them, and increases the excitability of nervous apparatus. We therefore expect from its action an in- creased transformation of tissue, or stimulation of the processes of nutrition, and a consequent repair of defects of nutrition, removal of atrophy, degeneration, sclerosis, etc. It is believed to be an excellent remedy for increasing the process of resorp- tion of fluid or solid material, and for repairing chronic processes of inflammation. It furthermore often soothes pain and spasms. The way in which warmth acts upon the cord has not been much studied. It is even doubtful whether it penetrates directly to the cord when applied externally—though it probably does so. On the other hand, the reflex action, effected by means of the cutaneous nerves, is certainly not to be underestimated. The results to be expected from its use are : dilatation of the blood-vessels, an increase in the quantity of the current of blood and the other fluids, and of the processes of tissue-change in the cord, an increased facility and rapidity in the nervous processes, and finally, a removal of excitements which often affect the cord, originating in the cutaneous nerves. It follows from this, in what morbid conditions of the cord the application of warmth will be considered most desirable. But let it not be forgotten that warmth is known to be easily 1 Berliner klin. Wochenschr. 1870. No. 48. 164 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. capable of producing over-excitement and exhaustion, leading to congestive states of the cord, and that the use of warmth is contra-indicated in all cases where such results are to be dreaded. The methods of applying warmth are very simple : cataplasms, hot sand-bags, Chapman's caoutchouc bags filled with hot water and laid along the spine ; hot-water fomentations, or (the mildest form of all) Priessnitz' s wet wraps, which gradually warm them- selves. Baths. Compare Braun, Balneotherapie. 3. Aufl. 1873.— Valentiner, Handb. der Balneo- therapie. 1873.—Seegen, Heilquellenlehre. 2. Aufl. 1862.—Helfft-Thilenius, Handb. der Balneotherapie. 8. Aufl. 1874.—Durand-Fardel, De la valeur des eaux mingrales dans le traitement des paraplegies. Bull, de Therap. Mai 30. 1857. — Q-otth. Scholz, Ueber Riickenmarkslahmung und ihre Behandlung durch Cudowa. Liegnitz. 1872.—Runge, Die Bedeutung der Wassercuren in chronischen Krankheiten. Arch. f. klin. Med. XII. p. 207. 1873.—Fr. Rich- ter, Ueber Temperatur und Mechanik der Badeformen bei Tabes und chron. Myelitis. Deutsch. Zeitschr. f. prakt. Med. 1875. Baths form a very important group of remedies in complaints of the spinal cord. Great results must be ascribed to them, in most of the chronic forms. It is very difficult, however, to define their mode of action and their indications, partly on account of our defective knowledge of spinal pathology, partly because the subject of balneotherapeutics has as yet received but little scien- tific development. The diagnosis of spinal disease is certainly in a very defective condition ; our ideas regarding the anatomical changes, as existing in individual cases and at determined peri- ods, are equally imperfect; hence the uncertainty in regard to indications, and the wide room for empirical treatment, which too often passes beyond the allowed limit of experiment. We will here speak of the different forms of baths, and their mode of action as taught by the science of balneotherapeutics, and shall attempt to state which forms are most suitable for the treatment of different spinal diseases or groups of symptoms. GENERAL THERAPEUTICS. 165 Warm Baths have from time immemorial been a favorite method of treat- ing diseases of the spinal cord—especially paralyses, which us- ually form the chief part of such as come for balneological treat- ment. This has been especially true of the indifferent or acrato- thermae ; but the weak brine baths, alkaline waters, sulphur- baths, etc., containing unimportant amounts of salt and gas, are quite similar to their mode of action. The same is true of steam- baths, hot sand-baths, and the like. The effect of warm baths is first seen upon the skin, in which a great dilatation of the cutaneous vessels occurs, followed later by a moderate contraction. Thereby the circulation in the skin is hastened, and a great evaporation and sweating follows, which is rendered easier by the removal of the upper layers of epider- mis. At the same time, the organism receives an access of warmth, or, at least, is enabled to lay up a part of its own store of heat. Thus the processes of oxidation are furthered, and the discharge of most of the functions of the body is facilitated, which accounts for the refreshing effect of a warm bath when one is greatly fatigued. For our purpose, the effects may be summarized as follows : The warm bath increases the facility of all the chemico-physical processes in the system, leading to stimulation of the metamor- phosis of tissue and freedom of function, without any subsequent reaction from excessive stimulation. At the same time, by shel- tering the body from the continual change of temperature of the outer air, it acts as a sedative. By the fluxion of blood to the skin it changes the distribution of this fluid, and acts as a derivative in congestions of internal organs ; it acts as a resorbent by stim- ulating the nerve-centres, by changing the course of the blood, and by the production of sweat, and by washing out the system. Warm baths are best borne by feeble individuals, whose power of resistance and of making heat are weakened. Their effect depends very greatly upon their temperature. If this be indifferent (32°-36° C. [90° to 97° Fahr.] ), they are believed to act chiefly as sedatives ; warm and very warm baths (36°-42° C. [97° to 108° Fahr.]) are more stimulating, produce strong excitement 166 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. of the blood-vessels, much sweating, increase of tissue-changes. Lukewarm baths (28°-32° C. [83° to 90° Fahr.]) are believed to have a special depriment effect in the case of nervous, irritable persons. As the temperature rises, therefore, the exciting qualities become more prominent; as it sinks, the soothing. The geographical site of the baths must be considered, together with the temperature, especially in the case of indifferent thermae, for experience seems to show that the higher the site the higher may be the temperature that is borne, and that, the more irri- table the patient is, the more elevated may be the spot to which he is sent for cure. This is an important point in practice. The indications which follow from these principles are not easy to state. Most of the circumstances are very complicated. If we confine our attention to the most prominent symptoms, the matter seems very easy ; when the symptoms of irritation pre- ponderate, and irritability is very marked (spinal irritation), we choose rather the soothing baths ; if symptoms of depression are prominent (anaesthesia, paralysis, etc.), the exciting baths at a higher temperature. But unless we consider that a decided degree of irritable weakness not only may be, but usually is present in cases of spinal paralytic affection, and that in such cases we usually have to do with an extremely irritable and exhausted nervous system ; unless we bear in mind that important disturbances of circulation and nutrition are usually present in the most impor- tant organs, which may possibly be affected injuriously by the warm baths, it will be impossible to avoid false steps. Nor have they been avoided, in fact; certain spinal diseases (tabes, mye- litis, etc.) have often been made worse by too warm baths. The degenerative and sclerotic forms of spinal disease seem to require the greatest care in this respect, and we are yet in need, before we can be quite safe in using them, of a more careful study of the special action of thermae upon these disturbances of nutrition. Our remedy, therefore, has not merely a directly exciting or composing influence upon the nervous system, but also one of far greater consequence, namely, the alterative action which it exer- GENERAL THERAPEUTICS. 167 cises (by virtue of increasing the metamorphosis of tissue and changing the direction of the blood-current) upon coarse and fine disturbances of nutrition. We shall not be able to define the indications until the latter mode of action is better understood. The warm springs are now used in exhaustion of the spinal cord after typhoid and other severe diseases, or excesses of any kind ; in spinal irritation (moderately warm baths); in paraplegia from shock to the cord (energetic use of very warm baths); in tabes (avoid very warm baths! select baths of indifferent temper- ature) ; in myelitis and softening of the cord (slightly warm); in meningitis exsudativa (all warm springs, especially those of higher temperature), etc. Fr. Richter believes that only baths of a moderate warmth or moderate coolness ought to be used in chronic inflammatory or atrophic affections of the cord. The warmer baths (from 32.5° C. [90° Fahr.] upwards) are considered by him the best adapted for chronic inflammatory states of the cord with preponderant symptoms of irritation. We give the following list of the most frequented warm springs, with the height above the sea-level and the temperature of the water : Schlangenbad (900'; 30-32.5° C. [86° to 90° Fahr.] ); Badenweiler (1,425'; 30-32.5°); Landeck (1,398'; 31.0-32.5° [88° to 90° Fahr.]); Wildbad (1,323'; 35.0° [95° Fahr.]); Ragatz (1,570'; 38.0° [100.5° Fahr.]); Pfeffers (2,115'; 38.0°); Romerbad (755'; 38.0°); Gastein (3,315'; 32.5-40.0° [90° to 104° Fahr.]); Warm- brunn (1,100'; 40.5° [105° Fahr.]); Wiesbaden (323'; 34.0-40.0° [94° to 104° Fahr.] ); Teplitz (648'; 37.5-42.5° [99° to 108° Fahr.]); Leuk (3,309'; 39.0-50.0° [102° to 122° Fahr.]); Baden-Baden (616'; 46.0-68.0° [115° to 154° Fahr.]); Plombieres (1,310'; 19.0-62.0° [6Q° to 144° Fahr.]). A proper selection may be made by attend- ing to the special indications, the individual conditions, etc. Weak brine-baths (containing not more than one per cent, of chlorides), most sulphur-baths, and the weak alkaline springs act exactly like indifferent springs, and may, according to circum- stances, be used in their place. Steam-baths, hot sand baths, hot air-baths are of a very high temperature; they produce powerful stimulation and diaphore- sis, and may be of use, especially from the latter peculiarity, in 168 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. very torpid cases of meningitis exsudativa. But it is always necessary to exercise the greatest caution in employing them for spinal complaints. The so-called Scotch douche (alternation of hot and cold water) produces a very exciting effect upon the skin and the ner- vous system ; it has also been recommended in spinal paralysis ; it requires to be used with great caution. Brine-Baths are very like warm baths in their effects ; the action of tempera- ture is the same in both cases, to which the effect of the salt contained must be added. The most suitable proportion is be- tween two and four per cent. The special effect of this ingredi- ent appears in a powerful stimulus of the nutrition and circula- tion of the skin, increase of the change of tissue, repair of disturbed nutrition, increase of resorption. On account of the exciting effect of the salt, their temperature may be somewhat lower than that of the plain warm baths. Their indications in spinal disease are the same as those for warm baths; and besides, they are often prescribed for the causal indication, in treating scrofula, vertebral disease, caries, etc. The air of the salt-pans, which may be breathed in many places while the patient is taking his bath, is cool, refreshing, ozonized, and in the case of many irritable patients is much to be desired as an accessory. The warm brine-baths containing gas are far more important than the simple warm ones. This class is represented by Rehme- Oeynhausen, Nauheim, the Schonbornsprudel in Kissingen, and the Soolsprudel in Soden a. T. Their effect is due to their tem- perature and the salt they contain, in the first place, and, next, to the abundance of carbonic acid, which acts as a powerful excitant of the skin and the nervous system. Its direct effect is a moder- ate subtraction of heat, followed immediately by a reaction, dur- ing which the withdrawal of heat continues, and at the same time a continuous stimulation of the nervous centres. It is as it were a combination of the stimulating and calming effects of the cool and the warm bath. GENERAL THERAPEUTICS. 109 The result is a general improvement of nutrition and the or- ganic functions ; hence, resorption and removal of pathological products ; at the same time, excitement of the nervous system may improve the nutrition of that department. These baths are cool; they must not exceed 32°C. [90° Fahr.]; they are usually taken without moving the water, but if we wish to increase the effect, the water may be agitated. They are indicated in weakness of the spinal cord following difficult convalescence or other exhausting influences, in tabes, in paralysis after meningitis, in myelitis, spinal paralysis of chil- dren, spinal irritation, etc. Chalybeate Baths, so-called, are baths with a very slight amount of iron, a more or less considerable amount of salt, and a very considerable quan- tity of carbonic acid. Their action is usually referred by balneologists to their tem- perature and the carbonic acid they contain, while the amount of iron is believed to be insignificant. The physicians continue to swear by the springs, but they fail to make a probable argu- ment for the effects of the iron, except as used internally. It is certain that these baths, owing to the presence of car- bonic acid, are among the most powerful stimulants of all, if warmed with precaution, so as to retain as much of the gas as possible. They are indicated wherever the thermal brine baths with much gas are required ; they should be avoided in all conditions in which great excitation is to be feared; but they should be applied wherever we have to do with a torpid, inexcitable state of the nervous system, especially when anaemia is likewise present. While in general the use of steel-baths abounding in Co2 is held unadvisable in diseases of the cord, and they are admitted only in very special forms of functional disturbance, Scholz has re- cently attempted to save the credit of the steel-baths, especially those of Cudowa, in spinal cases, and has stated their indications and results with exactness. He recommends them very highly 170 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. for chronic congestion of the cord, especially in anaemic persons and the subjects of nervous exhaustion ; only by exception in spinal meningitis, limiting their use to torpid individuals, and cases of a sluggish nature; also in the initial stages of chronic myelitis, with hope of success proportional to the weakness and anaemia of the individual and the sluggishness of the case ; in the "primary" form of tabes, without inflammatory symptoms, under the same conditions ; finally, in all cases, for the sequelae of spinal concussion, as soon as the stage of excitement is past. The best results are obtained with mitigated baths (diluted with fresh water). Although Scholz's presentation is not wholly convincing, yet it is proved that steel-baths, if used with care, are capable of doing good service in many even severe cases. They deserve to be tried thoroughly. Among waters of this class the following deserve mention : Schwalbach (900'), Pyrmont (400'), St. Moritz (4500'), Bruckenau (915'), Driburg (633'), Franzensbad (1300'), Cudowa (1235'), the Kniebisbader (1200-1900'), etc. Moor-Baths and Mud-Baths, so-called, form a separate class. Their action is as yet far from being explained ; it cannot yet be stated with definiteness. A part of the effect is due to their quality as warm baths, but this is accomplished in some entirely specific and not yet understood way, since they are much less exciting than warm springs. They seem indicated wherever the thermal treatment is desirable, but its stimulant action is not likely to be well borne; especially, therefore, in weakly, irritable, and anaemic constitutions. Espe- cial benefit has been observed in spinal irritation and the so- called tabes dolorosa, then in paraplegias and contractures conse- quent upon myelitis, lateral sclerosis, compression of the spinal cord, etc. The temperature and duration must be regulated according to individual peculiarities. Good moor-baths are found in Franzensbad, Marienbad, Tep- GENERAL THERAPEUTICS. 171 litz, Driburg, Bruekenau, Meinberg, Elster, Eilsen, Nenndorf, Liebwerda, Pyrmont, Reinerz, etc. Pine-needle baths, which have been much used and praised, are only warm baths, in which a powerful stimulus is applied to the skin, not by high tempera- tures or by Coa, but by the ethereal oil and the extract of pine twigs. They may be used wherever the more stimulating forms of thermal treatment are indicated. Among the most important agencies that we possess are the cold and cool baths, including the use of cold water in the greatest variety of forms—what is commonly known as TJie Cold-water Treatment. This treatment, having of late years been administered in a rational manner and closely studied, has much increased in popularity. Its results in all possible forms of chronic nervous troubles are extraordinarily good. There is as yet no entire agreement in respect to the theory and the mode of action of the cold-water treatment. The condi- tions are very complicated, and it has naturally happened that individual practitioners of the method have reached more or less one-sided views ; some consider the exciting or depressing effects upon the nervous system the principal thing, while the effect in modifying the change of material is subordinate ; others try to refer all the effects to the vaso-motor action upon the skin, while a third party sees an explanation of all the leading phenomena in the alterative action upon the metamorphosis of tissue. It is certain that in the cold-water treatment we observe on the one hand an action upon the cutaneous nerves, and thence transferred to the entire nervous system; also, effects upon the cutaneous blood-vessels, and through them upon the distribution of the blood throughout the circulation ; and finally, changes in the circulation and the entire process of transformation of tissue, to which must be ascribed a very special influence upon the cure of severe chronic diseases. Our present knowledge of the subject amounts to about the following: A direct action upon the nervous system, of an exciting or a depressing nature, can be produced by the application of coid water; the subtraction of warmth acts as a 172 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. depressant, the stimulus of the cold as an excitant. According to the form, the temperature, the duration of the baths, we can make the one or the other effect more prominent (Petri). The soothing effect is always produced where the same portion of water remains in constant contact with the skin, as in half, full, and sitz baths without motion; in the wet pack, in wet rubbing without moving the cloth. The exciting effect is always produced when the layer of water in contact with the body is continually changed, so that the stimulus of cold is constantly renewed ; that is, in half, full, and sitz-baths with agitation, in rubbing down with a cloth which is moved, in washing, affusion, shower-baths, douches, surf-baths, sea- baths. The lower the temperature of the water, the more quickly and forcibly do these effects appear. The exciting action of the baths may be increased by previously wrapping the patient in dry blankets, while at the same time an excessive loss of heat is prevented, as the quantity lost in the bath is no greater than what has been saved by the wraps; this method is therefore of special value for persons who need to save their strength. A frequent repetition of these excitations increases the energy of the nervous system. In regard to the circulation, the following effects are to be seen in the skin, due for the most part to nervous influence: great ischemia, goose-flesh, shivering, and soon (though at various intervals), dilatation of the vessels, increased amount of blood, increased secretion from the skin and perspiration, increased development of warmth. These are the symptoms of reaction, which occurs with different degrees of facility in different persons, and is of very great importance in the cold- water treatment. In order to its proper development, a certain measure of force, a certain resistance is required; in badly nourished, weak, irritable, and anaemic per- sons, or those with degenerative disease of important organs, it occurs much less readily; for this reason these persons do not bear the cold-water treatment. The reaction is lively and vigorous in proportion to the lowness of the tempera- ture of the water and its degree of motion, that is, the force of the stimulus. It is favored by rubbing the skin at the same time, and especially by energetic mechani- cal dry-rubbing after the application of the cold. A frequent repetition of these actions upon the skin increases the circulation and nutrition of the skin permanently, thereby producing a change in the distribution of the blood. A more important effect is its derivative action upon chronic congestions of internal organs, especially the spinal cord. But this can only be obtained with safety when at the same time all injurious irritation of the diseased organ is avoided. The cold water may act more directly upon the circulation in internal organs, by producing ischsemia of these organs through reflex action; thus, Runge states that quite cold baths, applied to the lower extremities, have a direct vaso-motor action upon the cord, diminishing the quantity of blood contained in it. But in aiming at this, it is important that the reaction in the skin should have developed before that in the spinal vessels is commenced, in order that the secondary hyperaemia may be directed principally to the skin. For this purpose it is useful to apply water not GENERAL THERAPEUTICS. 173 merely to the whole surface, but especially to the parts which are related more closely to the affected organ, that is, the skin of the lower extremities and the back. In regard to the processes of nutrition and change of tissue, it is settled beyond a doubt that every subtraction of warmth from the outer skin is followed by a con- siderable increase in the production of warmth (this forms a portion of the phenom- ena of reaction) ; that the secretions increase, the appetite is improved, etc. It is further probable that the repeated excitation of the nervous system has directly an influence upon the changes of tissue, increasing the formation and destruction of most of the tissues ; and that the nutrition of the portions of the central nervous system which are affected by the stimulus is stimulated and improved. We are in- clined to believe that this method will certainly cure slight disturbances of the nutrition of the cord, and that, under some circumstances, even severe degrees of change may be gradually repaired. In brief, then, cold water acts as follows: It strengthens the functions, improves the nutrition, increases the circulation of blood, in the skin ; it thus alters the distribution of the blood, and the process of circulation in the system ; it relieves, at first temporarily, afterwards permanently, hyperaemia of internal parts (F. Richter) ; it quiets or excites the nervous system in various degrees; it tones the nervous system by the functional excitement and by the improved nutrition; it accelerates the process of change of tissue, and increases the total nutrition ; it promotes resorption and formation. If we add to this the effects which may be had from certain forms of baths, the increased sweating, the consequences of the increased consumption of water, the muscular movements which are necessarily increased, the effects of diet, climate, altitude in the case of cold-water cures, it becomes evident that we possess but few remedies which have so powerful and various an influ- ence upon the nervous system. In point of fact, the cold-water cure has been much and advantageously employed in diseases of the cord. Thus, for conditions of irritable weakness of the cord (chiefly by withdraw- ing caloric and moderate stimulation—cold wraps kept on till warm ; rubbing down with moderate friction), for passive hyper- aemia of the cord (washing and affusion of the back, stimulant sitz-baths, and long-continued moist cold wraps applied to the body), for fluxionary hyperaemia (soothing friction, soothing sitz-baths with cold compresses on the back, etc.), for tabes dor- 174 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. salis (chiefly mild treatment, according to circumstances more stimulating or soothing), for chronic myelitis (the same). The greatest attention must always be paid to the individual; it should not be forgotten that every powerful action of cold produces a powerful reaction, to sustain which a certain amount of force is needed ; for which reason, let none be subjected to the treatment but those who possess a certain power of resistance. Weakly, irritable, anaemic persons bear only the more soothing or the very mildly exciting procedures, under certain precau- tions. In all cases, it may be set down as a rule that the tem- perature should not be below 20° C. [68° Fahr.], unless special trial shows that lower temperatures are well borne. The Sea-Bath is a special and very important form of the cold-water treatment. Its effects are very energetic, because several factors coincide, among which the sea-air is by far the most important. It is, properly speaking, a climate cure associated with a very power- fully stimulant form of the cold-water treatment (?*. e., a full bath in vigorous motion, at a very low temperature). The proportion of salt in the water of the North Sea, the Mediterranean, and the Atlantic is equivalent to that in a brine bath of medium strength, and serves to increase the action upon the skin. The result is a great increase in the change of tissue, increased excretion and formation, increased need of nourishment, increase of bodily weight, tonic action upon the nervous system. But the sea-bath is adapted only to able-bodied persons, whose appetite and digestion keep pace with the requirements made upon the system. Weak persons with feeble appetites or bad stomachs are not suited ; the most that can be done for them is to cause them to enjoy the sea-air, or, in some cases, to add thereto the benefits of bathing in warmed sea-water. The very powerful stimulant and refrigerant effects of sea- baths make them unfit for most cases of spinal disease. They are useful in spinal irritation and spinal weakness, but only in able-bodied persons; in tabes and similar diseases, only in the lightest form and at the very beginning, or as a concluding treat- GENERAL THERAPEUTICS. 175 ment after cure is nearly complete—but only when the organs of assimilation are in a fairly good condition. In any case, the baths must be used with great care, and the chief value ascribed to the breathing of sea-air, to the climate cure. Climate Cures There exist no spinal climate cures for disease of the spinal cord. But it is known that a very favorable influence is exer- cised upon many severe neuroses, including those of spinal origin, especially when of a functional nature, by certain climates and regions. The sea-air, of which we have spoken, is an example of this. Very much the same is true of the mountain air; it has the same power of stimulating the changes of tissue and the appetite, it aids the performance of sensory and motor functions ; the bodily exercise taken in the mountains has an especially enlivening effect upon the nervous system. The higher and drier the site, the more marked are these tonic effects—as, for example, in the Ober-Engadin. Beneke' has made comparative examinations of the action of sea and mountain air, and has reached the conclusion that the increase of metamorphosis of tissue is decidedly greater at the sea-shore than on mountain-summits (3,000'-6,000'), because the subtraction of heat is quicker and greater. Initable, nervous people, who cannot bear great alteration of tissue, had better choose a residence in the mountains. Experience confirms this in a satisfactory manner. Every one knows the beneficial effects of a continued resi- dence in various elevated places in Switzerland, the Tyrol, etc., upon so many nervous patients, those with spinal irritation, spinal weakness, impotence, and so forth. And in the more severe cases, the same may be recommended as after-treatment. The choice among suitable places is extremely large: it should be made with careful regard to all individual peculi- arities. 1 Zur Lehre von der Diffcrenz der Wirkung der Seeluft und der Gebirgsluft. Deutsch. Arch. f. klin. Med. XIII. p. 80. 1874. 176 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. After thus enumerating the different forms of baths and their modes of action, let us formulate briefly the indications, giving some theoretical deductions, which may be of use to the begin- ner as a clew to treatment, though they require much further confirmation by practice. a. Purely functional disturbances of the cord, fine changes in nutrition without demonstrable alterations—as in spinal irri- tation, spinal weakness, concussion without coarse lesion, etc. For the treatment of these we may take into consideration warm springs, thermal brine baths abounding in gas, steel-baths abound- ing in gas, the cold-water cure, sea-bathing, and mountain cli- mates. The selection must depend, firstly, upon the individual- ity of the patient; for irritable, weak persons without much en- durance, let the acrato-thermae be chosen ; the more irritable the subject, the higher should be the location. Or at most, a mild cold-water cure with moderate temperatures. For more vigor- ous persons with good digestion, the cold-water treatment and the sea-bath, or the thermal brine baths, may be considered. For very torpid persons, the same baths and the steel springs. The choice must further depend on the morbid symptoms and their personal variation ; with violent symptoms of irritation in very irritable patients, the cooler acrato-thermae, the more soothing forms of the cold-water method, sea-air, a mountain climate; with preponderant symptoms of debility in torpid persons, the warm springs, the stimulant forms of the cold-water treatment, the thermal brine springs, steel-baths, and sea-baths. b. Hypercemic states of the cord and its membranes. For passive hyperaemia (so-called haemorrhoidal tabes, etc.) the stimulant methods of cold-water treatment, steel-baths, and thermal brine baths are the best. The thermae are contra-indi- cated. For active hyperaemia, select the more soothing forms of the cold-water treatment, combined with derivation to the skin (soothing frictions and sitz-baths with cold compresses to the back, etc.). Thermal brine baths and steel-baths require great precaution. Warm springs and sea-baths will usually do harm. c. Chronic inflammation of the spinal membranes, especially if associated with fluid exudation. Here warm springs, thermal brine baths, a powerful cold-water treatment will be useful; in GENERAL THERAPEUTICS. 177 short, anything that promotes resorption and vigorously stimu- lates the processes of metamorphosis of tissue—but always sub- ject to the distinctions and contra-indications already stated under a. d. Chronic textural changes in the cord itself: inflammation, degeneration, softening, atrophy, sclerosis, etc. Little is to be expected except in the earlier stages of these complaints, and in slight cases. The object is, to stimulate moderately the trans- mutation of tissue, and the cord, so as to remove the disturbance of nutrition ; and for this purpose warm springs, thermal brine baths, steel-baths, moor-baths, and cold-water treatment are use- ful. But we must always be extremely prudent. We should remember that our patients are almost always irritable and weak persons, suffering from a serious organic lesion, incapable of enduring any severe shocks ; and that any increase of the hyper- aemia of the cord may prove dangerous to them. Therefore, use only warm springs of an indifferent or lukewarm temperature ; mild cold-water cures; mitigated steel-baths; well-regulated thermal brine baths. Consider that the effect, at best, must be slow and gradual, and that the cure cannot be completed by a stay of four or six weeks at the baths. The selection among the different baths should be made according to the peculiarities of the individual; that of the spe- cial method, according to the character of the case, the leading symptoms, concomitant hyperaemia, etc. In general, avoid in- dulging too much hope in these cases! Such are the general principles for the balneo-therapeutic treatment of disease of the cord. In the special part we shall see how far they may be applicable to the different classes of disease. Progressive experience will, without doubt, greatly modify them. A great deal might be added under this important head, but we have not the space. It must be constantly remembered that attention to individuals is of the first importance. An exact diagnosis and a thorough estimate of the individual must go hand in hand in forming plans for treatment. And complica- tions, causes, external conditions often have to be considered, so that the selection is extremely difficult. The physician's practi- VOL. XIII.—12 178 ERB.—DISEASES OF TnE SPINAL CORD AND ITS ENVELOPES. cal tact and skill have here a wide field for displaying them- selves. Electricity. Remak, Galvanotherapie. 1858. p. 443 et seq. Application du courant constant au traitement des nSvroses. Paris. 1865.—Ranke, Ueber krampfstillende Wirkung des constanten elektrischen Stroms. Zeitschrift f. Biologic II. 1866.—Flies, Galvanotherap. Mittheilungen. Deutsche Klinik. 1868.—Erb, Galvanotherap. Mittheilungen. Arch. f. klin. Med. III. 1867.— The Same, Anwendung der Elektricitat in der innern Medicin. Volkmann's Sammlung klin. Vortr. No. 46. 1872.—Brenner, Untersuchungen und Beobachtungen auf dem Gebiete der Elektrotherapie. Bd. II. 1869. p. 81.— Uspensky, Einfluss des const. Stroms auf das R.-M. Centralbl. f. d. med. Wiss. 1869. No. 37—Burckhardt, Ueber die polare Methode. Arch. f. klin. Med. VIII. p. 100. 1870.—Ziemssen, Elektrici- tat in der Medicin. 4. Aufl. 1872. pp. 24, 37, and 143.—Also the text-books of electro-therapeutics by M. Meyer, Duchenne, Benedikt, M. Rosenthal, Beard and Rockwell, and others. No other remedy has, within a recent period, gained so much ground as electricity in the treatment of spinal disease. But few can be compared with it for activity. It is among the numer- ous services rendered by Remak that he brought spinal disease within the sphere of scientific galvano-therapeutics, and obtained many striking successes with that treatment. At first, great obstacles stood in the way of a general accept- ance of his views ; first, the doubt as to the possibility of reach- ing the cord with the electric current, which wTas expressed by no less an authority than Ziemssen; and then a scepticism in re- spect to the genuineness of his successes, which was in part justi- fied by the excessive claims of the specialists, and in part was supported by the failures which unavoidably occurred in old, severe, and absolutely incurable cases. These obstacles are now overcome; no one now doubts the possibility of reaching the spinal cord with the electric current, and the numerous and unanimous experience of almost all elec- tro-therapeutists no longer allows us the right to doubt that elec- tricity has accomplished many, in some cases very remarkable, cures in diseases of the cord, and that it has essentially improved the hopeless prognosis of many spinal diseases. GENERAL THERAPEUTICS. 179 We must therefore pay especial attention to this remedy. In this place we have only to speak of the direct treatment of the lesion of the cord. For in most diseases of this sort there are two things to be distinguished: the electrical treatment of the cord itself and its affection, and the treatment of separate symp- toms of the affection. Each of these two may be attended to separately, or they may be combined. As to the second point, we refer to the proper section in Volume XI. of this Cyclopaedia, in which the electrical treatment of paralyses, anaesthesiae, neu- ralgias, spasms, etc., is given in full. Here we encounter at once the question of the mode of action upon the cord and its diseases. Upon this point little is known, and the material in our possession is more than scanty. Physiology furnishes us with almost no facts to the purpose. The experiments on stimulation of the cord have produced few results of consequence; it is still a debated question whether the substance of the cord is excitable or not, and whether all the phenomena of excitation may not be referred to irritation of the roots. The question, however, seems to have been answered in the affirmative by the studies of Fick, Engelken, and Dittmar, showing that at all events the white columns of the cord are excitable. Some facts, also, discovered by physiologists (Nobili, Mat- teucci, Ranke), in relation to the power of the galvanic current to quiet spasm— facts discovered during the treatment of toxic tetanus by strong galvanic currents sent lengthwise of the cord—are perhaps useful, but they require a fresh revision, in view of the more recently discovered facts of the action of powerful currents in arresting reflex actions. The primitive researches of Uspensky, which have shown that the cord acts as a peripheral nerve (!), both for conduction and for reflex actions—that it assumes the conditions of anelectrotonus and catelectrotonus—are quite useless for our purpose. Of the action of electrical currents upon the nutri- tion of the cord, nothing is known by physiology. Almost all our knowledge is drawn from pathological and therapeutical experi- ence, and consists chiefly of purely empirical facts, which are usually far from being understood. Our positive knowledge is really limited to this: that a number of diseases of the cord, especially chronic forms, are relieved or cured during the use of electricity, em- ployed in various ways. The precise connection between the therapeutic results and the methods used is, however, usually obscure, especially as, in many cases, we are unable to form any clear idea of what diseased condition exists in the cord and its membranes, or what it is that we are removing by electricity. We know, further, that individual symptoms of spinal disease may be removed by electrical treatment of the cord, as tetanic spasms, contractures, tremor, lanci- nating pains, anaesthesia, paralysis, etc. But these facts are not always beyond a 180 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. doubt; for example, the results obtained by Mendel in tetanus with galvanic cur- rents may be referred to a simultaneous action upon the peripheral nerves. In the interesting observations by Dr. Rabow, communicated by Leyden,1 the hypothesis of a simultaneous action upon the periphery is almost always admissible; and the explanation of the facts there described is at the present time impossible. We possess, therefore, only inferences and hypotheses regard- ing the possible action of electricity in the various categories of disease. Thus, in the so-called functional disturbances of the cord, we may first consider the exciting and modifying agency of electric currents; probably, however, the so-called catalytic action (comprising effects produced upon the blood-vessels, upon resorption, osmosis, change of tissue, etc.) is of importance, as relieving the minute disturbances of nutrition. In disturbances of circulation (hyperaemia, stasis, exuda- tion) the explanation may be deduced from the powerful action of electricit3r upon the vessels and the vaso-motor nerves, upon the circulation of fluids, resorption and the like. In marked anatomical changes (chronic inflammation, degen- eration, atrophy, etc.) we must again refer to the "catalytic" action of the current, which can alone explain the fact and the rationale of the cure of these diseases. It follows that the so-called catalytic action of the electric current probably constitutes the chief point in the treatment of most diseases of the cord. It is a pity that this action is so obscure, and so little susceptible of an explanation. We do not care to present hypotheses. The catalytic action is probably quite independent of the direction of the current. The special action of the two poles is also very obscure in this respect, although the attempt has been made to define it. The simple passage of the current, in sufficient strength and for a sufficient time, through the diseased region, seems to be the essential thing. All details of application must be discovered by empirical methods. From these principles, the chief rules for the electrical treat- ment of the cord naturally follow. ] Klinik der Riickenmarkskrankheiten. I. p. 185. GENERAL THERAPEUTICS. 181 The first point to be deduced is that the galvanic current should be used almost exclusively in these affections; first, on account of its physical properties, it being able to penetrate more easily and surely to the depth required than the faradic current;' and second, on account of its preponderant catalytic action, which is possessed in but a slight degree by the faradic current. Experience has fully confirmed this position ; even the most obstinate adherents of the faradic current claim for it little or no success in organic diseases of the cord. We shall see further on, however, that they are possible to a cevtain extent. As regards the special methods of applying the galvanic cur- rent 2 in diseases of the cord, we have first to settle the question, whether the cord can be reached at all. The possibility of this is proved by my experiments upon the dead subject, and by numerous facts, discovered by myself and other observers in the case of the living human subject; not to mention numerous therapeutic successes. No one now doubts the possibility of reaching the spinal cord with the galvanic current. The principal object, in most cases, is to produce as general and as powerful a passage of the current through the spinal cord as is possible, especially in its diseased portions. The cord is a deep-seated organ, and we must employ quite powerful currents in order to reach it. And this can be suitably accomplished without hurting the patient, only by using very large electrodes, applied not too near together. Too many offences are committed against this rule, which is a simple inference from Ohm's laws. If small electrodes are used, the strength of current required to affect the cord sufficiently will produce intolerable pain. I have often seen persons with sores on their backs, produced by the very pain- ful application of Stohrer carbon electrodes (quite unfit for this purpose); but who have not seemed to me to have derived the least benefit from the treatment. I always use, for galvanization of the cord, electrodes of at least ten centimetres (4 in.) long and five (2 in.) broad. 1 Ilelmlioltz, Verhandl. des naturhistor. med. Vereins zu Heidelberg. Bd. V. p. 14, 1869. 2 The same principles apply for the most part to the use of faradism. 182 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. The greatest density of current is found immediately under the electrodes; the portions of tissue lying between them are not reached by any great quantity of the current, probably not enough to have any therapeutic effect; hence it follows that the diseased regions should be brought in contact with the poles throughout their whole extent. According to circumstances, inclination, or theoretic views, the operator will prefer for the purpose the one or the other pole. As the action of the poles upon the cord is unknown, and as probably both poles are use- ful in producing the catalytic action, it is perhaps desirable in many cases to let both act, one after the other. The relative position of the two electrodes will be determined by the seat and the extent of the lesion in the cord. If the disease is chiefly distributed in the longitudinal direc- tion—and this is the most usual case—it is probably best to place both poles on the vertebral column, one in the lumbar re- gion, the other at the nucha. One pole, say the lower, being fixed, the other may be moved quite slowly down over the back, and thus brought in contact with a great part of the cord; and likewise, the upper being fixed, the lower may gradually be car- ried over the most part of the cord. Thus the " stabile" effect may be made to preponderate, as is desirable in producing cata- lytic actions, while the point of application is gradually changed. In diseases of a more circumscribed locality (apoplectic foci, spinal paralysis of children, circumscript myelitis, etc.), we shall do best to cover the diseased spot entirely with the pole which is intended to produce its effect, and to put the other pole upon the anterior surface of the body, the abdomen or sternum ; this is the surest way of causing a direct passage of the current through the cord ; or if desired, we may cause both poles to act, one after the other. Here, also, the electrodes should be made as large as possible. In all these applications, interruption or reversal is to be avoided as far as possible, unless there exist special indications for their employment. The direction of the current seems to be nearly indifferent, in respect to results. In general—probably from some undefined impression—the ascending current is preferred. The chief point GENERAL THERAPEUTICS. 183 will always be tc secure the action of the single poles upon the entire extent of the cord. In selecting the poles there are certain rules observed which require to be confirmed by accumulated experience. Thus, we may be decided to prefer the anode in case symptoms of irritation are prominent, in excitable and sensitive persons, in recent, active processes, and when we fear evil results from secondary hyper- aemia. The action of the cathode will be preferred in disease of a more torpid nature, in persons but slightly irritable, in old processes, associated with thickening and increased dryness of the tissues (atrophies, scleroses, etc.). Generally, however, both poles will be used with advantage. The cord may also be influenced indirectly by the electric current. It may be reached by the so-called indirect catalysis of Remak, through the sympathetic. This process is said to ena- ble us to exercise a regulative influence upon the processes of nutrition in the cord, by galvanization of the cervical sympa- thetic, by excitation of the vaso-motor (and trophic) paths which pass through it. The influence is a possible one, and even prob- able, but is not proved. Flies has made further observations upon this point. The possibility of this action has induced me in many cases to apply my treatment in such a way that the sympathetic may be included in the action. The cathode is fixed over the ganglion superius on one side of the neck, and the anode upon the opposite side of the spinal column (quite close to the spinous processes), first between the shoulder-blades, then moving downward very slowly (avoiding labile treatment) till the conus terminalis is reached; and then the same is repeated upon the other side. To this is usually added direct treatment throuo-h the vertebral column, anode below and cathode above, slowly changing their positions. I believe that I have seen excel- lent results from this treatment; perhaps, however, this depends merely upon the more favorable way in which the cord is reached by the current. The cord may also be influenced from the skin. A reflex stimulation, transferred from the sensory nerves to the cord, may very well act like a direct stimulation. Certainly a great part 184 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. of the effects of the cold-water treatment, or of carbonic acid in baths, and the like, depends on this circumstance. We have nothing precise upon this point; it seems probable, however, to me, that a part of the results which are obtained in spinal dis- eases by peripheral electrization of the skin and the muscles, is referable to this cause. For this purpose cutaneous faradization and faradization of the muscles may be employed, as well as gal- vanization. These are the cases which give faradization a just title to comparison with galvanism. Thus, in M. Meyer (3. Aufl. p. 336), there is a case of spinal disease, which was cured by faradization of the skin with a wire brush. The remarkable centripetal action of the galvanic current, produced by irrita- tion of peripheral nerves, discovered by Remak,1 was thought by him to promise great results in practice; but the matter has remained in obscurity, not having been further looked into. The "general faradization and galvanization," recommended by Beard and Rockwell,2 probably acts like peripheral faradization. It consists of a stimulation of the skin and the muscles, extending over the whole body. Beard3 has also recommended a method of " central galvanization" as especially efficacious in all sorts of central lesions, especially in conditions of spinal exhaus- tion. It may be useful in many cases. The cathode is placed upon the epigas- trium, while the anode is applied successively to the vertex, the vertebral column, the cervical sympathetic, in the labile manner. Ranke (loc. cit.) believes that an improvement of the condition of the muscles, and the consequent increase in the strength of the normal ascending current of the spinal cord, will act favorably upon spinal nervous weakness, etc. Finally, M. Meyer 4 has very recently pointed out that galvanic treatment of the points of the spinal column, which are painful under pressure (found in many affections of the cord, especially tabes), often succeeds wonderfully. He applies a current of medium strength for five or ten minutes, placing the anode (unmoved) upon the sensitive points. The duration of single applications may be quite brief—from a minute and a half to five minutes. This is usually enough. Too long applications easily produce disagreeable excitement. The sessions are given daily or less frequently. The duration of the entire treatment is very undetermined; it depends upon the 1 Allg. med. Centralzeitung. 1860. No. 69. 5 Med. and Surg. Uses of Electricity. 1871. p. 186, etc. 3 See Virchow-Hirsch's Jahresbericht fiir 1871. I. p. 376, and 1872. I. p. 404. 4 Berl. klin. Wochenschr. 1875. No. 51. GENERAL THERAPEUTICS. 185 character of the disease and the success obtained. It is often well, after an electric treatment of several weeks, to interpose a considerable period of rest, which may properly be filled up by a visit to spas, a change of climate, or some similar alternative. The diseases are usually very tedious in their course. It is well not to make too light of the administration of elec- tricity ; it is not for every one to undertake. It requires much practice and experience. Manual skill, great technical experi- ence, attention to a great variety of points, careful attention to the individual symptoms are absolute requisites. With the direct treatment of spinal diseases we often have to associate a treatment of the symptoms—as paralysis and anaes- thesia, spasm and neuralgia, weakness of the genito-urinary organs, paralysis of sphincters or of the muscles of the eye, atro- phy of the optic and auditory nerves, etc. All this must be done in accordance with the general rules of electro-therapeutics, with special regard to the individual and to the seat of lesion. Blood-Letting m&y be indicated, under certain circumstances, just as in dis- eases of other organs ; thus, in severe acute inflammations, hy- peraemias and stases, with the consequent irritation or paralysis. General blood-letting is seldom indicated, and is to be gov- erned entirely by general therapeutic principles. Local blood-letting is best practised on the back, at both sides of the vertebral column, owing to the connection between the inner and the outer plexus of vertebral veins; wet cups or leeches may be applied there. For many cases of abdominal plethora, hemorrhoidal affections, etc., blood-letting at the anus is very useful. Derivatives. These formerly played a very prominent part; scarcely a patient with disease of the cord escaped, even from the severest of them all. The back of a chronic spinal patient was usually covered with the scars of blisters, issues, moxa, and the hot iron. In our day we are much less disposed to use these remedies, and perhaps make too little use of them. 186 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Their application and their modes of action are very manifold, comprising derivative influence upon states of sensory excite- ment, change in the molecular condition of the nervous system, arrest of reflex actions, withdrawal of blood by the action upon the circulation, derivation of inflammation and exudation by establishing an exudative or purulent inflammation of the skin. All this may also act upon the spinal cord, and probably does act upon it directly, for the cord is undoubtedly the first of the central organs to receive this class of impressions. But, unfortu- nately, we know no more regarding it. The statements of Busch ' in respect to the application of the hot iron in various neuroses, especially spinal diseases, are very interesting. He found at the autopsy of one such a case that the iron, applied to the back of the neck, acts to a great depth ; in the deepest layers of muscle in that region there were found portions suffused with blood, and even the meninges under the burnt places were found reddened with hyperaemia. Busch is in the habit of burning on both sides of the vertebral spines, in longitudinal strips; he considers this a very powerful derivant in affections of the cord. If it is allowable to transfer to the pia mater of the cord the facts observed by Schueller in the pia of the brain — and there can be no doubt of its propriety — then the effect of very large sinapisms, or, more properly, vesicants, would be a temporary dilatation, followed by a very marked and continued contraction of the vessels of the pia. We may employ as derivatives cutaneous faradization, sina- pisms, vesicants, pustulating ointments, issues, moxae, and heated iron. The place for application will almost always be the back, opposite to the diseased spot. External Frictions. These are much used and highly esteemed among the non- medical public, but are usually rejected by physicians. In this respect medical scepticism often goes too far. 1 Berl. klin. Wochenschr. 1873. Nos. 37-39. Session of the niederrhein. Gesellsch. at Bonn. GENERAL THERAPEUTICS. 187 It is certainly conceivable that the irritation produced by friction with spirituous or other substances upon the skin may act like the stimulation of baths or electricity, exciting and enliv- ening the action of the spinal cord and bringing to pass a better functional condition and nutrition in it, or else, that the quieting, soothing effect upon the peripheral cutaneous nerves produced by inunction with warm oil or narcotic salves, or fomentations and wraps of a similar nature, has a soothing action upon the central nervous system, and thus contributes to the removal of diseased conditions. I believe that I have in a few cases, quite accidentally, proved to myself the efficacy of such procedures, and am therefore unwilling to see them quite abandoned. No great results will be reached, it is true, but the external applications may be used as subsidiary remedies, and to sus- tain the patient's courage. According to circumstances, we have the choice between the more soothing frictions (with warm oil, infused oil of hyoscya- mus, opium or belladonna ointment, etc.), and the more stimu- lating and invigorating frictions (with French brandy, spirit of ants, of wild thyme or of camphor, liniment of ammonia or of camphor, etc.). 2. Chemical Remedies—Internal Remedies. Cf. Nothnagel, Handbuch der Arzneimittellehre. 1870.—Husemann, Handbuch der gesammten Arzneimittellehre. II. 1875.—Schueller, Ueber die Einwirkung eini- ger Arzneimittel auf die Hirngefasse. Berl. klin. Wochenschrift. 1874. Nos. 25 and 26.—Brown-Sequard, Lect. on the Diagnosis and Treatment of the Prin- cipal Forms of Paralysis of the Lower Extremities. London, 1861. p. 110. We have entered upon a region which is still very obscure, and in need of thorough study. Of its contents, we know next to nothing ; the little that we have learnt from therapeutic experience is neither sufficiently established by facts nor based upon intelligible scientific principles. We are acquainted with the specific action of some few reme- dies upon certain functions of the cord, but these actions are seldom required. We are still quite ignorant in regard to most of the remedies we employ, how they act upon the cord and its 188 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. nutrition — although we are especially fond of using them in organic diseases of this organ. We therefore limit ourselves to as brief an enumeration as possible of the internal remedies, leaving the most of what is to be said to the special part of this work. A leading remedy in disease of the spinal cord is certainly strychnia, with the preparations of nux vomica. Its physi- ological action consists in a very great augmentation of the spinal reflex action, probably due to a direct irritation of the central ganglion cells by the poison. It also stimulates the vaso- motor centres very powerfully. Upon the motor nerves it seems to have no influence, but upon the sensory apparatus it acts by increasing their capacity for excitement. Finally, it is said to increase considerably the flow of blood to the spinal cord. Strychnia has been applied in many ways to the treatment of spinal diseases. But in most cases it is totally useless, for the increase of reflex excitability can be of little use to the patient so long as the disturbance of nutrition exists, which causes the paralysis. It then does nothing but produce energetic reflex jerkings in the paralyzed parts, without aiding the restoration of tissues (Gull). In very irritable and easily exhausted patients, in irritative processes in the cord (tabes, myelitis, spinal irritation, etc.) it seems to do positive harm, and its use has been of late almost abandoned. Even such fortunate cases as those lately published by Acker,1 are hardly to be considered in comparison with the numerous cases of failure. The use of strychnia is, however, only allowable in old cases of palsy, or when the principal lesion has been repaired without a full recovery of function. (Nevertheless, in the most of such cases electricity will be a much surer and more harmless agent.) It ought also to be tried in purely functional weakness of a torpid nature, in order to add to our knowledge of the subject. In such cases it seems to act in moderate doses as a nerve-tonic. In cases of spinal anaemia producing disturbance of nutrition, it may be used. Finally, it seems to act well in paralysis of sphincters, in weakness of the genito-urinary organs, in enuresis nocturna, per- 1 Arch. f. klin. Med. XIII. p. 438. GENERAL THERAPEUTICS. 189 haps when these disturbances depend on anomalies of the reflex centres in the lumbar cord. The watery extract of nux vomica is given in the dose of from one-half to three grains (0.03-0.20); the alcoholic extract, in the dose of from one-sixth to one grain (0.01-0.06) ; the tinc- ture of nux vomica, from five to fifteen drops; and nitrate of strychnia, from one twenty-second to one-sixth of a grain (0.003- 0.01), best by subcutaneous injection in the same doses. Coniine acts in some respects in the opposite way. It directly paralyzes the motor nerves, but seems also to have a specific action upon the spinal cord, as it powerfully depresses the reflex excitability. It is therefore available for the relief of spasmodic conditions, especially those of a reflex character. (Dose of the conium herb, from three-quarters to four and a half grains (0.05-0.30); coniine, from one-sixtieth to one twenty-second of a grain (0.001-0.003), dissolved in water.) Curare has a very similar action, directly paralyzing the motor nerves and diminishing the reflex action of the cord. It is a very uncertain remedy, and may be dispensed with. Calabar bean lessens and destroys the excitability of the ganglia of the cord, especially in the gray anterior columns, giv- ing rise to paralysis, loss of reflex excitability, and of the sense of pain. This remedy is therefore to be used in cases of exagge- rated reflex action (in tetanus, the intoxication of strychnia, reflex contractures). Dose of extract, from one-twelfth to one- third of a grain (0.005-0.02), in solution or pills. Ergotin (or ergot) has a powerful effect upon the vessels, and according to Brown-Sequard, a special tendency to the vessels of the spinal cord. It is said to produce at the same time a dimi- nution of reflex excitability. It affects all the smooth muscular fibres, especially those of the bladder. It is employed in fluxionary hyperaemia and paraplegia; in the latter disease it is especially useful (according to Brown- Sequard) when there is hypergemia or chronic inflammation of the cord and its membranes, while it is contra-indicated in the absence of symptoms of irritation or hyperaemia. (Dose of aqueous extract of ergot, from one and a half to seven and a half grains (0.1-0.5) internally, from one-sixth to one and a half 190 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. grains (0.01-0.10) subcutaneously ; of tincture of ergot, from ten to thirty drops. Atropine (or belladonna) has also a powerful action upon the vessels, and in large doses, according to Brown-Sequard, it spe- cially contracts the vessels of the cord. It further depresses the excitability of the motor and sensory nerves and muscles; its action upon the cord itself is unknown. Brown-Sequard recom- mends it in the same affections as ergot. (Dose of extract of belladonna, from one-sixth to one and a half grains (0.01-0.10), of sulphate of atropia, from one one-hundred and twentieth to one-thirtieth of a grain (0.0005-0.001-0.002). Nitrate of silver. This remedy was first recommended by Wunderlich ' in progressive spinal paralysis, and since then has been much used in tabes and other forms of sclerosis of the cord. It is undeniable that in many cases it has produced most decided effects : that it removes the pain, lessens the anaesthesia, improves the ataxia and the paralysis, and in many cases brings about a complete cure. But its precise mode of action and its special indications are as yet entirely unknown. Injurious effects are reported by many physicians. Dose from one-sixth to one-third of a grain (0.01-0.02), three times a day, best given in the form of pills ; to be continued for a long period. Iodide of potassium has been much used in diseases of the cord, as in so many other neuroses ; and not rarely with success. Its mode of action and the special indications for its use are quite as obscure as those of nitrate of silver. Its well-known action upon a variety of pathological products, various forms of inflam- mation, exudation, etc., furnishes so tempting an excuse, that it is tried over and over again. It is prescribed a good deal in exudative inflammations of the meninges, especially in the chro- nic stage ; in chronic inflammations of the cord itself, especially when they can be ascribed to a rheumatic origin ; in new forma- tions, sclerosis, etc. Its chief employment is found, of course, in cases where syphilitic action is suspected. Let the dose not be too small; from fifteen to forty-five grains (1.0 to 3.0) each day. Nearly the same is true of the mercurial preparations, so frequently used. 1 Arch, der Heilkunde. II. 1861. p. 193, and IV. 1803. p. 43. GENERAL THERAPEUTICS. 191 Bromide of potassium, among other effects, lessens the reflex activity of the cord, and afterwards paralyzes the peripheral nerves. It contracts the vessels of the brain, and is believed to act thus as an hypnotic. It therefore appears indicated in cases of increased reflex excitability, and in reflex contractures; it further appears useful in pain, neuralgia of centric origin, sleep- lessness, and conditions of sexual irritation. The dose given is from fifteen to thirty grains (1.0-2.0); or from one and a half to two and a half drachms (6.0-10.0 grammes) a day. A portion of the toxic effects of arsenic are produced upon the spinal cord; but we do not know them very precisely. Probably the chief part is due to the effect upon the general nutrition and the tonic action upon the nervous system; it is highly recommended by Isnard, and is given in the usual manner. Phosphorus has been repeatedly recommended for various neuroses, and in tabes, paraplegia, etc. It has not yet obtained a general recognition; it seems to be very dangerous, and not specially efficacious. Of the physiological action of zinc and its preparations upon the cord and upon spinal symptoms, wTe know almost nothing. It is much used empirically as a nervine, and may perhaps be of value in conditions of functional weakness. It is most employed in the form of the oxide and valerianate. Quinia is held by many physicians, both old and young, to be useful to the spinal cord. Physiological researches give us few grounds for this belief. Its use in practice has been confined almost exclusively to its anti-febrile and anti-zymotic effects; it has also an invigorant action. It cannot be doubted that quinia has a powerful action upon the central nervous system, but the manner of its action, and the parts affected, are quite unknown. It is employed in spinal nervous weakness, in excentric pains, in fever, in spinal complaints which depend on malaria. The dose is graduated according to the effect sought; small doses are the favorite ones for the strengthening effect. The sodio-chloride of gold has been repeatedly recommended as a remedy in spinal complaints; its claim to the title is still 192 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. doubtful. The dose is from one-sixth (0.01) to three-quarters of a grain (0.05). We might prolong this enumeration at pleasure, but the reader doubtless has enough ; further explorations of this dark and doubtful region will prove of little advantage. We would add a few words upon the diet cures, which are believed to act like courses of internal drug medication. They are not of much importance in diseases of the cord. But milk cures, whey and grape cures, and the like, may produce a desirable effect upon the general nutrition, and thus upon that of the spinal cord. The same is true of courses of mineral water, taken inwardly. Nothing is known of any specific action upon the spinal cord and its affections. Nevertheless, such courses may be required by certain causal or symptomatic indications, and may then have a most excellent effect. 3. Symptomatic Remedies and Methods. We are very often compelled to give sedatives in spinal dis- eases ; especially for the relief of the frequent excentric pains, pains in the back, painful reflex contractions and spasms, etc. In addition to the ordinary narcotics we possess a number of remedies, discovered empirically. The best of anodynes—opium with its preparations—increases the reflex excitability of the cord, and does not depress it except in large doses. It must, therefore, be avoided in cases of reflex spasm, but is of very great value as a simple antidote to pain. This is especially true of subcutaneous injections of morphia. But the patient must not be allowed to form a habit of relying upon it, as that always exercises an unfavorable influence upon the general progress of the disease, and the habit is extremely hard to break up. It is recommended to make trial of the remedies above named —coniine, atropia, calabar, etc. It has been found empirically that in many cases bromide of potassium, quinia, etc., have a specially quieting influence. GENERAL THERAPEUTICS. 193 Electricity also often has a very good effect; the relief to lancinating pains, especially by local faradization or galvaniza- tion, is often quite magical—though usually but temporary. For painful priapism, or great sexual excitement, use bromide of potassium, lupulin, camphor, etc. For obstinate sleeplessness, the ordinary hypnotics are used ; they often fail, and their continued employment is not without danger. We must then have recourse to all auxiliary methods. The cold-water treatment (cold washing of the feet, Priessnitz's packing of the calves) is very advisable. In other cases we shall make more use of irritants, as in paralysis, anaesthesia, weakness of the bladder, etc. Here elec- tricity is the chief remedy. After it, strychnia, ergot, etc. Tonics are often indicated, as the preparations of iron, the chalybeate springs ; also quinia, various bitters and tonics, ac- cording to general principles. In many diseases of the cord, the treatment of cystitis forms a specially important point, as this often constitutes the first serious danger to life. The observance of suitable prophylactic rules will be of the first importance in this complaint; and of these the chief one is —never to allow the urine to stagnate in the bladder. The evacu- ation ought, therefore, to be aided by pressure upon the bladder, or by exciting reflex action by kneading and pressing the wall of that organ ; or by raising the patient in order to gain the mechan- ical advantage. If necessary, catheterize regularly and from the beginning, twice a da}r, but with extreme precaution and cleanliness. It is also advisable to assist and complete the evacua- tion by the principle of the siphon, depressing the outer orifice of the catheter below the level of the fundus vesicae. In all cases we should see that the bladder is frequently evacuated, and should lessen the tendency to decomposition in the urine by making the patient drink copiously of common water, by the use of the waters of Ems, Selters, or Wildung, by exhibition of sali- cylic or benzoic acid. If there is incontinence of the bladder, the best means for keeping the patient in a state of tolerable cleanliness consists in a regular artificial evacuation. Frequent washing, the use of 194 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. portable urinals, or (in the case of women) placing sponges in front, are also necessary. When catarrh of the bladder has appeared, it may be arrested in its further progress, or even cured, by preventing the process of decomposition, and checking the tendency of the urine to be- come alkaline. For this purpose salicylic acid is found a most excellent remedy, according to the experience of Fuerbringer,1 which my own in part confirms. From thirty to sixty grains are given daily in watery solution or emulsion by the mouth, and injections into the bladder (1 part to 500) may be added. It brings back the acid reaction, removes the foul odor, and clears up the urine. Benzoic acid is said by Gosselin and Robina to act similarly, and is claimed to be the best agent for restoring the acid reaction to ammoniacal urine, and relieving the catarrh which depends upon this condition. (Dose from thirty to ninety grains daily in emulsion or powders.) The use of lime-water, Wildung water, and various alkaline waters (Ems, Vichy, Selters, etc.), seems to have a good effect in light cases. Clemenss recom- mends ergotin for the same purpose. As a direct remedy for catarrhal inflammation of the bladder, the usual astringents are given—uva ursi, tannic and gallic acid, copaiba, oil of turpentine, tar-water, etc. But in all severe cases, accompanied with abundant formation of pus and mucus, a good deal of ammoniacal decomposition, ulceration, etc., it will be indispensable to wash out the bladder, regularly and with great precaution. Injections for this purpose are composed of lukewarm water, which may gradually be made colder, of salt water, weak solutions of tannin, nitrate of silver, salicylic acid (1 : 500), etc. They may be made either with a sim- ple syringe or with the irrigator, but the catheter d double cou- rant is the most suitable. In all such cases it is advantageous, while pursuing the above plan, to attack the palsy and anaesthesia of the bladder with elec- tricity. 1 Berl. klin. Wochenschr. 1875. No. 19. Zur Wirkungder Salicylsaure. Jena, 1875. p. 62. - Traitem. de la cystite ammoniac, par l'acide benzoique. Arch. gen. Nov. 1874. 3 Deutsche Klinik. 1865. No. 27. GENERAL THERAPEUTICS. 195 A careful regulation of the diet is very important. Patients with decided catarrh of the bladder must use the blandest and most digestible articles of diet, avoiding all acid and highly spiced articles; the use of beer and strong sweet wine is unad- visable ; but a light semi-acid white wine, or a good red wine, diluted with water, is allowable. Of almost more importance than the treatment of cystitis is that of bed-sores. These form one of the most horrible complica- tions, infinitely increasing the patient's sufferings, and must be avoided by all possible means, as it is extremely hard to heal them when once fully developed. The chief remedies are of the prophylactic sort, and the princi- pal point to observe is the avoidance of all continued pressure on the skin. This can be attained by frequent change of pos- ture, by air-pillows, water-cushions, lying on bags of millet, on buckskin, etc. All filth and irritation of the skin where pres- sure is borne must be avoided as far as possible ; removal of faeces and urine, frequent washing, anointing with grease and oil are the chief precautions. And finally, a slight stimulation of the tone of the cutaneous vessels may assist in preventing bed- sores, for which purpose frequent washing in cold water, or in spirit, or the alternate application of ice and poultices (Brown- Sequard), or moderate cutaneous faradization may be used. If a bed-sore appears in a light form (superficial ulceration, furuncles, etc.), it may often be healed by simple treatment, though slowly. Great cleanliness, frequent washing, dressing with zinc ointment, or mildly irritant salves, chamomile water, or aromatic wine will be sufficient in connection with the prophy- lactic rules. The matter is less simple in the case of the true gangrenous sore, which often reaches an enormous size, and extends without cessation downwards and at its borders. The first object in this case consists in assisting the throwing off of gangrenous portions, and developing the reactive inflammation ; according to Brown- Sequard, the alternation of ice (for ten minutes) with poultices (for one or two hours) is an excellent means to this end. The dead tissues, separated by the line of demarcation, should be got rid of as soon as possible, and an antiseptic dressing applied. 196 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Carbolic acid has great advantages over the remedies formerly used (camphor wine, aromatic wine, "unguentum contra decubi- tus," etc.). It should be applied in a watery or oily solution, by preference upon good surgical wadding. Under this treatment I have seen the wounds take on the most healthy granulations, and even very advanced bed-sores heal.1 It is of ten very hard to find a suitable position for the pa- tient, especially when there are bed-sores on the sacrum, the ischiatic protuberances, trochanters, heels, etc. Much care and observation must be directed to the prevention of new sores. Water-pillows and air-pillows must be used in their various forms. In the worst cases I have found it useful to swing the lower leg on a pillow, placing the knee-joint and hip-joint in the position of rectangular .flexion; this may, to some extent, also free the sacrum from pressure. 4. General Observations—Method of Life. The general care of patients with spinal disease, their diet and manner of life, must be governed strictly in accordance with the requirements of the disease. Many mistakes and negligences are committed in these matters, which neutralize the success of the other treatment. The rules must differ widely, of course, in different cases. In the acute, inflammatory, and similar forms, the proper diet, rest in bed, avoidance of all excitement and effort must be ordered. But in the chronic forms also, in functional as well as organic disturbances, the patient must in general be very careful, and must observe the following general rules (with suitable adapta- tion to his case), with a strictness proportionate to the weakness and irritability of the patient's nervous system, to the amount 1 Hammond (Diseases of the Nervous System. 3d edition. 1873), following Crussel and Spencer Wells, recommends a simple galvanic element as an excellent means of curing bed-sores. A thin silver plate is laid on the sore, a similar plate of zinc, with a piece of moist cloth underneath, upon a distant part of the skin, and the two are con- nected by a wire. After a day or two the beneficial effects are seen. I have no per- sonal experience of this. GENERAL THERAPEUTICS. 197 of symptoms of irritation present, to the readiness with which he suffers from the effects of external circumstances. The diet must be corroborating and tonic in most cases, with- out being in any way exciting. Milk, meat, eggs, light vegeta- bles, puddings, and fruits are allowed and required; an abun- dant supply of fatty nutriment (butter, cream, oil, cod-liver oil) is perhaps useful in a good many cases; strong seasoning, and very complicated and heavy dishes must always be avoided. A glass of wine or beer at table is usually allowable, but their ex- cessive use is to be strictly forbidden. Strong tea and coffee must be avoided in most cases. Smoking within moderate bounds is allowed. In regard to the general regulation of the life, the allowable amount of work and rest, of bodily and mental activity, we must be governed chiefly by the state of the patient's strength. It is but rarely that chronic cases can be condemned to continuous confinement in bed; yet there may be many decided indications for it. Brown-Sequard directs the avoidance of lying on the back, as far as possible, in conditions of inflammation and hyper- aemia. It is usual and desirable to allow a moderate amount of active bodily exercise when practicable, but let the patient be warned against every excess of exertion! Great injury is thus often done ; for instance, by too long walks; the patient must be espe- cially cautious about this while taking a course at a medicinal spring. Mental effort, the practice of a profession, cannot always be forbidden on account of circumstances; and the disease is usually so tedious that such a measure would be excessively irksome. Let this, therefore, be allowed within judicious limits, every ex- cess of effort being forbidden, especially night-work, which is especially injurious. The same is true of sexual indulgence; between different persons and cases there is a very great difference of power. The permission must be determined by. the patient's condition ; in all cases it is well to limit the indulgence as much as possible, and in many to forbid it wholly ; in a small number, moderate indul- gence is permissible. 198 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. In most cases the need of sleep is among the things to be first attended to, and in connection with this, all exciting and fati- guing society must be forbidden. The patient must also avoid taking cold, and clothe himself accordingly. He may by degrees harden himself by using cold ablutions, and so on. A great deal of fresh air will almost always be beneficial to patients ; let them sit or drive in the open air, especially on the mountain and in the forest. This is the principal reason for ordering many patients to pass the winter in the south, especially when their home is in a rough northern climate, which keeps them in-doors the whole winter. Such patients will find a winter in South-western Germany a great pleasure ; others will like the banks of the Lake of Geneva, the Riviera, Meran, Venice, etc., where they may spend several hours every day in the air. All, however, will depend on individual circumstances. II. SPECIAL DISEASES. 1. Diseases of the Membranes of the Spinal Cord. 1. Hyperemia of the Meninges of the Cord, and of the Cord. itself. J. P. Frank, De vertebralis columnar in morbis dignitate. Select, opuscul. med. Ticin. 1792. p. l.—Ollivier, Traitg desmalad. de la moelle e"pin. III. 6d. 1837. Tom. II. pp. 1-137.—Hasse, Krankh. des Nervensystems. 1855; 2. Aufl. 1869. p. 656.—Brown-Sequard, Diagnosis and Treatment of the Principal Forms of Paralysis of the Lower Extremities. London, 1861.—Hammond, A Treatise on the Diseases of the Nervous System. 3d ed. 1873.—Leyden, Klinik der Ruckenmarkskrankheiten. I. 1874. p. 362.—M. Rosenthal, Klinik der Nerven- krankheiten. 2. Aufl. 1875. p. 270.—Gaune, Epidemie de congestion rhachid. Arch. gen. Janv. 1858. p. 1.—A. Mayer, Die Bedeutung des Ruckenschmerzes u. s. w. Arch. d. Heilk. I. 1860. p. 373.—Leudet, Arch, gengr. Mars. 1863. p. 257.—Desnos, Observat. de congestion meningo-spinale, etc. Gaz. mfid. de Paris. 1870. No. 14. p. 187.—Steiner, Fall von Riickenmarkshyperamie. Arch. der Heilk. XI. 1870. p. 233. It is impossible to treat of hyperaemia of the spinal meninges without including that of the spinal cord. And it is hardly con- ceivable that any considerable hyperaemia of the meninges should exist without a similar condition existing in the cord also, as the vascular supply of both is the same. The symptoms of menin- geal and spinal hyperaemia coincide ; their etiology and treat- ment are the same. Defective as is our knowledge of both forms of disturbance, we must therefore consider them together. Definition.—By hyperaemia of the cord and its membranes we understand an increased supply of blood in the tissues con- tained within the vertebral canal, the spinal cord, its membranes, and the extra-meningeal cellular tissue. This excess of blood 200 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. may be due either to an increased flow of blood, when it is usu- ally of an arterial character {active, arterial hyperaemia, fluxion), or to arrest of the return current of blood, when it is usually of a venous character {passive hyperoemia, venous stasis). In practice, these two sorts cannot always be clearly separated. The frequency and importance of spinal hyperaemia have certainly been over- estimated hitherto. This results chiefly from the fact, that in many fatal cases tkose who examined the body have been content with the mere macroscopic ap- pearance of hyperaemia of the cord, without reflecting that a cord which looks quite normal to the naked eye is by no means necessarily so in its finer anatomy. Ollivier, in especial, has gone much too far in this, and has thrown together under the title of "Congestions spinales" a variety of things which are certainly of a much more serious character. The spinal and meningeal hypersemias certainly need a fresh and more discriminating study. Etiology and Pathogenesis. Little is known as to the existence of any special predisposi- tion to spinal hyperaemia. On the contrary, it deserves special attention, that the arrangement of the vessels of the cord pro- tects it in a peculiar manner from mechanical disturbances of circulation, as is shown by Hayem's1 luminous observations upon the distribution of the arterial and venous vessels within the spinal canal. The many anastomosing arteries, coming from all sides, and the enormous venous plexuses, which carry off the blood from the spinal canal both above and below the dia- phragm, are the cause of this. The diseases of the vessels of the cord have not yet been accurately studied. In respect to the occasional causes, we must attempt to dis- tinguish the two principal forms of hyperaemia. Active hyperaemia has certainly some relations to hyperaemia of the brain; this follows from the fact that the spinal arteries originate from the vertebrals. But hyperaemia of the cord usu- ally recedes into the background, as compared with hyperaemia of the brain, if the latter is present. Hyperaemia of the cord and its membranes is produced— a. By functional stimulation of the cord. In this case, as Des hemorrhagies intrarhachidiennes. Paris. 1872. pp. 7-20. HYPEREMIA OF THE SPINAL MENINGES. 201 everywhere, the activity of the organ is accompanied by an in- creased flow of blood towards it; and in case of excessive exer- tion the flow may continue and form a pathological state, as in overwork of body, severe marching, violent sexual excitement, excess of coitus, spinal spasm, and so on. The absolute proof of the agency of either of these circumstances remains to be brought. b. By nutritive stimulation. Active hyperaemia accompanies a number of disturbances of the nutrition of the cord and its membranes, is never absent in acute inflammations of the organ, and in the first stages of the latter is often the only macroscopic appearance. c. By toxic stimulation. Poisoning with strychnia, nitrite of amyl, carbonic oxide, chronic poisoning with alcohol or ab- sinthe, etc., produce spinal hyperaemia. d. By collateral fluxion, as in sudden suppression of the menses, in dysmenorrhcea, in the turgor of haemorrhoids or men- struation, in suppression of haemorrhoidal bleeding, in sup- pressed perspiration of the feet or when the feet are always cold, etc. In most of these cases, nothing but the assumption of a lessened resistance on the part of the spinal vascular system can explain why this particular region should become the seat of hyperaemia. e. By the effects of cold. This is thought by Hammond to be the most common cause of spinal hyperaemia; a wetting to the skin, when one is making too great bodily exertions, is thought especially dangerous. Cold produces its effects both by collate- ral fluxion, through interference with the circulation in the skin, and also by a reflex action from the cutaneous nerves upon the spinal vessels, which are dilated. /. By traumatic causes, as shock to the cord, a fall on the back or seat, etc. (Leudet); the mechanism of this action is still obscure. g. Finally, severe febrile diseases (typhoid, acute exanthe- mata, malarial infection, etc.) have been observed to be accom- panied by spinal hyperaemia, and the latter has appeared epi- demically in a girls' boarding-school (Gaune). Of passive hyperaemia, the most prominent cause is to be 202 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. sought in general venous congestion or stasis, such as is pro- duced by diseases of the heart and lungs, or accompanies severe spasmodic affections (tetanus, eclampsia, etc.), and occurs dur- ing the death-agony ; also, in local venous stasis, especially such as is produced by obstructions in the portal system, or in the pelvic veins, in the case of hemorrhoids, abdominal plethora, affections of the liver, tumors in the pelvis or by the side of the spine pressing on the venous trunks and plexuses. Pathological Anatomy. The anatomical evidence bearing upon hyperaemia in the spi- nal canal is as uncertain and ambiguous as possible. Compara- tively very few spinal canals are opened at autopsies, which makes it hard to estimate the relative proportion of normal and of pathological conditions. The post-mortem changes add a great deal to the difficulty of establishing the fact of hyperae- mia ; the arteries are emptied, the veins over-filled; we may find, on the one hand, a deceptive disappearance of hyperaemia, which existed during life, and, on the other, a deceptive appear- ance of hyperaemia, having its origin during the death-struggle or after death, without having existed during life. Add to this the imbibition of the coloring-matter of the blood, and the gravi- tation of blood to dependent parts—all of them circumstances which may confuse the judgment and obscure the facts. Nevertheless, the existence of hyperaemia, in marked cases, can generally be detected with certainty. Active hyperaemia is betrayed by a rose-color or scarlet red- ness of the cord and its envelopes, by injection of the minute vessels, by tortuosity of the arteries and veins; the white sub stance of the cord appears of a rose-color ; the gray is darkened, reddish-gray, brownish ; under the microscope the finer arteries and capillaries are seen crowded with blood. In the more marked cases punctiform extravasations and ecchymoses are seen dotted over the membranes and in the substance of the cord, and often larger extravasations. The spinal fluid is usu- ally increased, is muddy, and of a reddish color. HYPEREMIA OF THE SPINAL MENINGES. 203 In passive hyperaemia the extra-meningeal plexuses of veins are especially crowded with blood, all their veins are enlarged and tortuous, and the coloration approaches a cyanotic hue. Ecchymoses may be present here also ; the spinal fluid is almost always increased to some extent. In a few cases something is seen which lies between the condi- tion of congestion and that of inflammation. In chronic or often-repeated hyperaemia the pia and arach- noid are thickened and opaque, and highly pigmented. These hyperaemias do not always extend over the entire spi- nal canal, but often are confined to the cervical, or lumbar, or other portions. The cerebral hyperaemia, and the diseases of other organs which cause spinal hyperaemia, need not here be described. Symptoms. In spite of the great certainty with which congestions and stases of the cord are spoken of, their symptoms are still ex- tremely obscure, and the diagnosis is surrounded by many diffi- culties and doubts. We may therefore sum up the subject very briefly, leaving to the future a more thorough elaboration of this branch of spinal pathology. The most prominent symptoms are those of sensory irrita- tion ; the patient complains of pain in the loins and along the spine; the pain is dull, oppressive, not very severe, and is not always increased by pressure upon the spinous processes. The additional symptoms of paraesthesia (tingling, formication, etc.) and tearing pain in the extremities (especially the lower) are soon perceived. A slight hyperaesthesia of the skin is usually associated with a moderate increase of reflex activity. The girdle sensation is often felt (Hammond). Symptoms of motor irrita- tion are more rare; as slight transitory jerking of the muscles, tiembling of the limbs, etc. The electrical excitability is said to be often increased (M. Rosenthal). All these symptoms can be derived without difficulty from the increased flow of blood, and the consequent stimulation of 204 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. the nervous apparatus, and doubtless belong principally to the condition of active hyperaemia; but they may also, in part, be explained by the mechanical irritation and the violence done to the tissues by the dilated vessels. Distinct symptoms of depression are also seen, and usually make their appearance at the beginning with those of irritation. A sensation of numbness and heaviness is perceived in the lower extremities ; slight anaesthesia is also demonstrable, but seldom in a severe form. Motor weakness is never absent, though usu- ally quite moderate in amount (slight fatigue, heaviness of the limbs), and it is rarely—perhaps in simple hyperaemia never— the case that complete paraplegia occurs. Symptoms of weak- ness or palsy of the bladder seem rare, but are occasionally de- scribed. Hammond says that he has often observed erection of the penis. It is not easy to explain the paretic symptoms. We may take into account the pressure of dilated vessels upon the ner- vous elements of the cord and the nerve-roots, the pressure ex- erted by an increased quantity of spinal fluid, and finally, per- haps, the defective nutrition of the nervous apparatus, dependent on the blocking of the circulation. The symptoms of spinal hyperaemia are, almost without ex- ception, bilateral, and are usually limited to the lower half of the body, or at least they begin in the lower extremities ; they seldom ascend to the upper, and if they do the extension is usu- ally rapid; the respiration, in such cases, is said to have been disturbed, with short, dyspnoic breathing, and even paralysis of both facial nerves (Steiner). Usually the symptoms exhibit a certain transitoriness, which is quite characteristic ; they change their seat and degree of se- verity quickly, and even grave symptoms may completely dis- appear with striking rapidity. Brown-Sequard says that he has observed all the symptoms of hyperaemia aggravated by lying on the back, with the head and legs raised, while they were relieved by lying on the face, or by standing and walking, owing to the effect of gravitation upon the circulation in the spinal canal. For this reason such patients are said to feel worse in the morning while in bed. Others say HYPEREMIA OF THE SPINAL MENINGES. 205 that standing and sitting make the symptoms worse, especially those of paresis, and refer this to the gravitation of the increased quantity of spinal fluid ; such patients are better in the horizon- tal posture. There is no fever in simple hyperaemia of the cord. The pulse may be accelerated, or retarded, if the hyperaemia extends to the spinal centres of cardiac innervation. The general health is more or less interfered with. Distinct groups of symptoms belonging respectively to active and passive hyperaemia have not yet been made out. But con- clusions drawn from the preponderant nature of the symptoms will in most cases be correct. If those of an irritative character prevail, we shall think rather of active hyperaemia ; if symptoms of depression, of a passive form. But we should remember that most of the symptoms may occur in either form, though in vari- ous degrees of intensity. Course.—The development of hyperaemia of the cord is either sudden, so that the entire series of symptoms is soon completed, or it is slow, and gradually increases in intensity; this is the more usual case. Having been developed, they continue with various degrees of fluctuation for days, for weeks, or months. The disease usually ends in recovery; this is often brought about rapidly, by critical hemorrhages (menstruation, hemor- rhoidal bleeding) or therapeutic measures. Relapses are not rare ; and the cure is often accomplished by a very gradual dis- appearance of all the symptoms. In many patients (those with piles, etc.), we find hyperaemia of the cord becoming habitual, returning regularly and fre- quently. This may lead by degrees to severer disturbances, by the development of chronic inflammations and proliferation. Death, as resulting from hyperaemia solely, is rare ; it is con- ceivable that it might follow an extension of the affection to the important centres in the medulla oblongata and cervical medulla. But, as a rule, the danger to life depends on hemorrhage, soften- ing, and other changes of the spinal cord. 206 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Diagnosis. A demonstration of the fact that hyperaemia can exist in the spinal cord and can be recognized by its symptoms is not re- quired. Although its existence is often very hard to demonstrate in the dead body, or quite impossible, yet is its existence in the highest degree probable, besides being proved by a number of clinical observations which are hardly susceptible of any other interpretation. Not all, nor nearly all, the cases known in literature by this name are to be considered as deserving it; few of the uncompli- cated cases which end in death can be reckoned as hyperaemia; and if nothing is discovered at the autopsy of such patients, the cause, doubtless, lies in defective methods of observation. It certainly seems to us improper to interpret as simple hyperaemia the large class of cases with severe and threatening symptoms {e. g., the case of Desnos, numerous cases in Ollivier, etc.); and the fact that nothing besides hyperaemia has been discovered in many instances of so-called acute ascending paralysis, after care- ful microscopical examination, is far from proving that the fatal result was due to hyperaemia. The diagnosis of hyperaemia of the structures within the spinal canal is chiefly based upon the slightness of the sensory and motor disturbances, which very rarely become severe ; upon the frequent and rapid changes in symptoms, especially as regards their location; upon their non-febrile, usually short and favorable course, and upon the success of treatment suited to relieve hyperaemia. It is obvious how uncertain these signs are, and how hard it is to separate them from those of slight inflammation or func- tional weakness. It is the duty of the future to throw light upon the matter. For the present, the following hints must suf- fice for the differential diagnosis. Spinal hyperaemia is distin- guished from Concussion of the spinal cord, by its comparative slowness of access, mildness, and rapid disappearance ; Spinal meningitis, by the absence of spasm of the back and neck, fever, and pains on moving the limbs ; HYPEREMIA OF THE SPINAL MENINGES. 207 Acute myelitis, by the absence of fever, severe symptoms of paralysis, contractures, paralysis of the bladder, and bed-sores ; Spinal apoplexy, by the comparatively slow development, slightness of the paralytic symptoms, and rapid termination in recovery ; Spinal anaemia, chiefly by the fact that lying on the back gives relief to the symptoms of the latter. Thus, by exclusion and by observation of the course of the disease, we shall in many cases attain a tolerably certain diag- nosis. The prognosis of spinal hyperaemia must be regarded as fa- vorable upon the whole. Serious complications may, of course, render it gloomy. In habitual, frequent hyperaemia, if the cause continues to exist, if the walls of the blood-vessels possess little power of resistance (involving the danger of hemorrhage), the prognosis will, of course, be serious. Treatment. Everything must first be tried, to fulfil the causal indication —in regard to which, detailed directions will not be required. The most favorable cases are those where we can ascertain that a discharge has been interfered with, or venous congestion exists, or exposure to cold has occurred; the remedies for these are obvious. As a direct measure against the hyperaemia, the patient should be made to take a suitable position, avoiding the back, and preferring the side or face, with the extremities as low as possi- ble. Next in order, blood-letting is the remedy most recom- mended. Venesection will be practised only when the symptoms are very violent—in plethoric, robust persons; a much better plan is to draw blood from the region of the spinal column, or from the anus, vagina, cervix uteri, etc., according to the nature of the case. From ten to twelve moist cups along the vertebral column, or a corresponding number of leeches, repeated according to circumstances at fixed intervals, will be most useful. The attempt has also been made to treat spinal hyperaemia by derivation to the skin. A great variety of remedies may be 208 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. used ; the physician may select according to his patient's special case, but the indications are, unfortunately, very unsettled. The cold-water treatment has certainly a considerable sphere. For active hyperaemias, the hydro-therapeutists recommend milder procedures, as cool affusion and wraps to the back, soothing frictions, and sitz-baths ; for the passive form, a more energetic course, including cold affusions and douches, exciting sitz-baths, energetic cold packing, and sea-baths ; for such cases the gaseous thermal brine-baths (Rehme and Nauheim) seem especially suited. A direct derivation of the blood to the skin is obtained by hot foot-baths with mustard and the like, by the warm douche applied several times a day to the back, by washing with a cold and a hot sponge alternately, by moderately warm full baths. Sinapisms, blisters, etc., may also be of use in some cases. A direct action upon the vessels of the cord has been attempted by applying Chapman's ice-bags to the back, and by the galvanic current. The indications for these measures are not precise, and it will be necessary in each case to be governed by the success that seems to be obtained. Derivation to the intestine is also much favored in the form of saline purgatives, or, in more chronic cases, of the saline medi- cinal springs (Homburg, Kissingen, Marienbad, Karlsbad, etc.). Among internal remedies, ergotin and belladonna should be tried by preference; the former must be given in large doses (Hammond). Diet and regimen must be governed by personal circum- stances ; everything which might increase the hyperaemia (espe- cially coitus) must be avoided. 2. Hemorrhages of the Membranes of the Cord—Haemator- rhachis—Meningeal Apoplexy. Ollivier, 1. c. 3e 6d. I. p. 465; II. pp. 90-137.— Hasse, 1. c. 2. Aufl. p. 664.— Hammond, 1. c. 3d edition, p. 440.—Leyden, Klinik der Riickenmarkskrank- heiten. I. p. 367.-3/". Rosenthal, 1. c. 2. Aufl. p. 274. Fallot, Hemorrhag. meningge spinale sousarachn. Arch. gen. 1830. T. XXIV. p. 438.—Boscredon, De l'apoplexie meningee spinale. These. Paris, 1855.— Ch. Bernard, Observ. d'he'morrh. rhachid. Union m6d. 1856. No. 62.—Jaccoud, Les paraplegies et Tataxie. Paris, 1864. p. 232.—Levier, Beitrage zur Path- MENINGEAL HEMORRHAGE. 209 ologie der Riickenmarksapoplexie. Diss. Bern. 1864. (Contains a copious list of authorities).—Rob. Jackson, Case of Spinal Apoplexy. Lancet. July 3. 1869. —Hayem, Des hemorrhag. intrarhachidiennes. These. Paris, 1872.—Rabow, Fall von Meningealapoplexie in Folge von iibermassiger Korperanstrengung. Berliner klin. Wochens. 1874. No. 52. Definition.—Haematorrhachis implies any effusion of blood in, about, or between the spinal meninges. It occurs rarely, but in quite a characteristic manner. The vertebral canal does not present favorable conditions for the production of hemorrhage, as has been reasonably explained by Hasse. Etiology and Pathogenesis. Little is known regarding the individual predisposition to meningeal hemorrhage. Most of the cases are observed in men. Of diseases of the vessels of the meninges (fatty degeneration, atheroma), we are mainly ignorant. The relation of hypertrophy of the heart to these hemorrhages has not been examined. Among the occasional causes, the first to be mentioned are surgical injuries of the vertebral column, with or without direct lesion of the membranes. Such hemorrhages have been observed to occur in consequence of stabs with swords and knives, frac- tures, contusions, and shocks of the column, a fall on the feet and seat, or upon the arms and back of the neck, in new-born children after severe labor, etc. Inflammatory and carious processes in the vertebrae have in some cases led to lesion of the membranes and to bleeding from them. Congestions of the vertebral canal and its contents (the causes of which have been enumerated in the previous section), especially those due to suppression of the menses or of a hemor- rhoidal discharge, are considered especially important causes of meningeal apoplexy. Mental emotions may act in a like manner by increasing the action of the heart. Excessive bodily exertions are a frequent cause of meningeal bleedings, probably through disturbances in the circulation: such are the lifting of a heavy weight (Rabow), sudden violent movement, etc. Among these should be included the meningeal VOL. XIII.—14 210 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES apoplexies which so often occur during the violent spasms of epilepsy, eclampsia, tetanus, trismus neonatorum, etc. The bursting of blood-vessels or aneurisms into the vertebral canal has been repeatedly observed (Laennec, A. Cooper, Pfeufer, Traube, and others). Blood effused in the brain or cerebral membranes often passes down and fills the cavity of the spinal canal. Of the occurrence of these bleedings in the various hemor- rhagic and infectious diseases (scurvy, morbus maculosus, hemorrhagic small-pox, typhoid, etc.) little is known, except from a few reports of autopsies (see Hayem). Pathological Anatomy. It is necessary here to distinguish the various forms according to the position, distribution, and extent of the bleeding. We pass over those small ecchymoses and suggillations which so often accompany hyperaemia and inflammation within the verte- bral canal. Bleeding between the dura mater and the vertebral canal (in the extra-meningeal cellular tissue) is probably the most frequent cause. A dark, usually coagulated extravasation covers the outer surface of the dura to a varying depth, and infiltrates the cellular tissue between it and the vertebral canal, especially at its posterior wall. This extravasation may enclose the entire dura, but more usually it embraces it only partially ; not rarely there are several separate foci. The dura is suffused with blood to a greater or less extent, and often covered with ecchymoses. The extravasation must be very considerable in order to produce a visible compression or change in the cord. It often extends around the nerve-trunks passing out of the vertebral canal. Bleeding between the dura and the arachnoid (in the so- called arachnoid sac) is usually diffuse, very movable, partly fluid and partly coagulated, and usually consists of blood ef- fused in the brain, though it may proceed from the bursting of vessels in the spinal meninges. Of the hemorrhage accompanying many forms of internal pachymeningitis, pro- MENINGEAL HEMORRHAGE. 211 ducing haematoma of the dura mater, and situated likewise between the dura and the arachnoid, we will speak under Inflammations of the Dura Mater. Bleeding in the arachnoid and pia (so-called subarachnoidal bleeding) is rare. It usually occurs in the subarachnoid cellular tissue, as the dense tissue of the pia seems little suited to extra- vasations. A more or less thick layer of dark-red, coagulated blood, infiltrated into the tissue of the soft membranes, sur- rounds the cord like a sheath, partly or completely, but in most cases it is limited in longitudinal extent, being confined to the length of one or two vertebrae. It may be found at various levels, and in all cases it inflicts severe injury upon the cord. In all these forms of bleeding, the meninges usually exhibit but slight signs of reactive inflammation. The cord itself may be more or less compressed, stained with- red, softened, and (in the neighborhood of the seat of hemor- rhage) hyperaemic. The same is true of the nerve-roots. The spinal fluid is turbid and of the color of blood. Little is known regarding the other changes associated with extravasations. But it is hardly doubtful that in the spinal canal the color soon disappears, and the extravasation is partly reabsorbed and organized. Adhesion of the membranes, prolifer- ation of connective tissue, and strong pigmentation of the mem- branes, are considered as the final changes. Symptoms. The disease usually begins suddenly and violently—often in the manner of apoplexy. The patient suddenly falls, with vio- lent pains, almost always without serious disturbances of con- sciousness and sense. This mode of attack may be more or less complicated by the causes, by the nature of the injury, etc. A slow development of the symptoms is rarer; with warnings of various kinds, symptoms of spinal congestion, lumbar pain, headache, for a longer or shorter time before the attack. Pare- sis then slowly appears, often unaccompanied by pain. The se- verity of the symptoms may increase after a few hours or days. The characteristic symptoms are first those of excitement, caused by physical irritation of the meninges with their abun- 212 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. dant nerves, the nerve-roots, and the cord itself, next those of paralysis, dependent on the pressure of the extravasation upon the cord and nerve-roots. According to the seat of the extrava- sation, it may press more upon the sensory or the motor por- tions. The phenomena of excitement are the most prominent at the first, and chiefly consist of a violent pain, localized at a spot answering to the seat of the bleeding, and radiating in various directions, usually corresponding to the distribution of the nerve- roots first attacked. With this are conjoined excentric sensa- tions, pain, formication, burning, tingling, etc., in the same re- gions ; hyperaesthesia is also occasionally mentioned, but this seems rather to belong to the period of reactive inflammation. Symptoms of motor excitement appear at the same time, which seem to be of characteristic importance. Spasmodic jerk- ing of the muscles, occasionally increasing to complete convul- sions, trembling of the extremities, tonic tension and contracture of various groups of muscles, are the chief of these. They may become so active and so prominent that a special form of '' con- vulsive" meningeal apoplexy has been distinguished. These spasms are partly deducible from direct irritation of the motor roots, and partly from reflex excitement. The vertebral column is stiff and painful at this stage, mak- ing it very hard, or quite impossible, to rise in bed, sit, or bend. Great excitement and loss of sleep are caused by these pains and the muscular contractions. The remarkable observation by Jackson proves that these symptoms of irritation are not necessarily always present; in the case given by him they were entirely want- ing. It is not long, especially if the quantity of blood effused is considerable, before paralytic symptoms appear in the lower half of the body, but seldom reaching a great development, or amounting to complete paraplegia. As a rule, the patient has a furry feeling, numbness, sensations of swelling and heaviness in the limbs and trunk, with more or less distinct anaesthesia in the same parts. A feeling of very great muscular weakness and ex- haustion indicates the same disturbances in the motor sphere ; a MENINGEAL HEMORRHAGE. 213 more or less severe paresis is more frequent, and complete paral- ysis is rare. The distribution depends on the seat of extravasa- tion. Reflex excitability has been found depressed in a few cases, but this probably occurs only in the regions supplied by the nerve-roots directly affected, though it might be exaggerated in the regions posterior to such roots. Weakness of the bladder and rectum is rarely mentioned, but is usually present in severe cases. Fever is absent, at least at the beginning of the disease; it may appear during the irritative reaction which sets in on the second or third day, but never becomes excessive. According to the various levels occupied by the extravasa- tion in the cord, the symptoms differ a little. The following symptoms indicate that the cervical region is affected : The attack begins with pain in the arms and shoulders, with stiff neck and pain in the occiput; anaesthesia and paralysis most marked in the upper extremities ; oculo-pupillary symp- toms ; difficulty of breathing and swallowing ; violent dyspnoea ; retarded and weak pulse. The dorsal region is indicated when there is pain in the back and abdomen and pain in the form of a girdle, stiffness of the dorsal part of the spine, paralysis of the legs and the abdominal muscles ; retained reflex power in the legs. The lumbar region is indicated when there is pain in the loins, tearing pains in the lower extremities, the loins, perineum, bladder, and genitals ; stiffness of the loins ; well-marked paral- ysis of the lower extremities, with loss of reflex activity ; paraly- sis of bladder and rectum. Course and Termination.—After a sudden or gradual begin- ning, the symptoms usually remain stationary for a certain time, and sooner or later take a turn for the better. The symptoms of reactive inflammation are seldom prominent, or they disappear among the other symptoms. Slight fever appearing on the second or third day, with renewed pains, more distinct hyperaesthesia, etc., should be referred to the same; after two or three weeks these symptoms usually disappear. In the majority of cases the disease runs a favorable course, 214 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. unless the nature of the cause or the complications prevent it. A gradual improvement in the symptoms occurs, the paralysis disappears, but partial anaesthesia and paralysis often remain for a long time. The whole course is usually run in a limited time; in a few wTeeks or months a tolerably satisfactory cure may be completed. Death is not rare—often occurring in a few hours or days ; as when the extravasation is at a high level, and produces dis- turbance of the heart and respiration, or when blood effused extends upward to the brain, or when the central nervous system suffers a sudden severe impression (shock). If the extravasations are considerable, the severity of the compression may lead to complete paraplegia, cystitis, bed-sores, etc., and death may occur at a late stage. Diagnosis. The diagnosis of a meningeal hemorrhage is not always pos- sible. If other severe diseases of the nervous system are present (hemorrhage of the brain, tetanus, convulsions, injury of the cord), it will not be in our power to recognize the complicating element of meningeal apoplexy, except under very peculiar cir- cumstances. In such cases it will usually fail to be recognized, but that is seldom of much consequence. The diagnosis of idiopathic and uncomplicated meningeal apoplexy can, however, be established in many cases. It is chiefly based upon the sudden occurrence of the symp- toms, upon the peculiar combination of symptoms of meningeal irritation and spinal paralysis, upon the absence of severe cerebral symptoms, the paraplegic character of the symptoms at the outset, the speedy improvement in the more severe symp- toms, and the usually favorable termination. If we know the cause, that knowledge will often assist the diagnosis. There is a series of spinal troubles, which closely resemble meningeal apoplexy in their symptoms, and are hard to distin- guish from it; such are : Commotio medulloe spinalis (shock), in which the symptoms of spasm are wanting, and the paralysis reaches its highest point MENINGEAL HEMORRHAGE. 215 at the onset. It should be remembered that commotio and menin- geal apoplexy may occur together. Bleeding in the substance of the cord (spinal apoplexy) is usually followed by severe palsy, including especially a high degree of anaesthesia; the pain and tendency to spasm are less marked; the latter is said by Brown-Sequard to be always ab- sent in haematomyelia. This lesion usually causes rapid death, or incurable paralysis. Meningitis and myelitis can usually be distinguished with readiness ; they do not develop so rapidly, or if they do, they are always accompanied by fever. But the central myelitis which begins with fulminant symptoms (see below, under Mye- litis) may give rise to confusion. In the latter, however, severe anaesthesia is never wanting, and the paralysis, also, is usually complete from the beginning. For the diagnosis of the seat of the hemorrhage, the points given above may suffice ; it may be ascertained from the distribu- tion of the symptoms of palsy or irritation. The prognosis is alwaj^s dubious ; but if the causal injury be not especially severe, and the extent of the hemorrhage not very great, it may be considered as comparatively favorable. We may say that if the first few days are passed in safety, the prog- nosis will become more favorable. It is an unfavorable circumstance when the bleeding is very considerable, or is seated in the cervical region, or when marked reactive symptoms occur, or severe paraplegic symptoms, cysti- tis, bed-sores, etc. If the bleeding is of small extent and the symptoms corre- spondingly mild, if the reaction is moderate and the patient young, all these circumstances are in the patient's favor. Confinement to the bed of one or two months' duration, fol- lowed by a convalescence of several months, may be predicted. Treatment. Much can be done by way of prevention ; by treating hyper- aemia of the cord, or spasms, by regulating the menses, the hem- orrhoidal bleeding, etc. 216 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. When the symptoms of meningeal bleeding have occurred, the first thing to be prescribed is absolute rest in a proper posi- tion (upon the side or face). Then the bleeding must be pre- vented from extending ; the usual remedies consist of the ener- getic application of ice to the vertebral column, repeatedpoioerful purges, and full local bloodletting (on the spine or anus). The effect of these may be aided by hot applications to the extremi- ties, and by the internal or subcutaneous exhibition of large doses of ergotin. The diet must of course be properly regulated. Venesection can only be justified by very special circumstances (great plethora, violent action of the heart). If symptoms of inflammatory reaction appear, the local blood- letting along the spine may be repeated, and as Leyden recom- mends, small portions of mercurial ointment may be rubbed in, and calomel given in subdivided doses. The period of resorption demands special attention; it may be hastened by the internal and external use of iodine, by luke- warm baths, by a proper cold-water treatment, by the galvanic current. In later stages, the patient's strength may be supported and restored by tonics (quinia) and nux vomica. In many cases a symptomatic treatment is demanded ; thus, in the beginning, for the relief of pain and spasm (narcotics, etc.); later, for anaesthesia and paralysis (electricity); for cystitis, bed- sores, etc 3. Inflammation of the Spinal Dura Mater—Pachymeningitis Spinalis—Perimeningitis. Ollivier, 1. c. II. pp. 272, 280. 3d ed.—Hasse, 1. c. 2. Aufl. p. 689.—Leyden, 1. d. pp. 385-406.—if. Rosenthal, 1. c. 2. Aufl. p. 279. H. Koehler, Monographic der Meningitis spin. 1861.—Ruehle, Klin. Mittheilungen. I. Bd. Zur Compress, des R.-M. Greifsw. med. Beitr. I. p. 5. 1863.—Traube, Deutsche Klinik. 1863. No. 20; Gesamm. Abhandl. II.—Mannkopf Berlin. klin. Wochenschr. 1864. Nos. 4-7.—A. Meyer, De pachymeningitide cerebro- spin. interna. Diss. Bonn. 1861.—Th. Simon, Ueber den Zustand des R.-M. in der Dementia paralytica. Archiv f. Psych, u. Nervenkrankh. II. 1869. p. 137, 143, 347.—R. H. Mueller, Ueber Peripachymeningitis. Diss. Konigsberg. 1868.—#. Wagner, Arch, der Heilkunde. XL 1870. p. 322.—Charcot, Pachy- meningite cervicale hypertrophique. Soc. de Biol. 1871. p. 35 ; Gaz. mod. de INFLAMMATION OF THE SPINAL DURA MATER. 217 Paris, 1872. No. 9 ; Lecons, etc. 2C serie. 3e fasc. p. 246. 1874.—Joffroy, De la pachymgn. cervic. hypertroph. Paris, 1873. The inflammations of the spinal dura mater, though known for a long time, have not been closely studied till quite lately. The significance of the disease has been better recognized, and a sharper line of separation from the other forms of spinal men- ingitis has been drawn, since it has been observed to occur iso- lated and spontaneously. It is true that there exist but very few good observations ; for this reason, the symptoms and diagnosis are very imperfectly made out. But we may properly make a distinction of two forms, according as the outer surface of the dura is preferred, and the morbid products are deposited between the dura and the vertebral column (external pachymeningitis), involving the loose cellular tissue, or as the inner surface is attacked, and becomes the seat of deposits (internal pachymeningitis). a. Pachymeningitis Spinalis Externa—Peripachymeningitis. Definition.—TJiis disease consists of inflammation of the outer surface and layers of the dura and of the cellular tissue surrounding it. The morbid products, exudation, pus, connec- tive tissue, are deposited between the dura and the vertebral column. This form of meningitis has been studied in but very few cases, and is in much need of further examination. The chief cause of this form of inflammation consists in the presence of inflammation of the vicinity, which extends to the dura and the cellular tissue outside of the meninges. This is quite certainly the case in vertebral caries, and in deeply ulcer- ated bed-sores, which, especially when seated on the sacrum, easily provoke irritation of the structures within the cord. A similar thing, however—extension of the purulent and phlegmo- nous process of inflammation into the canal—has been observed in purulent inflammation of the dorsal muscles and the psoas (Traube), in inflammation in the connective tissue of the neck (Mannkopf), in the subpleural cellular tissue (H. Mueller), and all possible forms of chronic inflammation of the abdomen and 218 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. thorax, especially peripleuritis, and also neuritis migrans, have been named as possible causes of peripachymeningitis. It seems to us that this view of the secondary nature of the disease is carried quite too far. The observations which are quoted in proof certainly leave much room for doubt. Traube's cases are explained by him upon the supposition that the pachymeningitis externa was the primary complaint, the suppuration extending thence into the muscles of the back. This is quite in harmony with the clinical course and the results of autopsies. It is more natural and probable, a priori, that pus should force its way out through orifices in the narrow vertebral canal, with its rigid walls, and should afterwards spread in this direction or that, than that sup- puration of several muscles should find its way simultaneously into the vertebral canal. There is a case in the Medical Times for January 6,1855, p. 19, unfortunately reported very incompletely, which seems to confirm this view. An observation by Ollivier 1 seems to us of still more importance. In Mannkopf's case the secondary nature of the jjeripachymeningitic lesion could only be made extremely probable. R. H. Mueller's case cannot prove anything, as the connection between the peri- pleuritic" membranes and those of the peripachymeningitis was in no way proved, and there were also found similar membranes, quite isolated, on the outer surface of the cerebral dura mater. The case reported by Leyden2 lacks the confirmation of an autopsy. We are therefore probably justified in claiming the possibility of the spontaneous and primary origin of pachymeningitis ex- terna, especially as there is no solid objection to it. We must await the result of further observations, for infor- mation as to whether surgical injuries, exposure to cold, syphilis and other causes may not originate this disease. Pathological An atomy. More or less of the spinal dura mater is thickened ; its outer layers are separated by inflammatory exudations, infiltration with cells, etc. This alteration is usually confined to short por- tions of the cord, the level of a few vertebrae, but it may extend over the greater part of the dura. On the outer surface there is found a more or less abundant exudation of varying thickness ; it has been found as much as half an inch thick (Ruehle). This consists either of pus, either 1 II. p. 260. 3d ed. 2 Loc. cit. p. 391. INFLAMMATION OF THE SPINAL DURA MATER. 219 fluid, or dry and caseous, enclosed in thickened connective tis- sue, and with the extrameningeal cellular tissue infiltrated ; or of a soft, plastic, reddish gray young connective tissue, very vas- cular, sometimes covered with pus and full of small abscesses, sometimes undergoing cheesy degeneration. The last is the usual case in pachymeningitis resulting from vertebral caries (Mi- chaud); there is a fungoid growth, originating from the outer surface of the dura, which is stimulated to produce the growth by the presence of carious pus. The essential disease is, therefore, an inflammation of the outer layers of the dura and the surrounding cellular tissue, with exudation of a purulent, plastic, tuberculous, or other material. The inner surface of the dura is also often thickened and opaque, often covered with a delicate fibrinous deposit. The pia and arachnoid seldom participate, but they have been seen adherent to the dura, opaque, and infiltrated with pus. The cord itself is more or less compressed, flattened, pale, anaemic ; often softened, full of microscopic fat-granules and granular corpuscles, and presenting, more frequently than is supposed, the signs of transverse myelitis. In the neighborhood of the place compressed, red softening and hyperaemia are found ; in more chronic cases, ascending and descending secondary de- generation of the white columns (upwards in the posterior col- umns, downwards in the lateral). The nerve-roots which pass out at the seat of pachymeningitis are compressed, atrophied, inflamed, and soft. Add to these the anatomy of those processes which have acted as causes of pachymeningitis, or have accompanied it (vertebral caries, peripleuritis, muscular abscesses, phlegmons, etc.). Symptoms. The usual character of the disease is like that which will pres- ently be described under Leptomeningitis, a more common affec- tion. We therefore shall give but a short account of the chief symptoms in this place. The most important are as follows : Pain in the back, various in seat and extent, according to the 220 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. location of the disease. Stiffness of the r-ertehral column, which renders it difficult and painful to sit up. Tension and jerking in various groups of muscles. Excentric pains, in the form of a girdle or shooting into the extremities ; sensation of a cord tied around ; formication and slight hyperaesthesia of the skin. To these are added, sooner or later, the symptoms of com- pression of the cord, gradually increasing; paralysis of various degrees, sometimes more marked in the motor, sometimes in the sensory sphere, sometimes in both at once ; muscular tension, increased reflex action, especially those connected with tendons ; paralysis of the sphincters, and bed-sores. These symptoms are due, partly to compression, partly to the myelitis which com- plicates it. According to the nature of the original disease and the com- plications and secondary changes, disturbances of the general health, fever, and many derangements of internal organs may occur. The symptoms of pachymeningitis may develop in an acute or a chronic way ; in the acute (purulent) forms the symptoms of irritation are the more prominent, while in the chronic (plas- tic) forms these recede into the background, and the symptoms of compression of the cord dominate. Of the course of pachymeningitis externa nothing can be said with definiteness, in the present state of our knowledge. The unfavorable cases which come to an autopsy cannot indicate the average event, for it is impossible to estimate how many have run a favorable course without being recognized in our present uncertainty regarding the diagnosis. We certainly know that the form in which it so frequently accompanies caries of the vertebrae is quite frequently arrested and partially recovered from, since the paralytic symptoms caused by it disappear. We have learnt only thus much : that in the severer cases the course may be various, but usually is protracted, and does not termi- nate unfavorably nor lead to a slow convalescence, until after the lapse of a considerable number of weeks. The diagnosis is founded chiefly on the causal agencies we may be able to discover, and the associated, slowly increasing symptoms of meningeal irritation and of compression of the INFLAMMATION OF THE SPINAL DURA MATER. 221 com. The most difficult thing will always be to distinguish it from the other forms of meningitis. There is a diagnostic point —though of very doubtful value—which consists in the fact that external pachymeningitis but rarely ascends as high as the upper cervical region, and is therefore seldom accompanied by stiffness of the neck. In most cases, however, it will be impos- sible to decide whether the dura alone is affected, or whether the other meninges of the cord are also inflamed. The prognosis follows from what has been said regarding the course of the disease. In forming it we shall be obliged to pay especial attention to the causal element. In the treatment we ought principally to aim at a removal of the original lesion ; if wTe succeed in curing this, we greatly im- prove the chances of curing the pachymeningitis. The special directions for this purpose need not be given here. For the relief of pachymeningitis we proceed as is directed in the section on Leptomeningitis. It is of special importance to procure such relief in vertebral disease, where the improvement of the paraplegia depends upon the removal of the meningeal affection. In addition to treatment directed against the verte- bral disease, the measures regarded with most confidence are the energetic use of brine-baths (bathing and drinking), the use of iodide of potassium and iodide of iron, pencilling the back with iodine, frictions with mercurial ointment, and the like. The white-hot iron, a very old remedy, has recently been warmly recommended for obstinate cases by Charcot. b. Pachymeningitis Interna {Hypertrophica et Hemorrhagica). Definition.—Inflammation, chiefly of the inner surface of the dura ; deposition of morbid products (exudations, extrava- sations, proliferation of connective tissue) on its inner surface, between dura and arachnoid. Frequent implication of the arach- noid and pia. Two principal forms of this disease are known, possessing to a certain extent clinical characteristics; a simply hypertrophic form, leading to thickening of the dura (and usually of the finer membranes also) with connective tissue; and a pseudo-membra- 222 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. nous, hemorrhagic form, characterized by a more or less abun- dant extravasation of blood. But few observations have been made as yet upon either. Etiology. The causes usually assigned are exposure to cold, and damp- ness of the dwelling (Charcot, Joffroy). Excessive use of alcoho? seems to have some effect. As to the hemorrhagic form, it seems to be established that it usually accompanies the affection of the same name in the cerebral dura mater, haematoma durae matris, and therefore owns the same causes. The disease has not infrequently been found with psychical disorders, especially dementia paralytica (Simon, A. Meyer); also as a consequence of continued abuse of alco- hol, of which Magnus Huss, Magnan, and Bouchereau have cases. Finally, Leyden describes a traumatic form ; but the case adduced to illustrate it is not above doubt, as the patient was a drinker, and had suffered from symptoms of disease before the fall which caused the fracture of his skull; it is, therefore, not quite certain whether the fissure was the cause of the internal hemorrhagic pachymeningitis. A. Meyer says that both his cases occurred in cavalry soldiers, a class which is exposed to frequent falls and shocks. Pathological Anatomy. In the hypertrophic form we find a great thickening of the dura, chiefly caused by a considerable proliferation of its inner layers, which change into a hard cicatricial mass of connective tissue, with usually a distinct concentric arrangement of layers. Usually there is an intimate adhesion to the soft membranes, which are also thickened and proliferated, and form one continu- ous mass with the thickened dura mater; often, however, they are comparatively unchanged. Thus there is formed a more or less extensive deposition, which compresses the spinal cord from one side or the other (usu- ally from the rear), or which embraces it like a ring for a greater INFLAMMATION OF THE SPINAL DURA MATER. 223 or less distance. The cord is sometimes simply compressed, pale, and soft, but more usually it presents all the marks of transverse myelitis of various extent, with secondary degeneration, forma- tion of cavities, etc. The nerve-roots which are involved in the disease are wrapt up, compressed, and often in a state of ad- vanced atrophy. The muscles which belong to them possess the microscopic characteristics of the usual degenerative atrophy. In the hemorrhagic form the dura is covered to a greater or less extent with a mass of exudation, soft, rusty-brown in color, composed of fibrin and connective tissue, which is strewn with numerous extravasations of blood, and not seldom contains one or several large sacculated masses of blood. These masses con- tain dirty-brown, decomposed blood, numerous blood-crystals, pigment, detritus, etc. The enveloping mass of exudation is, in many places, yellowish, easily broken or torn, is disposed in layers, is attached but slightly to the dura or the arachnoid, and possesses an abundance of vessels. These sacs of blood may vary in size and number. The hem- orrhagic false membrane often extends over a great part of the cord, entirely enveloping it. The process is exactly the same as that of haematoma of the cerebral dura mater ; it is probable that the fibrinous inflamma- tion is the primary element, and the bleeding only secondary. Yet it is not impossible that a primary bleeding may give rise to a subsequent inflammation. The condition of the cord is as in the other form. The pia is usually tinged with blood, and so is the abundant spinal fluid. Symptoms. The hypertrophic form is at present thoroughly understood only as occurring in the cervical region, which seems to be its favorite seat; when situated there it has a somewhat character- istic course, and is described by Charcot as "pachymeningite cervicale hypertrophique." He makes a first stage of the symptoms of irritation, which lasts two or three months, and is chiefly characterized by pains. These are very violent in the back of the neck and head, the 224 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. shoulders, and arms ; are continuous, and from time to time ex- perience exacerbations ; are often connected with a painful sen- sation of being bound with a cord in the upper part of the chest. The neck is stiff, but the spinous processes are not specially sen- sitive to pressure. Formication and numbness, and sometimes also slight weakness of the upper extremities, appear at this stage. Trophic disturbances of the skin are not infrequent— eruptions of herpes, development of vesicles on the upper ex- tremities. Nausea and vomiting are but rarely observed. The transition to the second stage, chiefly characterized by paralysis and atrophy, is very gradual. The upper extremities are more or less completely paralyzed, especially the district of the median and ulnar nerves, while in all cases hitherto observed the radial region has remained comparatively free. The result of this is the formation of a peculiar position of the hand in ex- tension, the fingers being held like claws. This paralysis is con- joined with severe and quite uniform atrophy, so that the gen- eral aspect of the case reminds one of progressive muscular atrophy. The faradic excitability of the muscles is diminished or suspended. Contractures of the muscles appear, and single spots of anaesthesia of greater or less extent. All this is doubtless mainly the result of the affection of the nerve-roots. At a later period, paralysis and contracture of the lower ex- tremities occur. Atrophy, however, is not associated with the affection in these parts, or not until a very late period. In severe cases complete paraplegia with marked anaesthesia, paralysis of the bladder, bed-sores, etc., may arise, and bring on the fatal ter- mination. These severe symptoms are doubtless to be referred to trans- verse myelitis at the spot compressed, and descending degenera- tion of the lateral columns, originating at that point. But the course is not always so bad ; there are cases in which the symp- toms cease to make progress, or even are distinctly improved; but the disease is always chronic. The symptoms of hemorrhagic pachymeningitis interna are still very obscure, and in most cases are complicated by those of the coexistent cerebral affection. The usual symptoms of a sloio INFLAMMATION OF THE SPINAL DURA MATER. 225 meningitis, with periods of exacerbation, pain in the loins and back, tearing pains in the extremities, stiffness of the vertebrae and of the nucha, increasing weakness of muscles, sometimes ris- ing to complete palsy and paraplegia, moderate contractures, hyperaesthesia and anaesthesia of the skin in various degrees, weakness of the bladder, etc., are sufficient, in case certain causes are present (as drunkenness, paralysis, haematoma of the cerebral dura mater), to arouse a suspicion of disease of the spi- nal dura, and, at least in many cases, to lead to a probable diag- nosis. We have yet to learn whether this disease, like the cerebral form, is marked by aggravation of the symptoms from time to time, and whether this fact can be made useful in diagnosis. The disease, in this form, will usually take an unfavorable course. The diagnosis may be inferred from the previous brief sketch of the two forms. Pachymeningite cervicale hypertrophique has a certain resemblance to progressive muscular atrophy, atrophic lateral sclerosis (Charcot), etc. The most important points of distinction are the stage of pains, the partial anaesthesias, para- plegia without atrophy, etc. It will not be always possible to distinguish it from meningeal tumors. The hemorrhagic form is in need of a more exact diagnostic boundary. The prognosis requires no remarks. The treatment will resemble that of meningitis in general (see next section). In more acute cases antiphlogistics of all sorts will be of use. In later stages and chronic forms we may have recourse to derivatives, preparations of iodine, galvanism, and the use of baths or the cold-water treatment. Prominent symptoms, as pain, paralysis, atrophy, etc., require a special symptomatic treatment. VOL. XIII.—15 226 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 4. Inflammations of the Pia Mater and Spinal Arachnoid— Leptomeningitis Spinalis—Perimyelitis and Arachnitis. P. Frank, 1. c. 1792.—Ollivier, 1. c. 3d ed. II. p. 232.—Hasse, 1. c. 2. Aufl. p. 690.— Hammond, 1. c. 3d ed. p. 444.—Leyden, 1. c. pp. 406-443.—M. Rosenthal, 1. c. 2. Aufl. p. 283.—Eoehler, Monographic der Meningitis spinalis. Leipzig. 1861. (Contains a great deal of valuable matter and very full references.) Klohss, Diss, de myelitide. Halis. 1820. Hufeland's Journ. XVI. 1823.—Funk, Die Ruckenmarksentztindung. Bamberg. 1825.—Henoch, Schmidt's Jahrb. Bd. 28. 1846.—Evans Reeves, Diseases of the Spinal Cord and its Membranes. Monthly Journ. of Med. 1855. p. 506; Edinb. Med. Journ. 1855-56. pp. 120 and 302. — Noetel, De meningitide spinali. Diss. Berlin. 1861.— Beaumetz, Mening. spinale, suivie de roideur des extrem. infSr. Gaz. des Hop. 1861. No. 129.—Brown-Sequard, Lectures on the Principal Forms of Paralysis of the Lower Extremities. London. 1861. p. 66, etc.— Camerer, Ueber Meningitis spin, chron. und deren Differentialdiagnose. Wiirtemb. Correspondenzblatt. XXXII. 1862.— Jaccoud, Lecons de clinique medicale. 1867. pp. 372-420 — Vulpian, Note sur un cas de mining, spinale et de sclerose corticale annulaire de la moelle ep. Arch, de Physiol. II. p. 279. 1869.—Liouville, Etude anato- mo-pathologique de la meningite cer£bro-spin. tubercul. Arch. d. Physiol. III. p. 490. 1870.—Stokes, Chronic Inflammation of the Spinal Cord and its Mem- branes. Dubl. Journ. of Med. Science. Vol. LVI. p. 62. 1873.—Bruberger, Fall von Meningitis syphil., etc. Virch. Arch. 1874. Bd. 60. Compare also von Ziemssen, Meningit. cerebrospin. epidemica, in Vol II. of this Cyclopaedia, and the full references there given. Inflammation of the soft membranes of the spinal cord is the most important and the most frequent of spinal meningeal affec- tions ; and this is what is intended when spinal meningitis with- out further designation is spoken of. All treatises by the earlier authors relate to this. But a great deal has been thrown under this title which must certainly be separated from meningitis, or which occurs simultaneously with it. It is reserved for future investigations to show more clearly than has been done the line of demarcation between meningitis and myelitis; for this pur- pose accurate histological examination of the cord by the latest methods in cases of meningitis is absolutely needed. We have, however, very little positive information upon this point. It would seem hardly probable that any considerable inflam- mation of the pia mater could exist without involving the cord to some extent. The pia distributes the vessels to the entire INFLAMMATION OF THE SPINAL PIA MATER. 227 cord ; from it pass out the processes of connective tissue which compose the framework of the latter ; so that any inflammatory irritation affecting the vascular district of the pia must be felt more or less in the vessels of the cord, and when once a morbid process is established in the connective tissue of the pia, it is hard to see why it should not spread to some extent in the cord. A certain degree of independence on the part of the two vas- cular districts of the pia and the cord must be admitted, as each may be affected singly ; this fact is certainly established in rela- tion to the cord, and suggests to us that the nervous elements themselves possess some influence upon the disease, and that they may be primarily attacked, or, at least, may bear a promi- nent part in the production and localization of diseases of the connective substance. It is in diseases of the pia mater that we shall be obliged to pay special attention to the possibility of an implication of the cord. This has been done far too seldom, in my opinion ; patho- logical anatomy has devoted too little attention to the point. The most that has been done has been to demonstrate an implication of the nerve-roots that pass through the diseased membrane; or an affection of the cord in very severe cases. Few observa- tions have been made systematically and with the aid of delicate methods. Mannkopf, in epidemic cerebro-spinal meningitis, has seen abundant cell-infiltration following the course of the vessels even into the cord. Fronmueller has seen the central canal full of pus-cells in the same disease ; Liouville, in tubercular menin- gitis, has seen tubercles in the processes of the pia, in the fis- sures of the cord, and Vulpian has demonstrated in one case of inflammatory thickening of the pia an annular sclerosis of the cord, extending to some depth, especially in the posterior columns, the dependence of which upon meningitis is, however, at the least doubtful. This deficiency has been made good by the investigations of Dr. F. Schultze,' relating to three cases of leptomeningitis spina- 1 Berl. klin. Wochenschrift. 1876. No. 1. Dr. Schultze has permitted me to view his microscopical preparations bearing on this point, and it is my agreeable duty to acknowledge gratefully the various assistance which the free use of his numerous and excellent preparations has rendered to me. 228 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. lis which show a very considerable implication of the nerve-roots and the cord itself. The principal results of these investigations is the following; for some further details the reader is referred to the pathological anatomy of acute meningitis. The nerve-roots are in a state of marked inflammation (infil- tration with cells, especially in the neighborhood of the vessels, the nerve-fibres swollen, granular, beginning to break down, the axis-cylinders swollen and granular); the bundles of root- fibres which enter the cord are more or less considerably swollen. In the cord itself, there is found a peripheral interstitial myelitis (infiltration of the neuroglia with cells and nuclei) penetrating to a greater or less depth, or actual parenchymatous myelitis in large and small foci (enormously swollen axis-cylinders, cloudi- ness and granular decay of the medullary sheath, axis-cylinders breaking down, etc.). In the gray substance there were found signs of cedematous swelling in the ganglion-cells, but no other distinct changes. Only the central canal appeared closely packed with round cells, and its vicinity also infiltrated to a considerable distance with the same elements. It certainly follows from these facts that we shall have to take a somewhat different point of view from what has previously been customary in explaining the origin of the symptoms of spinal leptomeningitis. It is quite clear that the inflammation of the pia can produce no very marked symptoms by itself ; the principal would be that of pain and the consequent reflex phe- nomena, owing to its abundant supply of nerves. But the most important and essential symptoms must arise from an affection of the nerve-roots and the cord itself; and for this reason it will be very desirable to distinguish between purely meningeal and purely spinal symptoms, as well as those referable to the roots. A delicate clinical analysis will be required to distinguish these groups of symptoms. I have premised these remarks in order to facilitate the under- standing of the symptoms of meningitis, and to indicate the de- feats in our knowledge. As for distinguishing the inflammation of the pia, the so- called perimyelitis, from arachnitis, I consider it impossible both upon pathologico-anatomical and practical grounds. INFLAMMATION OF THE SPINAL PIA MATER. 229 Finally, the best division that we can make in practice—in spite of the great variety of form which spinal leptomeningitis may take—seems to me to be that which recognizes but two chief forms, the acute and the chronic. a. Leptomeningitis Spinalis Acuta. By this title we understand afebrile inflammation of the soft membranes (pia and arachnoid) of the cord, beginning with vio- lent symptoms and characterized chiefly by an exudation of a purulent-fibrinous, more rarely a sero-fibrinous nature. It occurs most frequently in an epidemic form, and in association with the corresponding affection of the cerebral membranes, as cerebro- spinal meningitis. But it also occurs sporadically; and this form is that which will occupy most of our attention. Etiology and Pathogenesis. The predisposition to acute spinal meningitis is quite general, although the causes upon which it depends are not yet ade- quately known. It attacks by preference children and young persons, and the male sex ; it is more frequent when there is ten- dency to scrofulosis and tuberculosis; all sorts of weakening influences (bad dwellings, poor food, sexual and other excesses, etc.) increase the tendency. As regards the way in which these causes act upon the spinal membranes, we know nothing precisely. Among the immediate causes, exposure to cold certainly plays a very important part. It has often enough been observed that sleeping on damp ground or snow, or the action of a cold wind striking upon the back while sweating, or an unexpected fall into the water, and other similar occurrences, have led to an attack of acute leptomeningitis. But in this case, as in most in- flammations of internal organs caused by cold, we know nothing with certainty of the delicate mechanism of the entire process. The action of the sun's heat, insolation, upon the back is a very questionable source of acute spinal meningitis. Surgical lesions, however, constitute an unquestionable and very frequent cause. The disease has been observed after simple 230 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. concussion of the spine, as in falling down stairs ; after cutting, stabbing, and gunshot wounds of the spinal column and its con- tents; after luxation and fracture of the vertebrae; after the operation for spina bifida, etc. Inflammations and other affections of neighboring parts are often propagated to the spinal meninges and arouse inflamma- tion in them ; thus caries of the vertebrae, acute inflammation of the dura spinalis and the extra-meningeal cellular tissue, deep bed-sores reaching to the cavity of the sacrum ; bursting of cavi- ties in the lungs into the vertebral sac ; carcinoma of the vertebrae ; and finally, acute inflammations of the cord itself, which extend to the pia. The most frequent cause among this class is the acute inflammation of the cerebral pia mater, which is usually complicated with that of the spine. The spreading is usually effected through the open communication between the cerebral and the spinal cavities, through the anatomical continuity of the meninges, the current of the cerebro-spinal fluid, the gravitation of the inflammatory products, extravasations, etc., into the spinal cavity, and there setting up an inflammatory irritation ; and finally, it is doubtless due to other causes acting upon both the cerebral and spinal meninges at once. Thus it is easily understood how the inflammation of the cerebral pia mater so often extends downwards to the spinal pia mater. Of tubercular basilar 'meningitis, according to recent observa- tions, a tubercular spinal meningitis is a quite regular accom- paniment. Hence the appearance of spinal symptoms in this disease. The publications of Weberl and Bierbauma are of comparatively little force as evidence. The most important cases are three by Koehler,3 which demonstrate the coexistence of tubercle in the pia mater of the brain and of the cord. Also two cases presented by the same author in his monograph.4 Liouville has recently stated that the occurrence is a very regular one, and that among numerous cases, he has seen it in every one. In F. Schultze's three cases, above mentioned, the spinal pia participated each time in the cerebral inflammation. Leyden,5 also, gives a case of this kind, without making any exact statements regarding the frequency of its occurrence. It is certainly much more frequent than has been supposed. 1 Deutsche Klinik. 1852. No. 34. p. 380. 2 Journ. f. Kinderkrankh. Bd. 26. p. 355. 1856. 4 Loc. cit. p. 127. 8 Ibidem, Bd. 32. 1859. p. 409. 6 Loc. cit. p. 438. INFLAMMATION OF THE SPINAL PIA MATER. 231 Among the somewhat ctoubtful causes of acute spinal menin- gitis may be mentioned dentition, suppressed perspiration of the feet, suppression of the menses and of hemorrhoidal bleeding, disappearance of acute exanthemata, etc., although instances of all these are given in the older literature. The disease also occurs now and then in company with, or during convalescence from febrile diseases (pneumonia, acute articular rheumatism, etc.), or infectious diseases (acute exan- themata, cholera, typhoid, etc.). But this seems to apply chiefly to the epidemic variety. In child-birth, Koehler has repeatedly observed acute spinal meningitis. Finally, we must speak of epidemic and infectious influences. The form of spinal meningitis which originates in company with cerebral meningitis under the action of some as yet unknown infectious material, and has repeatedly during the present cen- tury assumed the dimensions of a wide-spread epidemic, is by far the commonest and the most important. We can only refer to von Ziemssen's admirable delineation of the disease, in Vol. II. of this Cyclopaedia. Gaung' reports the occurrence, in a girl's boarding-school, of a light epidemic of favorable termination, not going beyond the symptoms of hypersemia of the cord in some cases. The immediate cause was unknown. Pathological Anatomy. The morbid changes found in acute spinal meningitis differ according to the stage of the disease. In general, three periods may be distinguished, which of course pass imperceptibly into one another : 1. A stage of hyperaemia and commencing exuda- tion. 2. A stage of serous or purulent fibrinous exudation, and <$. A stage of resorption or termination in some other way. The one most commonly observed is the second ; the first much more rarely, especially in the fulminant attack of epidemic cerebro- spinal meningitis. In the first stage, the pia contains a great deal of blood, is colored from a rosy to a dark red tint, is full like velvet, and in 1 Arch. gen. 1858. 232 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. places is dotted with blood, or with ecchymoses of various size, while the blood-vessels are very full. The tissue is succulent, swollen, imbibed with serum, and the cerebro-spinal fluid is slightly turbid. The arachnoid shares in these characters to a greater or less extent; the hyperaemia usually extends also to parts of the dura of various extent, and is also to be seen in the substance of the cord itself. The second stage comes on by degrees ; the watery contents of the tissues increase, the spinal fluid becomes more and more turbid, fibrinous flocks and plates are formed in the subarachnoid tissue, or adhere to the surface of the dura ; the pia is more and more opaque, the subarachnoid tissues swell to a gelatinous mass which more and more conceals the former redness. The purulent character of the exudation becomes more and more distinct; the opacity increases, the tint alters to a whitish yellow, or green- yellow, and at last the whole pia and subarachnoid tissue are infiltrated uniformly with pus. The spinal fluid, growing more turbid, assumes a sero-purulent appearance and contains numer- ous flocks of fibrin, some floating and some covering the free surfaces of the meninges. In some cases there is to be seen, in addition to the exudation, a variable number of small miliary nodules, gray or whitish yellow, chiefly distributed in the course of the vessels, in the pia, and arachnoid, but not infrequently strewn over the surface of the dura in considerable numbers (tuberculous meningitis). In this form the exudation is usually of a rather gelatinous consistency, serous, yellowish in color, and rarely constitutes a strictly purulent infiltration. The distribution of the exudation varies greatly. Sometimes it is spread over a larger, sometimes over a smaller space, but it usually covers the greater part or the entire length of the cord ; the posterior surface is apt to have more of it than the anterior, owing doubtless to the patient's lying on his back. It is evident from what has been said, that the exudation frequently extends to the membranes of the brain, though in very various amount. In such case a direct connection between the masses in the brain and cord can always be shown to exist along the base of the brain, although the quantity deposited on the medulla oblon- gata is often remarkably small. INFLAMMATION OF THE SPINAL PIA MATER. 233 The arachnoid is almost regularly involved in the inflamma- tory exudation. It is opaque and thickened, infiltrated with serum or pus, and often abounds with gray miliary tubercles; in such cases the subarachnoid connective tissue is always infil- trated similarly, and in its swollen condition forms a layer of exudation, surrounding the cord like a sheath. The dura spi- nalis is less frequently mentioned as involved, yet it is often hyperaemic, often opaque to a considerable extent, and covered with thin, fibrino-purulent exudation. In a few cases peripachy- meningitic hemorrhages have also been seen. The nerve-roots are always more or less involved in the in- flammatory changes ; they are enveloped in thick masses of exu- dation, swollen, softened, their fibrillation is indistinct, their consistency diminished. Of the condition of the cord itself in acute meningitis our information is quite scanty ; it has been found pale and cedema- tous, at other times more hyperaemic, but usually softened; the softening may be somewhat uniform, or it may be disseminated and limited to certain spots ; in a few cases a purulent infiltra- tion of the cord, of variable extent, could be distinctly seen with the naked eye. Microscopical examination discovers in the soft membranes of the cord all the signs of exudative inflammation—abundant cell-infiltration, especially along the vessels, great fulness of the capillaries, swelling and spreading of the bundles of connective tissue, etc. Such tubercular nodules as may be present show the char- acteristic histological marks, and are chiefly found along the vessels. F. Schultze found abundant infiltration with cells in the walls of the vessels which run in the anterior and posterior nerve-roots ; the infiltration extended to the neuroglia. Some of the nerve-fibres of the roots appeared altered, their medullary sheath being cloudy and granular, the axis-cylinders decidedly swollen and in a state of granular degeneration. The bundles of roots which passed into the cord seemed, therefore, to be thickened at many points, and could be followed for a short distance into the cord, where they resumed their normal dimensions and appearance in the neigh- borhood of the gray substance. In the cord, F. Schultze distinguished two sorts of affection. Either there was infiltration with cells and nuclei, affecting chiefly the neuroglia, without direct im- plication of the nerve-fibres, and limited to the peripheral layers of medulla (peri- pheral interstitial myelitis), or the nerve-fibres were principally involved in the inflammatory processes (parenchymatous myelitis), so that distinct myelitic foci of various extent and position could be recognized. Thus there were found in the 234 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. transverse section (especially in the lateral columns) narrow wedge-shaped regions of inflammation, with the point directed towards the centre, of which the longi- tudinal extent varied. Single nerve-fibres in the condition of inflammatory swell- ing were found at all parts of the transverse section. In the vessels of the cord no essential changes were found; in the gray substance not much that was abnormal could be seen, except an apparently cedematous swelling of many of the ganglion- cells ; the central canal, however, was regularly obliterated, plugged with roundish cells, and its vicinity also infiltrated with similar round cells. The second stage is that in which death usually occurs; hence its anatomical changes are the best known. In cases not terminating in death a third stage must be admitted, in which a complete restoration to the normal state occurs with complete resorption—a process which can only be observed by fortunate accident—or various permanent changes occur, residua and con- sequences of the acute process of very various significance, and not rarely developing in a chronic way. The most frequently seen are opacity and thickening of the soft membranes; adhe- sions of these membranes to one another and to the dura are not rare ; large accumulations of fluid in the arachnoid space (hy- drorrhachis); more rarely chronic processes develop in the cord which continue to increase—sclerosis and atrophy of the cord, either affecting single columns, or distributed in the form of islands of disease, or diffused through the whole medulla. We have, therefore, after acute spinal meningitis, either the perni- cious changes, progressive chronic meningitis or myelitis, or else those comparatively harmless processes (opacity, thickening, cal- careous plates, etc.), which are so of ten found in the body with- out having given rise to special symptoms during life. The anatomical changes of the other organs during acute spinal meningitis require no special description here. They dif- fer, according to the course of the disease and the manner of death, but do not present anything especial. The most impor- tant of them have been sufficiently described in Vol. II. under Cerebro-Spinal Meningitis. Symptoms. Characteristic as are the features of acute spinal meningitis it is yet rarely found pure and isolated ; it is especially common INFLAMMATION OF THE SPINAL PIA MATER. 235 to find the cerebral pia mater affected at the same time, which complicates the picture and hinders the precise interpretation of the symptoms. Yet with some attention and experience the characteristic features of spinal meningitis can be deduced from the symptoms as a whole. General Description.—Acute spinal meningitis usually be- gins suddenly; often with fulminant symptoms. Distinct and marked precursory symptoms are observed in only a minority of the cases ; general heaviness and depression, slight chill, and a little gastric disturbance, fleeting pains in the head and back, restlessness and sleeplessness, preceding for a time the outbreak of more serious symptoms. The proper commencement of the disease is marked by a more or less severe chill, directly followed by violent febrile symp- toms ; the temperature is raised, without any regularity of curve, the pulse is full, hard, rapid, very rarely retarded at the outset. Vomiting and severe cerebral symptoms are observed only in the cerebro-spinal form. The painful symptoms very soon become the most prominent; the chief one consists of an intense, deep-seated, boring pain in the back, which is much complained of. According to the local- ization of the inflammation, the pain may occupy various places (loins, back, or nape of the neck), and have a various extent, but is increased less by pressure on the spinous processes than by movement of the vertebral column and the extremities; it is usually very violent, but remitting ; and from the place where it is seated, pains shoot out around the trunk in a ring, or extend to the extremities, piercing them in all directions. Thus all movements are rendered extremely painful. The pain in the back is regularly and characteristically asso- ciated with a severe rigidity of the spine, most marked at the height of the disease. The best-known variety is that which attacks the nucha, and is so constant in epidemics ; if the disease is situated lower down, the lumbar spine may be the chief seat of the painful stiffness, and when the disease is diffuse, the rigid- ity, produced by muscular tension and contracture, may extend to the entire column, and produce a very close resemblance to tetanic spasm. 236 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Quite analogous phenomena are observed in the muscles of the extremities; painful tension and stiffness, not rarely in- creased to the point of extreme contractures, producing rigid immobility of the limbs ; in some places spasmodic twitchings occur, which give the patient extreme pain, and somewhat re- semble tetanic spasms, but seldom amount to general convul- sions. Such twitchings, in single muscles, are apt to be produced by attempts to use them. The skin of the extremities and the trunk, as far as its sensi- tive nerves originate from roots which are involved in the inflam- mation, is in a state of marked hyperaesthesia, so that every touch, every movement of the patient, calls out expressions of pain, even in cases where the consciousness is quite impaired. Hyperesthesia of the muscles seems to be equally demonstrable in many cases. The reflex activity is usually increased at the beginning, but diminishes during the course of the disease. With these sensory and motor symptoms, disturbances of the evacuation of urine and faeces are early allied ; these functions are performed with difficulty, owing, as is usually supposed, to a spasmodic condition of the sphincters; artificial means are often required in order to regulate them. Disturbances of the thoracic viscera do not occur unless the cervical part of the cord is involved in the inflammation. In this case difficulty of breathing appears, due to the rigidity and painfulness of the muscles of respiration; in the advanced stages, serious symptoms of dyspnoea occur, which may increase to complete asphyxia. Disturbances of the action of the heart (great retardation or acceleration) may be added. Cerebral symptoms, as vertigo, violent headache, delirium, unconsciousness, coma, etc., are not rare ; when they occur, it is usually in cases in which some degree of implication of the cere- bral pia mater is present. They may appear at an early period, or later in the course of the disease, and when fully developed, often indicate the probability of a fatal event. As the disease progresses, the symptoms of irritation may become less and less prominent, and give place to more distinct symptoms of paralysis ; but both classes of symptoms may be INFLAMMATION OF THE SPINAL PIA MATER. 237 intermingled in various ways. Pareses and paralyses occur; the immobility of the limbs is no longer owing to muscular tension, but to motor weakness ; symptoms of vesical paralysis occur; the cutaneous sensibility is lessened, and even high degrees of anaesthesia may appear; at last, paralysis of the respiratory ap- paratus may lead to very threatening symptoms. When the disease has reached this height, everything may rapidly go from bad to worse, and death may soon occur; the immediate cause of death is usually a progressive paralysis of respiration and circulation, associated with deep coma, and not rarely with a great rise of temperature during the agony. At other times the course is more protracted ; the severity of the symptoms lessens, deceitful signs of temporary improvement appear, while the disease, as a whole, continues to make prog- ress; severe paralysis, bed-sores, etc., appear, and death follows after long suffering. A secondary implication of the cord is always to be supposed in such cases. Improvement may really occur; in slight cases this is often wonderfully speedy, with a short convalescence, while in severe cases it is more gradual, and has many fluctuations. The conva- lescence is then tedious, the forces recover themselves but slowly, the abnormal irritability disappears very gradually, and the patient needs care for a very long time. Incurable injuries are often left behind ; paralysis and atrophy of single muscles and groups of muscles, or of whole extremities, contractures, anaes- thesia, etc. Signs of degeneration and sclerosis of single columns of the cord may continue after the disease is over. Interpretation of the symptoms.—Among the most constant and important is, without doubt, the pain in the back. It is usually very severe, deep-seated, boring, and tensive, of various extent, but hardly ever absent. It is a special characteristic, that it is very much increased by every movement of the trunk or limbs, so that the patient is often compelled to maintain absolute repose from this circumstance alone. The movements connected with evacuation of urine and faeces also naturally increase the pain in the back. Pressure on the vertebral column does not always increase it. This dorsal pain doubtless owes its existence to inflammatory 238 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. irritation of the nerves of the pia and dura, to inflammation of the posterior roots, and the consequent hyperaesthesia, but hardly to an inflammatory implication of the cord itself. Pains in the extremities, of a tearing or boring character, and increased by every movement, are seldom wanting, and have doubtless the same origin. They correspond in their location and extent with the inflamed portion of the cord. To similar processes of irritation in the motor apparatus may be referred the equally frequent and important symptoms of muscular tension, contractures, spasms, stiffness of the spine or neck, etc. The most characteristic of all is the stiffness of the spine and neck, with the head drawn backwards, the back stretched, often in the position of opisthotonus, and stiff and hard, especially when active or passive movements are made. In the extremities, the extensors are most affected, but often the flexors ; the limbs in this condition are often of the hardness of stone, and immovable. This tension relaxes a little at times, is especially increased by attempts at moving, but is usually not much increased by reflex irritation. The pathogenesis of these motor symptoms is not yet settled. It is commonly believed that they originate in the reflex way, owing to the abnormal irritation of the posterior roots, and might be regarded as reflex contractures. This may be true to some extent and in some cases. It is, however, quite certain that the muscular tension is half voluntary in character, or is in- creased by a voluntary act, which has for its object the preven- tion of movement when all movements are so painful. The chief weight, however, should be laid upon direct irritation of the motor apparatus. Such a condition may depend in part on inflammatory irrita- tion of the anterior roots, in part on irritation of the motor paths in the lateral columns by secondary points of myelitis (as F. Schultze has shown). If the latter were the correct solution, it would lead us to infer that the fibres for the trunk-muscles occu- pied some exposed situation (possibly in the external periphery of the lateral columns), in order to explain the great amount of rigidity in these muscles and in those of the nucha. The assump- tion of a direct irritation of the motor apparatus is confirmed in INFLAMMATION OF THE SPINAL PIA MATER. 239 an interesting manner by two cases in which Leyden1 saw the muscles of the back of the neck paralyzed in the latter part of the disease. And, in fine, the clonic muscular twitchings which occur spontaneously, or during efforts to move, may best be ex- plained by direct irritation of the motor paths. It is hard to say how the hyperaesthesia, which is almost always present in a high degree, is to be explained. It is most marked in the skin, but extends also to the deeper parts, the joints, muscles, etc. It may be so severe that the slightest touch or change of position calls forth the strongest expressions of pain; even unconscious patients may shrink and make motions of defence, when taken hold of. All voluntary movements of the hyperaesthetic parts cause severe pain. The hyperaesthesia is usually most marked in the lower extremities and the lower half of the trunk, while it is less marked and more rare in the upper limbs. We are not yet in a position to assign any cause for this hyper- aesthesia except the inflammatory irritation of the posterior roots, and perhaps also an implication of the white columns of the cord. It must be admitted that this explanation is very inade- quate. The anaesthesia and paralysis which appear at a later stage are more intelligible. They vary much in form and distribution; there may be a paralysis of single muscles or groups of muscles, with or without atrophy ; paralysis of an entire lower extremity, or paraplegia ; the upper extremities are reached, or are the ex- clusive seat of paralysis, in few cases. In complications with cerebral meningitis, paralysis of some cerebral nerves, disturb- ances of the senses, etc., are frequent. These paralyses often dis- appear quickly as the disease improves, while at other times they improve very slowly, or may be quite incurable ; and from these circumstances inferences may be drawn as to the nature of the causal lesion. We cannot be much mistaken if we ascribe the majority of these sensory and motor paralyses to the demonstrably severe affection of the posterior and anterior roots. It requires no ex- 1 Klinik, etc. I. p. 417. 240 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. planation to show that the swelling and opacity of the nerve- fibres and axis-cylinders may very easily reach a point which is incompatible with the further performance of their functions; that plastic infiltration of the neurilemma may so compress the root-fibres as to render them unfit for conduction ; and that the embedding of the delicate bundles of root-fibres in a considerable mass of fibrinous exudation will very easily destroy the function of the roots. It is, however, also possible that the myelitic points in the white columns of the cord, especially in the lateral columns, may in the course of the disease become dangerous to various paths of conduction, and produce paralysis. And finally, we may remember that the presence of a large fluid exudation in the sac of the dura may compress the cord and the nerve-roots to such an extent as to produce paralysis. This lesion will become probable only under special conditions, as when the paralysis is diffuse and not very severe. The symptoms on the part of the vegetative organs are less constant, and often hard to interpret; their physiological con- nection with the cord is well known to be undetermined in many points. In the urinary apparatus, a frequent disposition to pass water, in connection with ischuria or complete retention of urine, has often been observed ; it has been usual to explain these symptoms as the consequence of a direct or reflex spasm of the sphincter of the bladder. At a later stage, well-marked weakness and paralysis of the bladder often occur, usually accompanied by paraplegia. For the explanation of this we require the same facts which explain motor paralysis; the mechanism of the various forms is that which has been stated on page 79 et seq. The composition and quantity of the urine seem to depend on the severity of the fever ; it is at first saturated, dark, scanty, clouded with urates, but later becomes abundant, light, and clear. In a good many cases (especially Of the epidemic form), an un- usual excess in quantity has been observed, which is usually ascribed to a direct nervous stimulation of the secretion, origi- nating in the cord ; and in like manner the rarer affection, melli- turia. 'inflammation of the spinal pia mater. 241 In the digestive apparatus we observe the disturbances which usually accompany febrile complaints, and in addition, most frequently constipation, which is referred by Koehler to spasm of the intestinal muscles, and consequent interference with peri- staltic action, and to the spasmodic tension of the abdominal muscles. This explanation may be correct in the first stages, but at a later point, the sluggishness and weakness which are so characteristic of intestinal movements in many spinal diseases are more probably the cause. The abdomen is usually sunken and tense ; swelling and meteorism are rare, and so is diarrhoea. Vomiting, which often occurs, is probably always due to a local- ization of the process at the basis of the brain, and therefore is most frequent in cerebro-spinal meningitis. The respiratory apparatus is remarkably affected in all severe attacks of spinal meningitis, especially when located in the cervical region. All the degrees of accelerated and difficult breathing occur, up to the extreme of dyspnoea, and even as- phyxia. The explanation is to be sought in the following cir- cumstances: irritation of the cervical roots, and the consequent spasmodic tension and immobility of the respiratory muscles, or, at later periods, paralysis of the same apparatus; irritation or paralysis of the respiratory paths in the lateral columns of the cervical medulla ; and finally, the direct affection of the medulla oblongata and the centres of respiration which it contains. Near the fatal termination, the Cheyne-Stokes phenomenon of respira- tion has been repeatedly observed, which probably always indi- cates that the medulla oblongata has been reached by the inflam- mation.1 The disturbances of the apparatus of circulation have been but little studied, and owing to their complicated origin, they are hard to interpret. They depend firstly and chiefly upon the fever. Increased frequency of pulse is the rule ; yet retardation often occurs, especially in cerebral complications; great irregu- larity in rapidity and rhythm is often observed; in fatal cases, towards the close, as the temperature rises, the pulse often be- comes too fast to count. It may be left to the reader to form 1 Cf. Erb, Arch. f. klin. Med. I. p. 185. 1865.— Leyden, Klinik, etc. I. p. 421. VOL. XIII.—16 242 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. for himself a suitable explanation of the disturbances in such a case, by reference to the physiological principles governing the innervation of the heart from the cord and medulla oblongata. The reaction of the pupil has not been fully studied; and it seldom gives us an unqualified indication. A striking contrac- tion may occur, as well as unilateral or bilateral dilatation. It will, however, not always be easy to decide whether paralysis or irritation of the oculo-pupillary fibres in the cervical cord is the cause of these disturbances, and whether the oculomotorius is not also involved. The cerebral symptoms which occur at times during spinal meningitis and regularly in the cerebro-spinal form—delirium, coma, general convulsions, epileptiform attacks, trismus, grind- ing of the teeth, disturbances of the organs of sense, spasm and paralysis of single cerebral nerves, vomiting, sleeplessness, loss of speech, giddiness, etc.—are merely enumerated here, as they have been fully described and explained under Epidemic Cere bro-spinal Meningitis (Vol. II.), and Cerebral Meningitis (Vol. XII.). The fever of sporadic spinal meningitis has been but little studied. The temperature seems to be very irregular; in the beginning it is usually high, but at the later period considerable variations occur, which may continue during early convalescence- In fatal cases a rise of temperature is often observed during the agony. As regards the fever of the epidemic form, see the trea- tise by von Ziemssen in the second volume of this work. Pathological eruptions of the skin (herpes, roseola, petechias, erythema, urticaria, erysipelas, etc.) seem not to be constant or particularly significant, except in epidemics ; we therefore refer to the place where the latter are described. The general nutrition usually suffers greatly ; the patient emaciates quickly and to a great extent, owing to the severity and duration of the fever, the deficient supply of food, the great physical suffering, and the loss of sleep. In severe and pro- tracted cases, emaciation may become extreme. As a matter of course, not all the cases of spinal meningitis are accompanied by all the above symptoms. In given cases, the appearance of the disease may differ greatly. The lead- INFLAMMATION OF THE SPINAL PIA MATER. 243 ing symptoms are more or less distinct in all cases, but the accession of the other symptoms, which are not invariably found, may give rise to many varieties of the disease, which cannot pos- sibly be enumerated here. Let it suffice to state that age and individual constitution may produce considerable differences in the course of the symptoms, and that the nature of the cause usually influences the form of the disease ; that essential or acci- dental complications with inflammation of the membranes of the brain, inflammation and other diseases of the internal organs, may greatly modify the character of the disease ; and that, finally, the portion of the spinal cord which is attacked has a great influence upon the symptoms. It is with regard to this latter point that we would briefly mention the chief signs for locating the disease in the lumbar, dorsal, or cervical region. If the lumbar region is the part chiefly attacked, we shall find pain in the loins and sacrum, stiffness of the lower part of the spine, pain radiating to the hypogastrium and the lower ex- tremities, spasm and paralysis limited to these parts, severe uri- nary difficulties, etc. If the dorsal region is also involved, the pain reaches a higher point of the trunk, pain and stiffness of the back go up as high as the shoulder, disturbances of respiration, praecordial anxiety, etc., are perceived, while the symptoms in the lower extremities continue. If the process extends to the cervical region, the characteris- tic symptoms of stiffness of the back of the neck, excentric phe- nomena [i. e., pain, etc., of a central origin] extending to the upper extremities, severe difficulty of breathing and swallowing, anomalies of the cardiac action, pupillary symptoms, etc., are observed. Finally, if the inflammation extends to the medulla oblon- gata and to the base of the cranium, then, in addition to the chief spinal symptoms, those of a cerebral nature become more and more prominent; vomiting, headache, delirium, paralysis of ocular muscles, trismus, disturbances of respiration and speech are observed, and impart to the disease a very characteristic appearance. 244 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Course, duration, termination.—In describing these, we must make a division into groups. In the severest cases death occurs early. In epidemics it has occurred within a few hours (meningitis cerebro-spinalis side- rans), but more usually is postponed for a few days; the vio- lence of the symptoms increases from hour to hour, tetanic spasms interrupt the constant rigidity of the muscles, severe dis- turbances of respiration and circulation occur, comatose symp- toms appear, and death follows amid profound collapse, often preceded by a great rise of temperature, and, in the last hours, a general relaxation of the muscles. In less violent cases the duration may be two or three weeks ; the severity of the symptoms fluctuates, but in general those which import danger increase, the patient's forces sink, and at last the serious symptoms above enumerated appear, and lead to death in like manner. There are other cases which have a very protracted course. The fever and the acute symptoms diminish, but there is no sign of recovery ; the most important symptoms persist and increase, giving rise to the chronic form of the disease. This form may either take the ordinary course of chronic spinal meningitis, or it may be aggravated by a deep affection of the cord, and the patient dies with symptoms of chronic spinal paralysis, often after many months. As to recovery, that is often hoped for in vain. In the most favorable cases it may occur very soon; the threatening symp- toms grow less so in a day or two, soon disappearing, or if re- turning, it is in a milder form and for a short time. This rapid convalescence is often introduced by critical symptoms—profuse sweating, bleeding from the nose, or hemorrhoidal or menstrual bleeding, abundant discharge of urine, etc.; and cases have been reported where patients have been able to go about their busi- ness in a week or two. But the recovery usually lasts longer; the convalescence drags on for weeks and months, the pains and paralytic symptoms disappear by degrees, the strength improves slowly, the patient has first to use crutches, and often lingers for months in an invalid condition, from which he finally recovers completely after several courses of treatment. Such are the cases INFLAMMATION OF THE SPINAL PIA MATER. 245 in which inflammatory products, exudations, adhesions, etc., re- main to retard recovery. There are, of course, a few cases in which incurable traces of mischief remain, after the general health has been fully restored; this constitutes an imperfect recovery. The patient is well, with the exception of some paresis or paralysis of certain groups of muscles, partial atrophy, local anaesthesia, permanent stiffness of the back, etc. A marked tendency to relapses, of various de- grees of severity, often persists for a time. Diagnosis. The symptoms, when fully developed, form a very character- istic group, not easy to be mistaken. The chief diagnostic diffi- culty arises when we have to separate this group from among more complicated symptoms, or to distinguish it from related diseases. The general marks of the disease are fever, pain and stiffness in the back, stiffness of the back of the neck, muscular spasms, hyperaesthesia and paresthesia of the skin, pains in the limbs, retention of the faeces and urine, dyspnoea, and, in the later stages, paralysis. Where all or most of these symptoms are present, it will be quite easy to form a diagnosis. We shall very often have to put the question whether an existent cerebral meningitis is complicated with the spinal affec- tion. In the cerebro-spinal form, the cerebral symptoms consti- tute the most prominent feature, while the presence of spinal inflammation is indicated by pain in the back and loins, stiffness of the nucha (which doubtless depends on an implication of the cervical medulla), stiffness of the back, Iryperaesthesia and pain in the extremities, particularly the inferior. The diseases most readily confounded with spinal meningitis are acute myelitis and tetanus. The diagnosis from acute myeli- tis may be hard to make in many cases, especially as (in our belief) the two diseases are very often united, and myelitic symp- toms are often of more prominence than those of the other dis- ease. But a little attention will enable us to decide the case on one or the other side with very great probability. In acute 246 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. myelitis the pains in the back and limbs, especially the excentric pains in the limbs, are very much in the background ; the stiff- ness of the back and neck are absent; hyperaesthesia is by no means prominent, and the limbs are not rendered immovable by pain and muscular tension. But in myelitis actual paralysis is very early a prominent symptom ; it occurs much more quickly and completely than in meningitis, and in the sensory sphere it is quite prominent in the form of early and severe anaesthesia. To this is soon added paralysis of the bladder and rectum, often acute bed-sore, and much increase of reflex action. The fever is not, however, so high. From these symptoms it will be easy to recognize myelitis if present, either alone or as complicating meningitis. From tetanus, the anatomical basis of which was often sup- posed to consist of acute meningitis, the latter can usually be distinguished with ease and certainty. Apart from the causal elements, which often much assist in making the diagnosis, the following criteria must be taken into account. Tetanus is a non- febrile affection—in the commencement, at least, it is always such; it begins with trismus, with scarcely an exception, while in meningitis this symptom is postponed to the later stages; there are never any signs of cerebral implication ; the peculiar expression due to rigidity of the facial muscles (Koehler, Koenig) is especially characteristic, but does not belong to meningitis ; in tetanus hyperaesthesia of the skin is absent, but the reflex excita- bility is increased to a degree which very seldom occurs in men- ingitis ; the spasms are much more violent and severe in teta- nus ; very severe dyspnoea and trouble in swallowing occur early, while in meningitis they accompany only the affection of the cer- vical region and the base of the brain, which is always denoted by marked disturbances of the cerebral nerves, changes in the pupils, etc., that do not occur in tetanus. It will hardly be necessary to give the points of diagnosis between spinal meningitis and acute febrile rheumatism of the muscles of the back, which is characterized by its light and favorable course, the local painfulness of the muscles, absence of pain in the limbs, of hyperaesthesia of the skin, paralyses, etc. Diseases of internal organs, as, for instance, inflammation of INFLAMMATION OF THE SPINAL PIA MATER. 247 the lungs and pleura, heart, oesophagus, abdominal viscera, etc., cannot possibly be confounded with spinal meningitis except in persons with marked spinal irritation, in whom all febrile dis- eases are associated with pain in the back, tenderness of the ver- tebrae, etc. This confusion may easily be avoided by careful attention and physical examination. Among the forms of spinal meningitis, the tuberculous is the only one deserving of careful attention, as its diagnosis is known to involve grave consequences in respect to prognosis and treat- ment. As it is probably always associated with tubercular basi- lar meningitis, we may refer to Vol. XII., where are given the points which need attention in distinguishing this form from the other forms of cerebral meningitis. A bad constitution, scrofu- losis, tuberculosis, slow development of the symptoms, moderate and irregular fever, retarded pulse, the cerebral symptoms, etc., will guide the diagnosis. Ophthalmoscopic examination, by show- ing tubercles in the choroid, will perhaps often decide the point. Prognosis. According to the form and causes of spinal meningitis, the constitution of the person attacked, the complications, etc., the prognosis will vary extremely. Only the strictest weighing of the case can make clear the leading points, which can only be given in outline in this place. Cases which begin and continue with sudden violence (foudroy- ant) are absolutely unfavorable. The tuberculous form is equally so. Those caused by deep bed-sores or severe vertebral lesions are very unfavorable. The rheumatic cases and those due to simple traumatic lesion are more favorable, and so are many cases of epidemic origin. The progress is influenced for the worse by the following cir- cumstances : a very youthful or very advanced age ; bad consti- tution, anaemia, the previous occurrence of severe disease, etc.; by the height to which the disease ascends in the spine, towards the brain ; by early symptoms of paralysis, signs of general loss of strength, high fever, continually rising temperature and in- 248 ERB.—DISEASES OF THE SPINxlL CORD AND ITS ENVELOPES. creasing frequency of pulse ; great difficulty in breathing, dys> phagia, severe cerebral symptoms, etc. The opposite of any of these conditions is favorable for the patient. A moderate intensity of the chief symptoms and the fever, in robust persons in middle life, will permit an especially favorable prognosis. But in all cases we should be cautious in making predictions. Acute spinal meningitis is always a serious disease. Even in what seem the lightest cases it should always be kept in mind that the inflammation exists in the immediate neighborhood of a vital and extremely delicate organ, and further, that when all immediate danger to life is past, a transition to the chronic form is but too easy, the prognosis of which is not at all favorable; and finally, that unforeseen relapses may occur, which will sud- denly alter the situation in a disastrous way. The prognosis in later stages, with regard to duration and mode of termination, sequelae, etc., should be made in accord- ance with general rules, keeping in mind what has been pre- viously said. We should be no less careful here ; for not rarely, in spite of the apparent insignificance of the residual affection, partial paralyses, atrophies, etc., will obstinately resist all treat- ment, while at other times they certainly yield with surprising quickness to rational treatment. Treatment. No effective prophylactic measures can be mentioned in spo- radic spinal meningitis; the precautions to be taken in the epi- demic form are given in Vol. II. In so acute a disease, we can seldom speak of fulfilling the causal indication. As a rule, we have little to hope from this; but in some cases the removal of foreign bodies, the treatment of fractures of the vertebrae, of suppuration in the neighborhood, of more remote diseases, and the like, may be necessary; of the manner of accomplishing this, we need not here speak. If the cause is unquestionably of a rheumatic nature, energetic diapho- resis may be tried. We shall usually have the disease in its full development to INFLAMMATION OF THE SPINAL PIA MATER. 249 treat. The severity and threatening nature of the symptoms usually tempt to energetic measures; and, in fact, much has always been done and many things recommended. Let us keep in mind, above all, that the treatment should be determined upon with careful regard to the individual circum- stances, the amount of strength, the causes, the prominent symp- toms, and that these ought to be our chief guide in choosing remedies. We shall, in the first place, always find reason for energetic antiphlogistic measures, among which bloodletting and cold are the chief. General bleeding, venesection, will be used only in the rarest cases, namely, in very robust, plethoric patients, and when the initial symptoms are very intense. Local bloodletting will generally suffice ; it must be free and frequent. Cups and leeches on the vertebral column are the best, in number dependent on the seat and extension of the disease, the patient's age and con- stitution. In many cases blood may also be drawn from the anus and vagina. The application of cold along the spinal column must in all cases be attempted, and, if possible, carried out with great thor- oughness. Unfortunately, it is often hard to fix the ice-bags on the spine, on account of the patient's restlessness, and yet cold applications and wraps, irrigation and affusion of the back can- not properly replace the bags. To this add a vigorous derivation to the intestine or skin. For the former purpose, drastic purges may be advised (the best is calomel with jalap), or strong saline purges, " aqua laxativa," etc. ; of course with allowance for individual constitutions. For derivation to the skin, the best and most successful method con- sists in the repeated application of large blisters along the spinal column. In the milder cases, frictions with pustulating ointment and painting with tincture of iodine along the vertebral column, hot mustard foot-baths, sinapisms to the back and calves or thighs, etc., are sufficient. The white-hot iron seems not to act especially well; it might at most be tried in desperate cases of disease in the cervical region. Mercury has always been recommended as an antiphlogistic from the earliest times ; the most usual methods are the rubbing 250 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. in of mercurial ointment upon the back or extremities, in the quantity of from one to four grammes [from fifteen grains to a drachm] daily, and the internal exhibition of moderate doses of calomel (0.15-0.25 [from two and a quarter to four grains], two or three times a day); the usual precautions against salivation being of course employed. We have no certain proof of the efficacy of this method. Among the internal remedies, tartar emetic was formerly much given, but is now for the most part abandoned. It is for the future to determine whether ergotin deserves the recommendation given by Hammond on account of its action on the vessels. The entire surroundings of the patient must be arranged in conformity with the idea of antiphlogistic treatment; a quiet, airy, moderately warmed room ; absolute rest in bed, best on the side or face, avoiding the back as much as possible ; prevention of all noise and excitement; avoidance of bodily movement and exertion ; for nourishment, a fluid, easily digestible diet, at first cooling, but soon to be made tonic and roborant; for drink, water, lemonade, juices of fruit, mild acid drinks, but no spiritu- ous drink, no coffee or tea—such are the chief things to be attended to. But this is far from exhausting our therapeutic aims, for there remain very important symptomatic indications to be ful- filled, which usually become imperative, owing to the severity of the patient's sufferings. In the first place, sedatives are required, in order to relieve pain, sleeplessness, hyperaesthesia. The opiates are universally recommended for this purpose above all other remedies, and they have been sufficiently tested in the great epidemics of cerebro- spinal meningitis ; large doses of opium, subcutaneous injection of morphia. With this may be mentioned chloral hydrate, and in some cases the inhalation of chloroform. May not belladonna deserve the preference over opium in such cases ? Bella- donna is stated to contract the vessels of the cord, and it also possesses narcotic virtues. Favorable sedative results are also to be expected with certainty from the use of bromide of potassium. All these remedies seem especially efficacious when given directly after bleeding. Baths, especially lukewarm, protracted full baths, occupy INFLAMMATION OF THE SPINAL PIA MATER. 251 the second place as sedatives. If such are used, we may dis- pense with cold affusion of the head and back, unless the latter be called for by special indications—violent cerebral symptoms, delirium, collapse, etc. Moist packing of the whole body often soothes and brings sleep. For hyperaesthesia and pain, muscular tension and spasm, many trials of external remedies have been made ; little is to be expected of them ; the most likely to succeed are frictions with warm oil, chloroform liniment with infused oil of hyoscyamus, and similar applications. For the fever, we shall seldom have to take special measures; if necessary, we should employ the regular methods of large doses of quinia and cool baths. For weakness of the heart and threatened collapse, the usual analeptics are to be used when required, just as in other inflam- matory affections. For disturbances of respiration we can do but little, unless we succeed in directly checking the inflamma- tion in the cervical region. If convalescence has begun quickly and favorably, no further treatment is usually required, except care of the diet and the usual precautions against overexertion. To provide against re- lapses, the wearing for a long time of a vesicating plaster (of one- half the usual strength) upon the back has been recommended. But if the affection has only assumed the chronic form, it is needful, above all, to assist the resorption and withdrawal of the exudation, for which purpose iodine seems most suitable; to be used externally in the form of ointment, internally in large doses of iodide of potassium, to be continued for a considerable time. For the relief of this stage we must also take into account warm baths, thermal and brine baths, suitable water-cures, etc., accord- ing to the rules given in the following section on Chronic Menin- gitis. The residua and sequelae (palsy, atrophy, anaesthesia, weak- ness of the bladder, etc.) should be treated upon general prin- ciples, mostly with baths and electricity. Compare the sections on Chronic Meningitis and Myelitis. 252 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. b. Leptomeningitis Spinalis Chronica. By this term we understand a nonfebrile inflammation of the soft membranes of the cord, sloio in development and course, or one which has become sluggish after having run an acute course. The anatomical changes which characterize this form are usually slight, rarely well-marked. The symptoms, at first often very trifling, afterwards assume a more severe character, and may develop by degrees with very destructive effect. Chro- nic spinal meningitis is often the point of origin for chronic in- flammatory processes in the cord. Etiology. The causes of this disease are quite obscure in many respects ; the disease is very often unrecognized or disregarded, as its symptoms disappear amid the crowd of symptoms of severe com- plicating processes. The disease very often originates from the acute form, and has, therefore, the same cause. All possible debilitating influ- ences, bad nourishment, abuse of tobacco, etc., are said to favor the occurrence of this transformation, and, in general, to produce a certain predisposition to chronic spinal meningitis. In general, the same causes which produce the acute form may give rise directly to the chronic, provided that they are less intense, but perhaps more continuous or more frequently re- peated. Many cases are directly traceable to cold; the occupancy of damp dwellings, working in the wet and cold, bivouacking in bad weather (hence rather common among officers in the field— Braun), are those most usually spoken of. Traumatic lesions of moderate severity often lead to chronic meningitis. Especially, simple shocks, falls upon the seat or back, contusion of the spine, slight railway accidents and the like may by degrees lead to inflammation. Chronic inflammatory processes or neoplastic processes of neighboring parts often pass to the spinal membranes ; thus, in INFLAMMATION OF THE SPINAL PIA MATER. 253 caries of the vertebrae, chronic periostitis of the same, carcmoma, and other new formations of the vertebrae or the spinal mem- branes, etc. This connection is especially important in most of the chronic diseases of the cord,; in chronic myelitis, sclerosis, atrophy, and gray degeneration of the cord nothing is more com- mon than extension of the chronic inflammation to the soft mem- branes of the spine. Here are to be included the syphilitic and leprous affections which often occur in the vertebral canal, the specific products of which are usually surrounded by more or less extensive chronic myelitis. Bruberger once found an exqui- site syphilitic spinal meningitis of the cervical part of the cord in connection with syphilitic basilar meningitis. How far suppressed excretions {e. g., suppression of the hem- orrhoidal or menstrual discharge, or of perspiration of the feet, the disappearance of chronic eruptions, etc.) may act as causes of spinal meningitis, we dare not decide. The misuse of alcohol, however, seems to be certainly a very active cause (Huss). Excess of bodily effort and sexual excesses may be considered rather as predisposing than as direct causes. Koehler lays stress upon chronic disease of the heart and lungs, disease of the liver, and all sorts of circumstances which may give rise to impediments in the vertebral veins, as regular causes of chronic and slow inflammations of the coats of the cord, but he seems not to have paid enough attention to distin- guishing the simple hyperaemia of blocked circulation, with transudation, from actual inflammation. Pathological Anatomy. The morbid appearances are in most cases quite constant, showing, however, some differences in the intensity and extent of the process. Besides a more or less distinct hyperaemia, the principal ana- tomical characteristics of chronic meningitis spinalis consist in opacity and thickening of the pia and arachnoid, close aggluti- nation and adhesion between these and the dura, unusually firm adherence of the pia to the cord, and an abundance of spinal fluid. 254 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. The hyperaemia is mainly of a venous character; the small veins and capillaries are dilated, the color is rather a dark red, more or less diffuse. The thickening with connective tissue may be very great, so that the soft membranes assume an opaque tendinous appear- ance, and unite in forming one uniformly hard membrane. The latter may be pigmented in spots, sprinkled with small extrava- sations of blood and spots of pigment, and is often connected with the dura by means of more or less extensive false mem- branes. Jaccoud found in an interesting case great fibrous plates in the arachnoid along the region of the nerve-roots, almost continuous in the cervical and lumbar cord, affecting chiefly the anterior, less the posterior roots, and leading to atro- phy. It is more common to find a deposition of thin, small, more or less numerous plates of lime upon the arachnoid, which, especially in the lumbar region, are often found without any other marked sign of inflammation. An abundant secretion of spinal fluid is almost always found, seemingly in much increased quantity. Many cases, formerly described under the term hydrorrhachis, evidently come under this class. The serum is often clear and of the usual consistency, but is of tener turbid, flocky, tinged with blood, or mixed with an abundant fibrinous exudation. Stokes found an abundant puru- lent exudation in a case which had been unattended with fever. The dura mater often shares in the inflammatory process to a corresponding extent, being thickened, opaque, sometimes gran- ular, covered with growths of connective tissue and adhesions (cf. also what was said under Pachymeningitis Interna, pp. 221 and 222). The cord itself is implicated (myelomeningitis) in most cases, though in various degrees and to a various extent. Often only the processes of the pia mater which enter the cord appear thick- ened and swollen; but more frequently there is a more or less extended sclerosis (so-called) of the cord, in various forms. Such a sclerosis is sometimes annular in shape, beneath the pia, some- times it occurs as longitudinal bands in certain columns of the cord, sometimes is disseminated in spots, and sometimes it is a chronic myelitis, occupying the entire transverse section, and INFLAMMATION OF THE SPINAL PIA MATER. 255 extending to a greater or less distance longitudinally. We often see, originating in such seats of disease, degeneration ascending in the posterior columns, and descending in the lateral columns, and reaching to a great distance. The result of this process may be a considerable atrophy and diminution of the diameter of the entire cord. The nerve-roots are usually atrophied, pale, gray, degenerated; they are lost to the eye amidst the thickened and opaque mem- branes of the spinal cord, and suffer more or less radical changes, proportionate to the intensity and duration of the disease. The following additional affections of a secondary nature are found: atrophy and degeneration of peripheral nerves and mus- cles, bed-sores in all stages and situations, chronic cystitis, etc., and as accidental complications, disease of any of the internal organs. Symptoms. This subject is not quite clear. The disease has not been suffi- ciently studied, and, besides, is almost always-complicated with some other affection. In general the symptoms must be the same as those of the acute form, except that they are much slower and less violent in development, are without fever, and often are not prominent for a long time. When the disease develops from the acute form, the violent symptoms abate, the fever disappears, but a portion of the symp- toms—of .the pain and stiffness, the weakness and abnormal sen- sations—remains for a longer time, and, gradually developing, leads to an unfortunate condition : it has become chronic menin- gitis. In many cases repeated attacks of the subacute form recur; thus the disease becomes firmly rooted, the intervals between the attacks diminish, and the disease assumes a regular chronic form. In most cases, however, the disease first appears in the chronic form ; the beginning is quite latent, being, at least, not observed by the patient, or not considered of any special importance. The commencement is marked by occasional abnormal sensa- 256 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. tions in the lower limbs, gradually increasing pain, and some stiffness of the back. The pain of the back increases, but is usu- ally not very severe, being often described as merely a sense of drawing and pressure in the back, a feeling of weight; it is not usually increased by pressure on the spinous processes or the dorsal muscles, but usually is made worse by movements of the vertebral column. A certain stiffness of the nape of the neck is not usual in the early stages. The excentric symptoms in the trunk and limbs which follow are striking and important. Corresponding with the seat of the disease the annoying sensation of a girdle is often felt, and in the same region shooting and boring pains may occur, especially if provoked by movements. In the limbs a feeling of great heaviness early appears ; in the skin the patients speak of all kinds of paroesthesioe, often of a very singular character—tin- gling, cold, formication, and the like; these are very often ac- companied by tearing or shooting pains, either confined to the region of some nerve-trunk, or else changing from place to place. These pains are exasperated by movement, and not seldom by change of weather, dampness and fog, snow-fall, or a low ba- rometer. Finally, various degrees of cutaneous hyperaesthesia, not so marked as in the acute form, have been observed not infrequently. All these excentric symptoms are confined to the distribution of the nerves whose roots originate in the part chiefly affected. They may, therefore, be most marked either in the upper or in the lower extremities, but the latter is the more usual case. Symptoms of motor irritation are of subordinate importance in chronic meningitis, but are not usually absent. A degree of stiffness of the back, and sometimes of the neck, is almost an invariable symptom, and may in some cases become severe. Trembling of the extremities, twitching of certain muscles, sud- den starting of the body, involuntary drawing up or extension of the limbs are not rare. At almost any period in the subsequent development of the disease symptoms of increasing weakness, going on to lull paral- ysis, become prominent. The heaviness and weakness of the limbs become greater, the patient loses more and more of his INFLAMMATION OF THE SPINAL PIA MATER. 257 control over the extremities, symptoms of sensory paresis, of vesical weakness, of disturbed rectal function occur, and para- plegia develops, by degrees increasing in degree and extent. This paraplegia, though it varies much in different cases, is seldom complete, but usually comprises only a very severe pare- sis ; a certain fluctuation in the intensity of the paresis seems to be rather characteristic; the patient can perform this or that movement better on one day, worse on the next; it is thought that this fluctuation is connected with variations in the amount of fluid exudation in the spinal canal, or the fulness of the circu- lation ; if the spinal fluid is excessive, the paralysis increases when the patient stands, because the lower parts of the cord are more compressed, while, on the contrary, passive congestion may cause it to increase while the patient is lying on his back, and when standing or walking he is better. These two factors, there- fore, act in contrary directions. Severe anaesthesia is rare ; there is usually only a slight dull- ing of the sensations of the skin, limited to the soles, feet, and lower part of the legs. These disturbances are always accom- panied by marked paraesthesiae, not seldom mixed with hyper- aesthesia ; but the latter is usually not marked, though some reported cases give the impression that it may become very severe. The associated paralysis of the sphincters increases, and in severe cases there may also be a strongly marked atrophy of the muscles, with loss of electrical excitability. The disturbances of sensibility increase, the reflex function becomes extinct, bed-sores and cystitis appear, and the scene is closed by marasmus. Disturbances of any of the internal organs (of respiration, circulation, or digestion) are very common, and originate in the same way as in the acute form, although different from it in degree. The pathogenesis of the symptoms is about the same as in the acute form ; perhaps the cord is still more likely to be affected than in the latter. We can refer upon this point to what has been said under Acute Spinal Meningitis. Course, Duration. Result.—This disease is always slow and VOL. XIII.—17 258 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. chronic, extending to months and years, often many years. The symptoms often fluctuate considerably ; intercurrent, acute ex- acerbations are not rare. Some of the cases recover; these are the lightest, and those which have early been taken in hand. The return to health is always very slow and gradual, often occurs by successive steps, and is often interrupted by relapses; the sensory disturbances are usually the first to disappear, and the motor remain the longest. Even when recovery is complete the patient usually remains feeble for a long time, with a tendency to relapse. The cure is often incomplete. The improvement reaches a certain point, all symptoms of the active inflammatory process disappear, but residua and sequelae remain, doubtless due to the relics of exudations, compression of the roots by adhesions and thickening, cicatricial sclerosis in the cord, etc. In this category may be included partial or complete paralysis of single mus- cles or extremities, with or without atrophy, circumscribed anaes- thesia, weakness of the bladder, etc. The cure is often interrupted by repeated relapses. In a great proportion of the cases chronic meningitis leads directly to death. The processes and occurrences which may bring this to pass are many ; they usually include the symp- toms of grave spinal paralysis—paraplegia, vesical palsy, cys- titis, bed-sores, with consecutive anaemia and hydraemia, and, at last, general marasmus. In other cases, the sad termination is brought about by the extension of the process to the cervical region, causing progressive difficulty in breathing and degluti- tion, secondary pneumonia, etc. In yet other cases, life is speedily brought to a close by the sudden starting into activity of an acute purulent meningitis. There are many other compli- cations and accidents which may hasten the fatal termination of chronic meningitis. Diagnosis. Chronic spinal meningitis is often hard to recognize, because the symptoms remain for a long time extremely slight, and, taken as a whole, present an incomplete representation of the disease, or are obscured by complications. INFLAMMATION OF THE SPINAL PIA MATER. 259 When the whole of the symptoms above mentioned are pres- ent, we shall not hesitate long about the diagnosis. The only difficulty consists in distinguishing between the different forms of chronic myelitis, and this difficulty is the greater, as the two diseases are so often combined with one another. The following guide is offered: Pain and stiffness in the back, general pain in the extremities, extensive symptoms referring to the roots, a slight degree of paralysis, equably dis- tributed, and change in intensity dependent on change of position of body, are symptoms which speak strongly in favor of menin- gitis. The absence of increased tendinous reflex actions, of obsti- nate contractures, of painful muscular jerkings, may be inter- preted in the same sense. Myelitis must be thought of, when severe paralysis and anaesthesia are present, the pains are slight, the tendinous reflex actions are exaggerated, and considerable contracture, etc., is present. If there is palsy with great atrophy, without any disturbance of sensibility or pain, our first thought must be of myelitis of the anterior gray substance. From tabes dorsalis, as implying the symptoms of gray de- generation of the posterior columns, chronic spinal meningitis is very easy to distinguish ; the points to notice are the character- istic lancinating pains, ataxia, disturbances of muscular sensi- bility, etc. But it should not be forgotten that both diseases are very often combined, producing a mixed group of symptoms. In determining the nature of the disease which causes the spinal meningitis, we are guided by general considerations. The diagnosis of the location in the lumbar, dorsal, or cervical region lias already been mentioned. Prognosis. The disease is in general a grave one; a cure is hard to ob- tain, especially in rather old and tedious cases. But improve- ment and cure have occurred, even in seemingly hopeless cases, so that the prognosis is not absolutely bad, even in severe cases. We may always remember that the chronic inflammation of the spinal membranes need not be a continuous and limitless 260 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. process; that it is very susceptible of arrest and repair ; that the possibility of repair depends essentially upon the organization, calcification, retraction, which may have taken place in the pro- ducts of inflammation, but that, even after these have taken place, others may often be expected in the course of time, which give rise to considerable improvement of function. The prognosis may be made by taking such facts into ac- count, and with them the patient's age, constitution, and powers of resistance, state of nutrition, the causes, and the possibility of removing them, the anatomical changes already developed, the intensity of the symptoms, the results of treatment, etc. We must, however, avoid indulging in too great hopes of curing the disease. Treatment. The causal indication is the first to be attended to. To avoid needless repetition, we would refer to the given list of causes, the proper remedies for which are easily inferred ; and we will in this place only emphasize the necessity of carefully treating the acute form. We ought always to try to cure it completely, should observe the strictest watch during convalescence, should not let the patient return too soon to the exertions of his calling, should guard him from exposure to cold and other injurious things ; by these precautions many cases of chronic spinal men- ingitis might be prevented. In the treatment of the disease when developed, antiphlogo- sis is to be used very sparingly. We shall seldom effect much by bloodletting, energetic derivation to the intestine, etc., in such a chronic disease as the present. Yet there are cases in which these remedies deserve a trial. In robust, well-nourished persons, when the symptoms are rather decided, the pain of the back severe, etc., it will be suitable to apply every week or two from ten to fourteen moist cups along the spine ; for feeble pa- tients the application will be restricted to dry cups once or twice a week. Similar principles and special indications (as habitual constipation, hemorrhoids, etc.) will guide us in the use of pur- gatives. INFLAMMATION OF THE SPINAL PIA MATER. 261 Derivation to the skin is praised by almost all writers. Noth- ing seems more suitable for such cases than the repeated appli- cation of large blisters to the back. Brown-Sequard advises to do this every fortnight. The mild derivatives (sinapisms, pus- tulating ointments, friction with oil of turpentine and croton oil, painting with iodine, etc.) may be used in light cases and for the sake of change. The moxa or white-hot iron (burning in streaks along the spine) will be used only in severe and desperate cases. Of the drugs, the most justly celebrated is iodide of potas- sium ; it is given for a considerable time in the usual doses. It will be best to abstain from mercury in these chronic cases, unless syphilis exists. Nothing remarkable is to be expected from ergotin and belladonna. If we have cause to suspect the existence of an abundant serous exudation, wre may emploj^ diu- retics. In many cases warmth seems extremely useful; warm gar- ments, furs, and the like, warm wraps, frictions with warm oil, etc., are praised. Upon this fact seems to depend in part the unquestionable advantage of baths, which have effected many notorious cares in chronic spinal meningitis. Warm baths of all sorts, indifferent and brine-baths, gaseous brine-baths and chalybeate-baths, etc., may here be used. Braun, who has examined this point with care, states the rule for using them as follows: the baths should in general be protracted ; the more indifferent the spring, the longer may be the duration; the more abounding in salts and carbonic acid, the more should the bath be shortened. The tem- perature should at first be very carefully regulated; if myelitic complications exist, the higher degrees should be avoided, but in pure meningitis they seem the best borne, which may account for that dangerous credit which many warm springs have ac- quired in spinal paralysis. An enlightened diagnosis should be invoked in support of such treatment. In very obstinate cases we may try vigorous cold-water treat- ment, especially the wet pack, alternate cold and warm douches on the back, moor-baths, and hot sand-baths. Of the effect of the galvanic current in chronic spinal menin- 262 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. gitis, we do not yet possess full information. It is extremely probable, a priori, that the catalytic effect of the current will be strikingly useful in this disease. An observation by Hitzig' seems to confirm this most clearly ; the result was obtained by using descending stabile currents. My own experience in the matter is also very favorable, but my observations are too few in number to render a final decision possible. A trial of galvanic treatment (chiefly by stabile currents to the spine, with succes- sive action of both poles) is certainly always indicated, and may very well be conjoined with the use of baths. Much can also be done to relieve symptoms. For pain, the usual sedatives; for paralyses, anaesthesia, atrophy, etc., elec- tricity ; for weakness of the bladder, ergot, nux vomica, elec- tricity; for anaemia and cachexia, tonics, iron, quinia, strength- ening diet, a little wine, etc. The diet must be mostly tonic, adapted to promote and hasten the change of tissue. The habits are to be governed by the patient's condition and circumstances, and may be regulated by the general directions given at page 196 et seq. In all cases, after a cure has been attained, it is absolutely necessary to maintain a long watch over the health and habits in all respects. For a subsequent treatment, many cases will be benefited by electricity, cold-water cures, a mountain climate, and the milder sea-baths. 5. Tumors of the Spinal Membranes. Ollivier, loc. cit. 3d ed. p. 517.—Cruveilhier, Anatomie pathol. livraison. XXXII. pi. 1. XXXV. pi. YL—Hasse, loc. cit. 2. Aufl. p. 731.—Rosenthal, loc. cit. 2. Aufl. p. 346.—Hammond, loc. cit. 3d edition, p. 517.—Leyden, loc. cit. I. p. U3.— Virchow, G-eschwiilste. I. pp. 386, 423, 514; II. pp. 92, 120, 345, 354, 461.—Charcot, Lecons sur les mal. du syst. nerv. II. Ser. II. fasc. Paris. 1873. —Jaccoud,hes paraplegies et l'ataxie du mouv. Paris. 1864. p. 236.—Brown- Sequard, Lectures on Paralysis of the Lower Extremities, etc. 1861. p. 92. Athol Johnson, Fatty Tumour Connected with the Interior, etc. Brit. Med. Journ. 1857.— Virchow, Bosartige, zum Theil in der Form des Neuroms auftretende Fettgeschwulste. Virch. Arch. 1857. XL p. 281.—Traube, Fiinf Falle von 1 Virchow's Archiv. 1867. Bd. XL. TUMORS OF THE SPINAL MEMBRANES. 263 Ruckenmarkskrankheiten. Charite-Annalen. IX. 1861. (Gesamm. Abhandl. II. b. p. 994.)—Whipham, Tumour of the Spinal Dura Mater, Resembling Psammoma, etc. Trans. Path. Soc. XXIV. 1873. p. 15.—Benj. Bell, Tumour of the Pia Mater, etc. (fibro-nucleated growth). Edinb. Med. Journ. Oct., 1857. p. 331.—Loewenfeld, Faserig. Sarkom an d. Wurz. der zwei ersten Sacralnerven links. Wiener med. Presse. 1873. No. 31.—L. Benjamin, Neurom innerhalb der Riickenmarkshaute. Virch. Arch. 1857. XI. p. 87. — Seitz, Pseudoplasma medull. spin. Deutsche Klinik. 1853. No. 37.—Charcot, Hemiparaplegie deter- mined par une tumeur, etc. Arch, de Phys. 1869. II. p. 291.—Baierlacher, Zur Symptomatologie der Gesehwulstc am R,-M. Deutsche Klinik. 1860. No. 31.— Meschrde, Sarkom am R.-M. Ibid. 1873. No. 32.—Th. Simon, Tumor im Sack der Dura spinal., die Cauda comprim., etc. Arch. f. Psych, u. Nervenkr. V. p. 114. 1874.—Simon, Paraplegia dolorosa. Berl. klin. Wochenschr. 1870. Nos. 35 and 36.—Davaine, Traite des entozoaires, etc. Paris. 1860. p. 666.—Bar- tels, Echinoc. innerhalb des Sacks der Dura spin. Deutsches Archiv. f. klin. Med. V. p. 108. 18QQ.—Behier, Compress, de la mo'elle Spin, par un kyste hy- datique. Arch. g<5n. Mars. 1875. p. 340.— Westphal, Cysticerken des Gehirns und R.-M. Berl. klin. Wochenschr. 1865. No. 43. Of the new formations within the spinal canal, the most important and frequent are those proceeding from the spinal meninges. They mostly originate in the dura, and develop upon its outer or inner surface ; many new formations, however, spring from the arachnoid or pia, and remain limited to these membranes. The latter are not always the point of origin ; neoplasms arising from the neighboring parts often extend to the membranes, in- volve them in a secondary way, and then produce effects like those of primary meningeal tumors. It results from the narrowness of the space within the canal that the tumors usually found are of inconsiderable size, but that they very soon begin to awaken the most active disturb- ances through irritation and compression of important intra- spinal tissues. Most of the tumors reach only the length of two to four centi- metres, rarely that of eight to ten, within the canal; their thick- ness is from one to three centimetres. Of course, secondary tumors, and such as send out branches through natural or arti- ficial foramina in the spinal column, may reach a much larger size. The form is usually oval, that of an olive, or something so; 264 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. the rate and direction of their growth, and hence also the general character of the symptoms, depend chiefly upon the nature of the tumor. It is said to have been observed that such tumors assume a more vigorous growth during pregnancy. In enumerating meningeal tumors, we shall for practical rea- sons not limit ourselves to new formations in the stricter sense, but shall add many things which have the same clinical signifi- cance, as inflammatory new formations in the shape of tumors, animal parasites in the canal, etc. Pathological Anatomy. The exact histological diagnosis of many intra-spinal tumors is far from satisfactory. It is especially hard to make out in older observations to which of the present categories of new formations we ought to assign them. The observations of the last ten years, though not very numerous, show the existence of the following forms of tumors in the spinal meninges : Fibroma and fibrosarcoma.— Usually small oval tumors, three to five centimetres long, two to four thick, springing from the dura or the pia, and situated now within, now without the sac of the dura. They consist of connective tissue, with more or less abundant cells, spindle-cells, round cells (transition to sar- coma). Sarcoma.—Occurring in all possible forms, as hard and soft, fibrous, or cellular ; often with formation of cysts, cysto-sarcoma (observations of Baierlacher, Leyden, and others). Originates more rarely from the dura, more frequently from the soft mem- branes ; is more usually of a longish shape ; not seldom lobular, with a nodulated surface; considerable vascularity, and the usual histological characteristics of sarcomatous new formation.' Myxoma has been found by Virchow, Traube, and others in the spinal meninges. It originates almost exclusively from the arachnoid or the pia, and is a soft, juicy, lobulated tumor of moderate size and pale color. It may be pure ; more frequently it is a mixed product, a lipomatous or sarcomatous myxoma, etc. 1 See Virchow, Geschwiilste. II. TUMORS OF THE SPINAL MEMBRANES. 265 To the same series of new formations belongs psammoma, found by Whipham, Cayley, Charcot, Bouchard, and others—a sarcoma with granular concretions of lime imbedded in it. Usu- ally a small roundish or olive-shaped, smooth or lobed tumor, in most cases originating from the soft membranes. Lipomata have repeatedly been found in the vertebral canal, either caused by proliferation of the perimeningeal fatty tissue (Athol Johnson, Obre, Virchow), when it is situated outside of the sac of the dura, or originating from the soft membranes, and situated within the sac of the dura. An enchondroma as big as a hazel-nut, firmly adherent to the dura and the connected vertebra, has once been found by Vir- chow, and declared to be probably congenital. Osteoma, the formation of new bone, in the form of the so- called cartilaginous disks, is extremely common in the arachnoid, but in this form cannot be considered a tumor, and has no clini- cal importance. Ossification of the dura also occurs only in the diffuse form. Multiple fibrous melanoma has been seen in the spinal canal by Virchow and Sander. The name of neuroma has been given to many new formations occurring in the spinal canal, on the nerve-roots, especially on the cauda equina (Benjamin, Virchow). These are mostly the so-called false neuromata, and occur either singly or in numbers.' Carcinoma proper seems very rarely to spring from the spinal membranes ; I, at least, have had knowledge of no unquestioned case of primary carcinoma of this region, excepting the older and less reliable observations of "fungous" or "cancerous" growths. The tumors are almost always secondarily developed by extension from the vertebrae or other neighboring parts, or by metastasis from other organs. Such secondary carcinomata not seldom appear in the vertebrae, in consequence of primary cancer of the breast. We have spoken under meningitis of the formation of miliary tubercle in the membranes of the cord. With these are associated the tumors which originate in 1 See Vol. XL p. 599 et seq. 266 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. inflammatory, hemorrhagic, and other processes in the spinal membranes or the neighboring parts. Such are peripachymenin- gitic exudations, with or without caries of the vertebrae, those hard, circumscribed growths, of a purulent or caseous nature, of which we have before spoken, and which are so common in Pott's disease ; also the greenish-yellow, bacony, scrofulous exu- dations between the dura and the vertebral column ; and the haematoma of the dura mater, originating in pachymeningitis interna haemorrhagica. The syphilomata which are occasionally found in the spinal membranes are of a somewhat similar nature (Wilks, Virchow). They have been little studied ; they usually consist of gummata of the dura or the pia. Finally, we have to speak of the parasitic new growths which occur (though rarely) in the spinal canal. Cysticercus cellulosae has been found once by Westphal in the sac of the dura; there were numerous cysts in the lumbar portion, some free in the fluid, some firmly enclosed in the meshes of the arachnoid ; a few also in the thoracic and cervical portions. Numerous cysts in the brain. Only one of them contained a head. Clinical symptoms referred to the spine had been present. Echinococcus has been found more frequently (thirteen times in all) by Davaine, Cruveilhier, Lebert, Foerster, Rosenthal, Bartels, etc. The development of most of the cysts took place externally to the dura, and often led to considerable tumors out- side of the vertebral canal. In only two cases (Esquirol and Bartels) did they develop within the sac of the dura. They differ in size, and present the usual characteristics of colonies of echinococcus. With this we close our enumeration—perhaps an imperfect one. Respecting the seat of meningeal tumors, we need not add much. They may occur at any part of the canal, may compress the cord in front, behind, or at the side, may include various numbers of pairs of nerve-roots, etc. Each case will differ in these respects, but one thing is tolerably important and charac- teristic, namely, that the disease always occupies a quite limited and definite locality. TUMORS OF THE SPINAL MEMBRANES. 267 But, for the purpose of understanding the clinical symptoms and the entire course of the disease, it is of much importance to attend to the consecutive changes which always, though in vary- ing degree, accompany the formation of tumors in the spinal canal. The nerve-roots in the region of the tumor are sometimes found swollen, reddened, softened by inflammation, sometimes thin, flat, grayish and translucent, atrophied and degenerated, according to the duration and extent of the process. The cord itself always experiences some degree of compres- sion, which may change it to a flat, ribbon-shaped string, or, at least, produces a local indentation, more or less deep. Simple atrophy of the portion compressed is seldom the only change. It is much more common to find at the compressed point marked inflammatory symptoms {myelitis from compression), which can be followed but a short distance upward, and often a good way downward. The medulla is in a state of whitish or reddish soft- ening, is full of small hemorrhages, and exhibits under the mi- croscope many granular corpuscles amid the debris of nerve- elements. This change continues to a variable distance down- wards in the white substance, and more especially in the gray also. Cruveilhier once found the whole peripheral portion of the cord in a state of purulent degeneration. The examination of the hardened cord in these cases regularly shows secondary degeneration, ascending in the posterior col- umns, and descending in the postero-lateral (see farther on, II., No. 19). Simon has also found this ascending degeneration in a tumor of the cauda equina. In the membranes of the cord we almost invariably find signs of chronic inflammation (thickening, opacity, pigmentation, hy- peraemia, etc.) of various extent. In correspondence with this, an increase of the spinal fluid (hydrorrhachis) is pretty constant. In the peripheral nerves and muscles, degenerative atrophy is not rare ; usually in those nerve-districts whose roots are either directly included in the new formation, or are directly connected with degenerated portions of the gray substance. Such further alterations as are found on the bodies of those dead of meningeal tumors—bed-sores, cystitis, extreme maras- 26S ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. mus, changes of internal organs, etc.—will be described here- after Etiology. The causes of meningeal tumors are usually obscure. It seems to be established that surgical injuries are the most likely to produce them ; cases have been observed where the first symp- toms occurred after a fall or blow upon the back, or spine, etc. Exposure to cold has been assigned as the cause of the dis- ease in a number of cases, and, as it seems, with sufficient reason. It is remarkable how often it is recorded that the first symp- toms appeared during childbed, shortly after delivery. Observations by Cruveilhier and Kohts render it probable that excessive mental excitement, violent fright, may give the impulse to the formation of meningeal tumors. Finally, vertebral disease, the tuberculous and scrofulous diathesis, and syphilis, are among the causes of meningeal tu- mors, as follows from the preceding enumeration of the forms. The entrance of animal parasites is effected in the usual way by swallowing the eggs, or the proglottides of the various species of tape-worm. It is seen that these scanty facts leave a large part of the eti- ology of meningeal tumors in obscurity. Symptoms. The general outline of the symptoms usually caused by me- ningeal tumors may be drawn in a few words. If the disease begins (as it often does) quite in a latent and insidious way, the development of the tumor is usually first in- dicated by the presence of pain in certain nerve-districts, which increases in severity. Abnormal sensations in the trunk (feel- ing of a girdle) and the extremities, paraesthesioe, anoesthesiae, partial paralyses, are associated with the above—all at first localized in the same nerve-districts. Painful stiffness of a definite portion of the spine indicates more directly the seat of disease. After a period of various length, often after years, paraplegia TUMORS OF THE SPINAL MEMBRANES. 269 follows, and increases ; it begins as a progressive paresis, often unilateral, like Brown-Sequard's palsy, but usually making rapid progress across the body, and ending with absolute sensory and motor paralysis. The disease rarely remains stationary at a point of moderate severity, but usually goes on to extremes; and after great suffering, attended by all the horrible circumstances of the severest spinal paralysis, palsy of the bladder and rectum, cystitis, extensive bed-sores, general marasmus, etc., the patient is brought to a miserable end. Although the individual features of this sketch are by no means characteristic of meningeal tumors when taken separately, yet, when considered as a whole, they often enable us to recog- nize and to localize the disease with some accuracy. Upon closer consideration we find two groups of symptoms, distinguishable both by their succession in time and by their pathogenetic significance. These are : 1. Symptoms of local irritation and compression of the nerve- roots and the membranes first involved in the tumor. 2. Symptoms of irritation and compression of the cord itself, and of consecutive myelitis {myelitis by compression). Those of the first group are the earliest, and often precede the paraplegia by months and years; their character of course dif- fers in each case according to the location, direction of growth, and rate of growth of the tumor; so that no exhaustive state- ment can be made. But the numerous varieties may be inferred from the general scheme. All these symptoms arise from irrita- tion or compression of the nerve-roots, from consecutive irritation of the meninges, and, to some extent no doubt, from commencing irritation of the cord itself. Violent pains are next observed, the lancinating, tearing, boring character of which proves their excentric origin. They may remain confined to a single point, or attack a single nerve- trunk ; hence, according to the seat of the disease, they either surround the trunk like a girdle at various levels, or invade the upper or lower extremities, of one side or both. They may ex- tend suddenly or by degrees to neighboring nerve-districts, are often increased by movement of the spinal column, and seem to be made worse by sudden changes of weather (Bell). These 270 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. symptoms are so intimately associated with those of compression of the cord by tumors, that Cruveilhier distinguished paraplegia dolorosa, due to compression of the cord, from paraplegia non dolorosa, caused by primary disease of the cord. Paraeslhesioe also occur, corresponding to the extent of the pains—the sensations of tingling, formication, numbness, dead- ness, etc., either in the form of a girdle or limited to certain regions of the extremities. If motor roots are first exposed to the influence of the tumor, separate muscular twitchings, spasms, may appear at the be- ginning. These symptoms of irritation are almost always accompanied by distinct, sometimes very active pain in the back, localized in the neighborhood of the tumor, and usually accompanied by a local stiffness of the spine. Leyden points out the fact that the movement of the spinal column is often difficult and painful in a certain direction, because this motion brings a greater pressure upon the tumor. In the further course of the disease symptoms of paralysis appear sooner or later, corresponding to the locality of the dis- ease ; circumscript anaesthesia, often coinciding with the distri- bution of nerves which are especially painful (anaesthesia dolo- rosa), local paralyses and pareses of the corresponding muscular groups, atrophy, etc., compose an extremely complicated and varied group of initial symptoms. It needs only to be indicated how various are the phenomena of this first group in connection with different seats of disease; how when the cervical region is the part attacked, for example, one upper extremity may first be seized by pains, paraesthesiae, partial palsy and atrophy, before the symptoms of compression of the cord appear; how, when it is the dorsal region, the dis- ease will be introduced by intercostal neuralgias, paroxysms of visceral pain, zoster, etc.; how, finally, when the lumbar region is involved, all the above disorders may appear, now in the dis- trict of the sacral, now in that of the lumbar plexus, and put on a great diversity of form. Numerous and instructive examples of this are upon record. When the symptoms of the first group have existed for an TUMORS OF THE SPINAL MEMBRANES. 271 uncertain length of time (weeks, months, often several years), they are succeeded by symptoms of the second group, derived from the continuous pressure upon the cord, and usually from myelitis also (which hardly ever fails to be present); these be- come more and more distinct, and change the scene in a very disagreeable way. The development may be rapid or slow; it often occurs with almost suddenness in a few hours, and in such case is nearly always due to secondary myelitis, as it is seldom we can suppose so rapid an increase of the pressure of a tumor. The compres- sion is often limited at first to one lateral half of the cord, which may give rise to the characteristic symptoms of Brown-Sequard's hemiplegic lesion (paralysis of the side of compression, anaes- thesia on the opposite side ; see the section on Unilateral Lesion, II., No. 14.) for a longer or shorter time. Or the compression may occur on the anterior or the posterior surface of the cord, the result of which is, that in the former case the motor phenom- ena, in the latter the sensory, not only preponderate, but often are exclusively present for a time. After a variable time, the palsy invades all the paths in the portion of the cord adjoining the tumor, and we have the symp- toms of extreme compression of the cord. We shall describe them fully in the section on "Compression of the Cord" (see farther on, II., No. 5), and will therefore mention here only the most important in order to complete the description, referring for all details to that section. First of all there is severe paraplegia; motility and sensi- bility more or less completely paralyzed, up to the level cor- responding to the seat of the tumor; the limitation of these paralytic symptoms upwards is various^ strict. The bladder is paralyzed ; at first the symptoms of retention are prominent, and later those of incontinence, with continuous dribbling. The sphincter ani is also paralyzed. Violent pains in the parts below the seat of lesion usually follow. Although the doctrines of physiology are opposed to the supposition that such excentric pains could originate in com- pression or irritation of the cord itself, yet many observations (as those of Whipham, Leyden, Brown-Sequard) show that violent 272 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. pain of that kind in the legs may be caused by tumors seated in the upper dorsal or the cervical region. It is certain that in most cases the palsied parts are at times the seat of very severe pains, perhaps due to secondary myelitis. In the motor apparatus also, the symptoms of irritation do not fail to accompany those of complete palsy ; muscular twitch- ings, spasms, and contractions—at first temporary, then perma- nent—occur, while the muscles, at first quite relaxed, become by degrees tense and rigid (secondary degeneration of the lateral columns). In many cases there is a remarkable increase of reflex actions. Slight cutaneous irritation produces free and vigorous muscular contractions, powerful flexion or extension, active clonic tremor, more marked in the lower extremities, especially when the tumor is seated at an elevated point. If, however, the gray substance is compressed by the tumor (when located in the lumbar region), the reflex actions are wholly wanting. The same is the case when the gray substance is deprived of its functions by second- ary descending myelitis. For this reason, in the later stages, we often see the reflex activity diminish and disappear, when pre- viously it had been exaggerated. The tendinous reflex acts also seem considerably increased. The nutrition of the muscles is affected in nearly the same way; at first it is well kept up, but afterwards severe atrophy appears. The electrical reaction behaves in the same way; at first well preserved, it may afterwards sink and disappear. Paralysis of the bladder may lead, after a while, to cystitis, with ammoniacal decomposition of the urine and the presence of abundant pus. The absolute immobility of the patient, who is almost always forced to retain the dorsal decubitus, and the frequent befouling of his person with urine and faeces, etc., give rise to gangrenous bed-sores on the sacrum and buttocks, tro- chanters, heels, etc., which often make unchecked progress and produce the most shocking destruction. Chills, with very high temperature—a more or less continuous fever—appear. This, and the loss of fluids caused by the suppu- rating sores, and the loss of sleep and appetite from continual pain and abnormal sensation, continually increase the patient's anaemia TUMORS OF THE SPINAL MEMBRANES. 273 and cachexia, and cause a marasmus which of itself is sufficient to produce the fatal result. Death usually occurs in a state of sopor, with a rising temperature, and often after a very pro- longed agony. In other cases the patient's sufferings are brought to an end by bronchial catarrh or pneumonia, or an acute menin- gitis caused by bed-sores, or other diseases. According to the seat of the tumor, the rapidity of its growth, the patient's power of resistance, the sequence of these symp- toms may be rapid or slow. If the seat is high in the cervical region the course is usually very rapid, parah'sis of the respira- tory nerves producing early death by suffocation. Course, Duration, Termination.—The course is usually slow and insidious, especially at the beginning, and the first period of the disease may last several years. With the occurrence of paraplegia the second period commences ; this often comes on rather quickly, in a few days or one or two weeks, but may require a much longer time. In a few cases it is effected quite suddenly, and is then usually dependent on myelitis—as in a case by Ollivier, in which advanced softening was found after death. After paraplegia has appeared the progress is usually more rapid, but even at this point years may pass before death occurs. This, of course, depends on the rate of growth of the tumor and the height at which it is situated. Temporary improvement is occasionally mentioned, and great fluctuations in the severity of symptoms may be observed ; such are usually referred, for the most part, to the state of the compressive myelitis, but in part also to changes in the volume of the tumor caused by variation in the amount of blood contained, processes of softening, changes in the direction of growth, etc. j. The entire duration cannot always be easily determined, owing to the uncertainty as to the date of commencement. Some cases have terminated fatally in eight or ten months, while others run on for one, three, or five years ; and cases of much longer duration—extending to fifteen years—have been observed. The termination is almost always in death in the manner described. A permanently stationary condition or improvement, or cure, is rarely seen. Yet the possibility of such an event, at VOL. XIII.—18 274 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. least for certain forms, cannot be denied. In syphilomata and scrofulous tumors, in inflammatory new formations, in cysticerci (by shrinking or calcification), it may certainly be admitted, and in the case of others may be held an open point. It will cer- tainly be hard to prove such an event, both because the diagno- sis during life is very obscure, and because in cases which have recovered, it will seldom happen that the spinal canal will be opened post-mortem. Diagnosis. The diagnosis of a meningeal tumor is sometimes quite easy, but usually very difficult, and for a long time uncertain. When the symptoms as above given develop quickly and promptly, and with their full characteristics, or if the disease has passed into the second stage, there is usually no great difficulty. But previous to this point, years of uncertainty and guess-work may pass. And, on the other hand, in cases with slightly marked symptoms, the disease may possess an unlucky resemblance to a great variety of circumscript diseases of the cord, rendering a distinction impossible. The diagnosis chiefl}^ depends on the demonstration of a slowly developed compression of the cord (see farther on, II., section 5), which has been preceded by the signs of a circumscribed ir- ritation or compression of certain portions of the roots. It should be particularly noticed that the symptoms point only to a progression of the paralyzing lesion transversely to the cord, while an extension in the longitudinal direction is not percepti- ble, at least not upwards, while a descent of the process of mye- litis is not rarely observed. This, however, does not make much change in the symptoms. When we have made out the existence of a tumor with some degree of certainty, we may consider ourselves prepared to attack the second and more difficult question as to the nature of this tumor. In settling this question, we are often entirely deprived of guiding-points—especially as the position of the cord renders a direct examination in most cases quite impossible. In many cases something may be found to base a diagnosis upon, and in these, TUMORS OF THE SPINAL MEMBRANES. 275 after a careful estimation of all circumstances, we shall be obliged to follow general pathological principles. We shall infer, for instance, a peripachymeningitic exudation if Pott's disease or a marked scrofula exists; a carcinoma, if there is cancer of the vertebrae or primary cancer of some other part; a syphiloma, if syphilitic infection can be demonstrated; an echinococcus, if the parasite has been found in other organs, or tumors containing the cysts are demonstrated near the spine ; a neuroma, if neuromata are found in peripheral nerves, etc. In most cases, however, we shall be forced to confine ourselves to guesses. It is easier, inmost cases, to define the precise seat of the tumor, or, if there are several of them, at least that of the uppermost. This is done by following the rules we have repeatedly given, and which will be stated more precisely below, depending on the local distribution of the symptoms of irritation and paralysis. We may here add a word upon the tumors of the cauda equina, which usually proceed from the meninges, and have, in every respect, a great resemblance to those which are situated higher and affect the cord proper. They are hard to distinguish from the latter, but may be in many cases, perhaps, if it is borne in mind that tumors of the cauda produce exclusively nerve-root symptoms, and that the signs of compression of the cord, of secondary myelitis, etc., are absent. The higher the tu- mor, the nearer it approaches the lumbar portion of the cord, the harder will it be to draw the distinction. In respect to tumors seated lower, the following points may be attended to: the seat of the pains (which in such cases often attain enormous vio- lence) is strictly localized in certain nerve-districts; all nerves leaving the spinal canal above the tumor are free; thus, in myxo-sarcoma telangiectodes of the cauda, I observed the pain strictly limited to the district of the sciatic, while the crural and the dorsal nerves were perfectly free; constant violent pain in the sacrum. If palsy occurs, the reflex actions necessarily cease at once. Spasms are seldom observed; more frequently contractures. Atrophy of the muscles occurs rather frequently. The palsy and anaesthesia, by their localization, often give us the opportunity of fixing the upper limit of the lesion. Increase of the reflex acts and marked tendinous reflexions, do not occur. Paraplegia, palsy of the bladder, bed-sores, etc., may develop exactly as in tumors occupying a higher seat; but the symptoms of paralysis do not seem to belong necessarily to the disease, as is shown in my case (just mentioned), which terminated fatally before paralysis or anaesthesia occurred. 276 ERB.—DISEASES OF THE SPINAL COBD AND ITS ENVELOPES. Prognosis. It follows from what was said of the course, that the progno- sis of meningeal tumors is very bad in almost all cases. If there are actual neoplastic formations, the prognosis is absolutely bad. In the most favorable case, the disease may cease for a limited time to make progress, or death may be delayed. The more quickly the symptoms develop, the worse for the patient; and the worst is in carcinoma. In some other tumors, in the inflam- matory, scrofulous, hemorrhagic, and syphilitic forms, the prog- nosis is more favorable, and is decided upon general principles. If paraplegia has become complete, the case is usually hopeless. The early or late occurrence of the fatal termination then depends on the rapidity and intensity with which cystitis and bed-sores are developed. The prognosis of each case will depend on the circumstances and constitution of the patient, the possibility of sufficient attention to his wants, on the special prominence of certain symptoms or complications, etc. Treatment. This presents as little encouragement as the prognosis. For the disease properly considered (if there exists a new formation in the strict sense) as good as nothing can be done. Some suc- cess is to be hoped for in inflammatory, syphilitic, scrofulous forms. We should in general attempt to fulfil the causal indica- tion, as far as possible. The object of removing or diminishing the size of the tumor has been sought in a variety of ways, but mostly without success. All sorts of local derivatives have been tried, from painting with tincture of iodine and blistering, to the moxa and the white-hot iron. Internally, it will be proper to try iodide of potassium and ioduretted mineral waters, mercury, arsenic, etc. Some improve- ment in symptoms has been observed from the use of warm springs and brine-baths. As long as such temporary improvement (often lasting for quite a while) can be effected, and while the diagnosis remains uncertain, we shall always be tempted to make new trials. TUMORS OF THE SPINAL MEMBRANES. 277 If the diagnosis and the seat of the tumor are quite certain, we may perhaps consider the question of trepanning the verte- bral column ; but it is seldom that we shall find firm ground for undertaking such an heroic operation. And yet the success of this attempt is by no means beyond the limits of possibility, especially if the tumor lies outside of the sac of the dura, upon its posterior surface. If we are forced to open the dura, the dan- ger is much increased. At all events, the prognosis of the disease is so desperate that we ought to take the operation into consider- ation. Echinococcus cysts, growing from the spinal canal, should be opened and evacuated, or extirpated. In the great majority of cases, the chief object will consist in general attention to the patients needs, and treatment of the symptoms. In respect to the former, we have nothing to add to what we said in the general part of this work. Above all, we ought to prevent cystitis and bed-sores if possible, and to keep up the strength of the patient. As regards symptoms, the pains should be the first and con- stant object of treatment; they often bid defiance to all remedies, and enormous doses of morphine are usually required to render the patient's life tolerable. The entire range of narcotic and anti-neuralgic remedies must be tried. For the paralytic symp- toms nothing can be done directly. Cystitis and bed-sores are to be treated upon general principles. Addendum. Anatomical Changes in the Spinal Membranes, without Clini- cal Significance. Various changes in the spinal membranes are known to pathological anatomy which seem to produce no symptoms during life; sometimes they are senile changes, sometimes slight incidental inflammatory or degenerative disturbances, which remain without symptoms as long as they affect the membranes alone and do not involve the roots or the cord. These matters are about equal in importance to pleuritic adhesions in the respiratory apparatus. The physician, however, ought to know them, in order not to interpret things 278 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. which are usually innocent as the cause of symptoms observed during life. They are therefore briefly enumerated in this place. 1. Bony and cartilaginous disks in the arachnoid are very often found. These are small, roundish or angular plates, flat, from six to fifteen millimetres in diame- ter, somewhat thicker in the middle, and sharp on the edges. Their number in the arachnoid varies; they are especially frequent in the lumbar part and on the poste- rior surface of the cord, often composing a literal mosaic. While Ollivier' con- sidered them as purely cartilaginous, Virchow2 has shown that they consist of young bony tissue, and have a structure which agrees for the most part with that of the cartilage of bone; a striped basement substance in strata, inclosing star-shaped bodies, and passing by calcification directly into bone-tissue. Their outer surface is smooth, their inner more rough and jagged, so that they feel like a cat's tongue. In most cases they give rise to no symptoms whatever. In advanced age they are almost always present. They are often found in young persons who have ex- hibited no spinal symptoms. They certainly point to an irritative condition of the meninges, especially if they exist in large numbers. They are probably referable to slight, often-repeated irritation. The connection with epilepsy, formerly imagined to exist (Esquirol, Ollivier), is at all events very doubtful. 2. Diffuse ossification of the spinal membranes occurs now and then, but seems destitute of clinical significance. Diffuse ossifications have been described in the dura (Andral, Virchow), and small osteophyte elevations are also seen in the same membrane; the deposition of brain sand [corpp. arenosa] in the exudations with thickening of the dura (pachymeningitis arenosa3) may perhaps be included here. 3. The pigmentation of the pia may often reach so high a degree as to become pathological. Pigmented corpuscles of connective tissue are often found in the pia soon after puberty, especially in the cervical region. In marked cases this may give rise to a diffuse, slightly brownish, smoky gray or blackish coloration.4 A gradual transition from this state to actual melanoma has been observed. The simple pigmentation is destitute of pathological importance, and has no demon- strable connection with inflammation, or with epilepsy, as was formerly supposed. 4. Small tumors of all sorts may exist innocuously. Fibromas, cysts, melanomas, neuromas, etc., from the size of a hemp-seed to that of a pea, have been repeatedly observed in the cauda and the membranes without accompanying symptoms. This is very easily understood. 5. An increased amount of spinal fluid must not be regarded as a necessary cause of decided disturbances of function. Such an increase is most frequent (hydrorrhachis externa5) in the meshes of the arachnoid in connection with atrophy of the cord. As long as this has the char- acter of normal spinal fluid, its increase is not of any great importance. But if it is turbid, of a reddish or whitish tinge, contains numerous cell-elements, blood- 1 Loc. cit. 3. Aufl. IT. p. 466 seqq. 3 Virchow, ibidem. II. p. 117. 2 Geschwulste. II. p. 92. 4 Ibidem. II. p. 120. 5 Virchow, Geschwulste. I. p. 175. HYPEREMIA OF THE CORD. 279 corpuscles, etc., its increase is due to an increase of irritation or to a considerable blocking of the circulation of the spinal membranes, and then represents simply a portion of the general morbid process. But even then there is no reason for referring the cause of severe symptoms exclusively to the pressure of the increased volume of spinal fluid, as was formerly often done. II. Diseases of the Spinal Cord proper. Introductory.—Before entering upon the special considera- tion of these diseases, it will be suitable to give a reason for the order and distribution of the material which we have adopted. We cannot pretend, in the present state of our knowledge, to make a strictly scientific division of diseases of the spinal cord. To base such a division upon strict principles of pathological anatomy would be completely impossible, as we are in the dark with reference to the significance of many processes, and in many diseases are ignorant of any anatomical basis. A division by special localities is equally impossible, for in many diseases we are quite ignorant of the exact locality, and in other cases such an arrangement would involve a great deal of repetition. We must, therefore, resort to such methods as are convenient. It seemed to us that for practical purposes we ought to pre- sent as full an account as possible of the important parts of spinal pathology, without too much detail or repetition. The principle adopted is simple and intelligible, and sufficiently con- sistent with the rules of logic. In the first group, comprising eleven sections, we shall speak of the processes which occupy, or may occupy, the entire trans- verse section of the cord in a diffuse way; processes which do not, at any rate, either necessarily or regularly, imply a limita- tion to certain portions of the transverse section. They may extend longitudinally to various distances. They comprise hy- peraemia, anaemia, and hemorrhage of the cord, acute severe trau- matic lesions, and slow compression of the cord (Nos. 1-5). Then follow three diseases: concussion of the cord, spinal irri- tation and spinal nervous debility (Nos. 6-8), in which we are 280 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. aware of no anatomical changes, but are allowed to suppose at any rate fine disturbances of nutrition, which, more or less dif- fused in the transverse and longitudinal directions, are certainly not attached to certain parts of the transverse section. In Nos. 9-11 we shall present the inflammation of the cord (acute and chronic), simple softening, and that peculiar anatomi- cal change commonly known as sclerosis in patches—processes which likewise do not derive their characteristic features from their connection with any certain portion of the transverse sec- tion. In the second group (Nos. 12-16), we shall treat of those forms of disease, as far as known, which are marked by their more or less strict localization in certain portions of the transverse sec- tion of the cord, while their extension in the longitudinal direc- tion may greatly vary and change. To this class belong the degenerative processes in the posterior columns, in the lateral columns, and the lesions which are limited to one lateral half of the cord; also the acute and chronic processes confined to the gray anterior cornua. Under No. 17 we shall describe acute ascending paralysis, a form of disease still perfectly obscure, which, for the better un- derstanding of it, we shall place after the above-named diseases. The placing of tumors, secondary degenerations, and malfor- mations of the cord (Nos. 18-20) at the end of this series is justi- fied by their less frequent occurrence and importance, and the impossibility of including them directly in either larger group. Finally, in No. 21, we present a number of scattered facts, which have an undoubted, though in many cases an obscure con- nection with the pathology of the cord, and which deserve to be collected as material for the further development of the subject. As inducements to further investigations and researches, they may be granted a little space. 1. Hyperaemia of the Cord. We have already spoken of this, as indistinguishable from the same condition of the membranes, either by anatomical or ANAEMIA OF THE CORD. 281 clinical tests ; and would refer the reader to the complete account given on page 199 et seq. 2. Anaemia of the Cord. Hasse, loc. cit. 2. Aufl. p. 652.—Hammond, loc. cit. 3d edition, p. 396.—M. Rosen- thal, 1. c. 2. Aufl. p. 290.—Leyden, 1. c. II. p. 27.—Jaccoud, Les paraplegies et l'ataxie du mouvement. Paris, 1864. p. 293 et seq. N. Stenon, Element, myologise specimen. Flor. 1667.—Kussmaul and Tenner, Un- ters. iiber Ursprung und Wesen der fallsuchtartigen Zuckungen bei Verblutun- gen, etc. Molesch. Unters. zur Naturl. III. 1857. p. 59.—Schiffer, Ueber die Bedeutung des Stenson'schen Versuchs. Centralbl. f. d. med. Wiss. 1869. Nos. 37 and 38.—Ad. Weil, Der Stenson'sche Versuch. Diss. Strassburg, 1873.— Romberg, Lehrbuch der Nervenkrankh. 2. Aufl. I. 3. p. 2.—Barth, Oblitgrat. complete de l'aorte. Arch. gen. 1835. VIII. p. 26.—Gull, Paraplegia from Obstruction of the Abdom. Aorta. Guy's Hosp. Rep. 3d series. III. p. 311. 1858.—Cumings, Paraplegia from Arteritis. Dubl. Quart. Journ. May, 1856.— Panum, Zur Lehre von der Embolic Virch. Arch. XXV. 1862.—Brown- Sequard, Loctures on the Diagnosis and Treatment of the Principal Forms of Paralysis of the Lower Extremities. London, 1861.—Sandras, Traite des mala- dies nerveuses. Paris, 1851.—Service of Grisolle: Paraplegie apres une m£tror- rhagie considerable. Gaz. des hop. 1852. No. 108.—Moutard-Martin, Para- pl6g. causees par les hemorrh. utgrines ou rectales. Soc. med. des hop. 1852. Union m6d. 1852.—Abeille, Etudes sur la paraplegie indep. de la myelite. Paris, 1854.— Van Bervliet, Observ. de paraplgg. chlorotique. Annal. de la soc. m6d. de Gand. 1861.—Mordret, Traite prat, des affect, nerveuses et chloro- anfimiques. Paris, 1861. Definition.—By anaemia we understand a diminution in the amount of blood contained in the cord; and this may consist of: a. Diminution or complete suspension of the arterial supply to the cord—ischoemia ; or, b. Deficiency of blood in the cord, owing to the diminution of the total amount of blood, and bad crasis (oligaemia, hydraemia, etc.), and usually named anaemia without further definition. The first form has been experimentally studied, and has been in single cases made the object of clinical study. The second form is still less distinct clinically, owing to the frequent want of prominence of the spinal symptoms, and to simultaneous disturbances, cerebral and otherwise, originating in the anaemia, and obscuring the spinal symptoms. 282 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. It is plain that there are many transitional forms between these two, and that a sharp distinction is not always feasible, although we shall attempt to make it in the following presenta- tion. Both forms lead to the same result, although in some cases it may be developed quickly and in others slowly; the nutrition of the substance of the cord will suffer more or less, and this will bring about the corresponding disturbances. Pathogenesis and Etiology. The conditions which may produce a marked predisposition in certain persons to anaemia of the cord are not fully studied. Various points may, however, be mentioned wdiich deserve future attention. For instance, congenital narrowness of the calibre of the circulation, shown by Virchow to be so frequent an occurrence in chlorosis ; also congenital or acquired weakness of the heart; and finally, an undue excitability of the vaso-motor nerves, so common in nervous persons, which may sometimes be most marked in the cord. It is a fact which may be connected with these circumstances, that the female sex seems specially predisposed to certain forms, at least, of spinal anaemia. Dis- eases of the vessels of the cord also, which are of quite frequent occurrence, doubtless give rise to a certain predisposition to anaemia. I am inclined to refer to anaemia of the cord those slight attacks of feebleness of the lower extremities which are found in old people with marked atheroma of the arteries. The direct causes of spinal anaemia are better known. The first group embraces all those causes which produce a contraction or closure of the- afferent arteries of the cord (para- plegies ischemiques of Jaccoud). Of these we must first name compression, thrombosis or embolism of the abdominal aorta above the point of departure of the lumbar arteries. It leads to a severe ischaemia of those segments of the cord which receive branches from the corresponding lumbar and intercostal arteries. It has very long been known that compression of the abdominal aorta is fol- lowed very quickly by paralysis of the posterior half of the body (Stenson's experi- ment). The paralysis occurs a few moments after the compression begins, and was ANAEMIA OF THE CORD. 283 referred by a^. the earlier observers to a peripheral disturbance of the nutrition of nerves and muscles. Kussmaul and Tenner have, however, shown that anaemia of the cord leads to palsy much more rapidly than anajmia of the nerves and muscles. Schiffer has tested the question again, and has decided that anaemia of the cord itself is certainly the immediate cause of the palsy, that the nerves and muscles in this case remain excitable for a long time, and that in case of compression at a lower point, the paralysis occurs much later. It is also true that when the com- pression lasts a considerable time, paralysis of the cauda equina, the peripheral nerves and muscles follows. A. Weil has confirmed Schiffer's statements in all essential points. Such ischsemic paraplegias have been seen to occur in the human subject, in the rare case of thrombosis and embolism of the aorta (Barth, Gull, Leyden, Tutscheck, and others), although it is not always possible to decide whether their origin is spinal or peripheral. IVirombosis and embolism of given spinal arteries can only lead to quite circumscribed ischaemia, owing to the numerous arterial supplies which the cord possesses. This cause has been studied experimentally by Panum, but in man has been only accidentally observed, and its pathogenetic import is not yet sufficiently de- fined. Leyden has found capillary embolism of the cord in ulcerous endocarditis. It is still uncertain whether spasm of the spinal vessels can produce anaemia of the cord ; the fact is not well established, though not quite improbable. We may assume that a direct irritation of the vaso-motor paths concerned produces this kind of ischaemia; but the theory has been more generally accepted that irritations of peripheral organs, due to all sorts of causes, may produce such vascular spasm in the reflex way ; and this may be the origin of a great many of the so-called " reflex paral- yses." The latter view has been developed into a theory of "reflex paralysis" by Brown-SSquard in particular. The peripheral irritation causes a contraction of the spinal vessels, of various duration, which gives rise to palsy and a more or less per- manent disturbance of nutrition in the cord, as has been observed by Kussmaul and Tenner, and by Schiffer, to occur after simple compression of the aorta, if contin- ued for a sufficient time. Although it is not certain that such a permanent and severe spinal vascular spasm occurs, as is demanded by Brown-SSquard's theory, and although on the other hand many "reflex paralyses" can be referred to severe disturbances of nutri- tion, yet a transitory spasm of the spinal arteries is by no means inconceivable. 284 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Vaso-motor spasms of the skin of the extremities may last for hours and daye,1 and why not in the cord also ? And if such a thing occurs, severe disturbances must occur in the fine and delicate processes of nutrition of the central apparatus. It is self-evident that mechanical pressure upon the cord may produce ischaemia in a corresponding portion; in such cases, however, the symptoms are referable rather to pressure upon the nerve-elements than to compression of the blood-vessels. The second group of direct causes embraces all such as di- minish the total amount of blood, or cause a decided change in its composition, with a tendency to oligocythaemia, hydraemia and allied disturbances. (A portion of Jaccoud's paraplegies dyscrasiques.)' Upon the whole, the existence of severe spinal symptoms, especially of paralyses, in these conditions is comparatively rare, and the causal relation between the anaemia and the paralysis which follows is not always perfectly clear. It seems at first strange that the lower extremities should be almost exclusively affected ; but a closer consideration show's, as Jaccoud has admi- rably stated, that the fact is probably due to the greater claims usually made upon the activity of the legs at all times, which causes any general weakness to show first in them. It will also remain undecided in many cases whether and to what extent the symptoms of weakness depend on anaemia and disturbances of nutrition in the peripheral nerves and muscles. For this reason cases must be read with some caution. Several cases are described in which paraplegia followed great loss of blood, as in parturition, metrorrhagia, bleeding from the kidneys and intestine, epis taxis, etc. Jaccoud quotes such cases from Grisolle, Moutard-Martin, Abeille, Landry, and others. A similar effect is produced by great loss of blood, severe acute diseases, inanition, etc., which injure the nutrition of the cord by producing great anaemia. In chlorosis, states of weakness and palsy have been observed and referred to anaemia of the cord; such cases are rather fre- quent, though not so in comparison with the frequency of chlo- rosis itself. Jaccoud quotes such from Dusourd, Bervliet, Bou- 1 See Nothnagel, Vasomotorische Neurosen. Deutsches Arch, f. klin. Med. II. ANAEMIA OF THE CORD. 285 chut, Mordret, Landry, and others, and includes the paraplegia of pregnancy in the list. It appears that only quite severe cases of chlorosis cause such paraplegia. Pathological Anatomy. Anaemic portions of the cord look pale, bloodless, white ; no points of blood appear on their cut surface, and no full vessels are to be seen ; the gray substance is strikingly dull in color, and sinks a little upon the section ; the white is often found very soft and semifluent, and pushes out above the cut surface. There are, however, reports of cases in which the substance of the cord was found somewhat firmer and more resistent than usual. Perhaps these were different stages of the same change. The membranes also appear pale, their vessels partly empty and not easy to see. A distinct contrast to this is afforded by those sections of the cord in which the circulation is retained, which look of a rosy color and are harder in consistence ; an increased injection, with extravasations of blood, is often observed in the neighborhood of anaemic portions. In general anaemia the cord is usually anaemic also. It is not always easy to avoid confusing these phenomena with post-mortem appearances ; anaemia will therefore be con- sidered to have existed during life only when all the circum- stances which produce it in a corpse can be shown to be absent, such as a certain position, cadaverous swelling of the medul- lary substance, etc. In thrombosis and embolism of the small spinal vessels it is often possible to find the point of occlusion. Red softening exists in the region supplied by the plugged artery, and in its vicinity collateral fluxion. This has been found chiefly in ani- mals. Tuckwell has found similar appearances in man. Leyden observed microscopical embolic foci in ulcerous endocarditis. If the ischaemia is protracted, secondary changes occur— white and yellow softening of the corresponding portion of the cord, localized breaking-down, stasis of blood, etc. The minute 286 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. changes in nutrition which appear in a short time are not acces- sible to a pathologico-anatomical examination. Symptoms. Before describing anaemia of the cord, let us consider such facts as are derived from experimental physiology, and which, at least in the case of the acute ischaemic form, furnish us abun- dant information. When the aorta is compressed, motor and sensory palsy of the legs immediately occurs, the reflex acts cease, the bladder and rectum seem paralyzed. When the circulation is restored, improvement in these respects is slow in proportion to the dura- tion of the compression. Precisely the same symptoms occur in man after embolism of the aorta—rapid palsy of the legs, sphincters, reflex function, etc. Gull's case, in which he observed paralysis to occur in a few minutes, is an especially good instance of paraplegia from aortic obstruction. In most other cases of this class it is less easy to affirm that the paralysis originates from spinal anaemia; it is rather probable that the disease has a peripheral origin (see the cases of Romberg, Cumings, Leyden, Tutscheck, et al.). If the contraction of the aorta develops by slow degrees, the disturbances are of a gradual and less severe nature—slight feel- ing of numbness and of a limb asleep, weakness of the lower ex- tremities, which are easily fatigued when severe exertions are made. The symptoms of closure of the aorta become more and more distinct—absence of pulse in the crural arteries, coldness and oedema of the feet, enlargement of collateral arteries, etc.— symptoms which in acute cases appear very quickly. Here must be included a series of cases which present the symptom of inter- mitting lameness or palsy. In these no change is observed while the patient is at rest; but when he takes a brisker walk than usual, it is followed by distinct weak- ness or even palsy, which disappears when he takes rest, and again returns when he renews his muscular efforts. Such symptoms have been observed in horses, and are accounted for by occlusion of the aorta. A similar thing has been seen in man (Charcot, Frerichs—intermittent palsy in one lower extremity), the cause of which is also doubtless referable to the closure of one iliac or the aorta. But these seem ANAEMIA OF THE CORD. 287 to be only cases of peripheral palsy; the muscles, imperfectly supplied with fresh blood, become incompetent to their duty where severe exertions are demanded, while they are still able to perform a slighter task. All that has been said applies only where the ischaemia is sit- uated in the lumbar region of the cord. We know nothing in regard to the symptoms of ischaemia of the cervical part. Clo- sure of both vertebral arteries might be followed by ischaemia in this case also; but the derangement of the cerebral functions and those of the medulla oblongata would then probably be so severe as to mask the spinal symptoms, and death would follow speedily. The symptoms of vaso-motor ischaemia of the cord must be the same, but they can hardry be so severe. We know nothing with precision in regard to them, excepting those symptoms of "reflex paralysis" which are said by Brown-Sequard to origi- nate in this way. It is said to be characteristic of these paraly- ses that they originate in peripheral irritation, that variations in the severity of such irritation are followed by corresponding fluctuations in the symptoms of palsy, and that the latter often disappear when the former cease. It is evident how imperfect is this characterization. Anaemia originating in thrombosis and embolism of small arteries probably gives rise to merely local and subordinate symptoms, about which nothing is known definitely. If large spots of softening are formed, the symptoms of circumscribed destruction of the cord follow, which will vary somewhat accord- ing to the seat of lesion; we shall come back to these in the sec- tion on Softening of the Cord, No. 10, farther on. In the second group of cases of spinal anaemia the number of symptoms of anaemia is so great, involving most of the organs of the body, as to make it hard to sift out those proper to the affec- tion. The most constant seem to be those of motor weakness— weakness and great fatigue, which forbids all severe exertions, slight tremor when even the least muscular work is performed, and in the higher degrees, severe paresis, and at last paralysis. All this usually begins in the lower extremities, and extends very gradually to the trunk and arms. 288 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. The sensibility is usually intact; but paraesthesia of every sort, pain, and hyperaesthesia or slight anaesthesia occur. The reflex actions are often exaggerated ; only in the severest cases are they depressed. The sphincters do not seem to be usually affected, unless the severest anaemia with full paraplegia has been developed. At the same time, the most marked symptoms of general anaemia or developed chlorosis exist. It is said to be a marked characteristic of this form, that the symptoms are improved by continued lying down, which favors the flow of blood to the cord; changes of circulation produce the same effect upon the severity of the symptoms. It is impor- tant to note in conclusion that a tonic treatment with iron and stimulants quickly improves such cases. Hammond has tried to prove that the so-called spinal irritation depends on a local hyperaemia of the posterior columns. "We shall return to this point in speak- ing of spinal irritation (see farther on, No. 7). Course, duration, termination.—The disease may begin rap- idly and acutely, as in embolism, severe loss of blood, etc. At other times it is slower and more gradual, as in thrombosis, chlo- rosis, etc. ; the symptoms at first do not appear until certain efforts are made, but become by degrees more distinct and per- manent until the disease is fully developed. In its further course the patient either recovers rapidly, by the establishment of collateral circulation or regeneration of the lost blood, or perhaps by relaxation of a vaso-motor spasm; Or, after long fluctuation, a slow recovery occurs, especially when the circulation becomes free after having been disturbed for a sufficient time to leave considerable impairment of nutri- tion ; Or, finally, return to a normal state is impossible, the cord softens, producing all the symptoms of severe spinal paralysis, in the midst of which death at last occurs. Of the duration of the disease nothing need be said, as it may vary very greatly according to the cause, the possibilities of repair, the development of secondary changes of nutrition, etc. ANAEMIA OF THE CORD. 289 Diagnosis. We are not entitled to infer the definite existence of spinal anaemia from the above symptoms, unless the causes are clear. The acute ischaemic form often commences quite like a spinal hemorrhage or an acute myelitis ; the diagnosis becomes proba- ble only when the aorta can be proved to be closed, or a great loss of blood has recently occurred; and it may be confirmed by the rapid and favorable course of the disease. We have already said that an intermittent character of the paralytic symptoms could not probably be referred directly to anaemia of the cord. The chronic anaemic forms (dyscrasic) resemble chronic myeli- tis, or very slow forms of chronic meningitis, etc. If, however, chlorosis or severe general anaemia exists, we shall naturally think first of anaemia of the cord. The fact that the horizontal position relieves the symptoms may perhaps be made of use in the diagnosis ; but usually the decisive test will have to be fur- nished by the result of treatment. Vaso-motor ischaemia is probably hard to distinguish. Believ- ers in Brown-Sequard's theory of reflex paralysis will refer to it when peripheral irritation exists (diseases of the organs of uri- nation or digestion, or of the uterus, etc.). The idiopathic forms require some further study and proof. Prognosis. This depends chiefly on the causes, and on the possibility of removing them. We shall, therefore, have to decide the ques- tion on general principles. Of itself, spinal anaemia is nothing serious. If it has not lasted long, or has never been extreme, the prognosis is quite good ; especially so in chlorosis. But a severe anaemia may badly impair the nutrition of the cord, even when the disease has lasted but a short time, and may cause injuries which require a long time for their repair. Experi- ments have sufficiently proved this, and we ought, therefore, to be cautious in making the prognosis of such cases. If it be impossible to restore the circulation, and if softening VOL. XIII.—19 290 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. has once occurred, the prognosis is bad, provided large portions of the cord are affected. If there is softening of small portions of the cord, the prognosis should depend on the size and location of such spots. Treatment. Here the first point is the causal indication. If we succeed in removing the causes of spinal anaemia, the chances of restora- tion increase considerably. The reader is, therefore, merely reminded of the treatment of aortic thrombosis and embolism (proper position, stimulation of the function of the heart, etc.), of chlorosis and anaemia (tonics and iron), and of general nerv- ousness ; of the removal of sources of peripheral irritation, etc. These measures will generally include the chief part of the treat- ment. As direct measures for the relief of anaemia of the cord, we would recommend a suitable position, in order to favor the flow of blood to the cord. Brown-Sequard strongly recommends the dorsal decubitus, with raised head, arms, and legs ; and this should be maintained during the night, and several hours in the daytime. Drugs which increase the flow of blood to the cord, especially strychnia, opium, and nitrite of amyl. Brown-Sequard recom- mends strychnia above all others, and Hammond strongly sup- ports the recommendation ; he gives it in increasing doses (0.002- 0.015, [fa to | of a grain], three times a day), or, still better, in combination with phosphorus (extract of nux vomica 0.02 [^ of a grain], phosphide of zinc 0.006 [fa of a grain]). Galvanization of the spine, with the object of dilating the vessels of the cord and improving the spinal nutrition. Ham- mond especially recommends the ascending stabile current. Application of warmth to the back, by means of hot sand- bags, or Chapman's bags filled with hot water. For vaso-motor ischaemia, alternate cold and hot douches are recommended. We shall also seek to fulfil the symptomatic indications (relief of pain, paralysis, disturbances of circulation, etc.) by the usual remedies and methods. SPINAL APOPLEXY. 291 The diet and regimen must be governed by the existing indi- cations and circumstances. 3. Hemorrhage in the Substance of the Spinal Cord—Hae- malomyelia {Hoematomyelitis) — Hoemorrhagia Medullce Spinalis—Spinal Apoplexy. Compare the repeatedly• quoted works of Ollivier (1J. p. 167), Jaccoud (p. 251), Hasse (p. 667), Hammond (p. 440), M. Rosenthal (p. 292), and Leyden (II. p. 54). Also E. Levier, Beitr. zur Pathologie der Riickenmarksapoplexie. Diss. Bern, 1864 (con- taining all the older cases).—Hayem, Des hemorrhag. intra-rhachidiennes. Paris, 1872 (list of cases complete to that date).—Breschet, Hfiniatomye'lie. Arch, de me*d. XXV. 1831.—Grisolle, Rev. hebdom. des progr. des sci. med. 1836. No. 3.—Monod, De quelques maladies de la moelle Spin. Bull, de la Soc. anat. 1846. No. 18.—Cruveilhier, Anatom. pathol. livr. III. pi. VI.—Gendrin, De l'apoplexie rhachidienne. Gaz. des hop. 1850. No. 48.—M. Trier, Hosp. Med- delelser. Bd. IV. 1852 (quoted in Levier. Schmidt's Jahrb. Bd. 78. p. 293). —Lebcau, Cas d'hfimatomyelite. Arch. belg. de m6d. milit. Janv. 1855.— Barat-Dulaurier, Sur les hgmorrh. de la moelle. These. Paris, 1859.—Duriau, De l'apoplexie de la moelle epin. Union m€d. 1859. Nos. 20-25.—Brown- Sequard, Paralysis of the Lower Extrem. p. 86. 1861.—Colin, Hthnorrh. de la moelle. Soc. m6d. des hop. 1862.—Mouton, Consid. sur rhfimorrh. rhachid. These. Strasb. 1867.—Schuetzenberger, Apoplexie spinale. Gaz. med. de Strasb. 1868. No. 5.—Koster, De pathogenie der apoplex. niedull. spin. Nederl. Arch. voor Geneesk. IV. p. 426. 1870.—Gorsse, De riifimorrh. intramedull. etc. These. Strasb. 1870.—C. O. Joerg, Fall von Spinalapoplexie. Arch. d. Heilk. XI. p. 526. 1870.—Bourneville, Hemorrh. de la moelle ep. Gaz. mSd. de Paris. 1871. No. 40.—Liouville, H6matomy61ie avec angvrysmes. Soc. de Biolog. 1872.—Erb, Ueber acute Spinallahmung. Arch, fur Psychiatrie u. Nerven- krankh. V. 1875. Baob. 5. p. 779.—H. Eichhorst, Beitr. zur Lehre von der Apo- plexie in die Riickenmarkssubstanz. Charite-Annalen I. (1874) p. 192. Berlin, 1876.—E. Goltdammer, Zur Lehre von der Spinalapoplexie. Virch. Arch. Bd. 66. 1876. Definition.—The above titles include any kind of extravasa- tion of blood in the substance of the cord proper. This is as rare as meningeal hemorrhage, one important reason for which is cer- tainly the low and comparatively constant pressure of the blood in the small spinal arteries. The intra-medullary hemorrhages are seated almost exclu- sively in the gray substance ; their occurrence in the white sub- 292 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. stance is rare, and perhaps is never spontaneous and primary. Their extent is usually small, but is often considerable, and may reach to the whole length of the gray axis. In these diffuse cases, it seems at present quite doubtful (Charcot, Hayem, Koster) whether the affection is a primary idiopathic hemorrhage, and not rather a hemorrhagic myeli- tis. This is certain, at least, that a great deal has been classed as haematomyelia which is not included under spontaneous and primary bleeding ; such cases will have to be sifted in future. It is, no doubt, correct that in many cases of haematomyelia there is simply a myelitis complicated with hemorrhage (myelitis cen- tralis haemorrhagica) ; but this ought by no means to be so ex- tended as (with Hayem) to include all bleeding in the substance of the cord, and make it depend on previous myelitis. We are decidedly of the opinion, particularly upon the ground of clini- cal symptoms, that primary hemorrhage of the cord also occurs, though the way for it may often be prepared by the occurrence of slight alterations in the vessels or the cord. A case which seems to us to be very convincing in this regard is the one lately published by Goltdammer. The chief symptoms,. and the course of the disease, are so alike in both forms that we may treat of them together. We shall, however, return to the inflammatory hemorrhages of mye- litis at a later point. Pathogenesis and Etiology. Our knowledge of predisposition to hemorrhage of the cord is very scanty. The small number of cases hitherto reported seem to show that youth and middle age are the most frequently attacked (as the largest number occurred between the ages of ten and forty), in opposition to cerebral apoplexy, the frequency of which increases with advanced age. Men are attacked much oftener than women, probably on account of their modes of life. It is not known how far the occurrence of the bleeding is fa- vored by the existence of heart disease (hypertrophy of the left ventricle), spinal curvature, etc. SPINAL APOPLEXY. 293 It is, however, certain that disease of the spinal vessels (thickening, fatty deposits, increase of the nuclei in the walls, aneurysmal dilatation—Liouville) constitutes an important pre- disposing cause. The same is true of chronic affections of the cord proper (chronic myelitis, progressive muscular atrophy, tumors, etc.), which often are brought to a sudden close by hemorrhage. The influence of these circumstances may reach so far as to give rise to apparently spontaneous bleeding, for which reason we shall again speak of them among the direct causes. Among these direct causes we have to name, in the first place, surgical injuries. Spinal apoplexy has been known to be caused by a fall or blow upon the back, by vertebral fractures and dis- locations, by violent shocks in riding, by a fall down-stairs, etc., without any direct traumatic lesion of the cord. In the second place, all circumstances which produce a strong active congestion of the cord. Such are exposure to cold, sexual excesses and masturbation, extreme exertions of body, and the like. Fluxions originating in the collateral way ought also to be included, as the cases of spinal apoplexy following retention or suppression of the menses (Levier, Schuetzenberger), or sup- pressed hemorrhoidal bleeding, or those which occur in the neighborhood of inflammatory processes in the vertebrae, the dura, etc.; and with these should be included the spots of red softening which originate in embolism of the spinal arteries. And finally, inflammatory congestion, which so often leads to capil- lary hemorrhage in acute central myelitis and similar conditions. Anything which produces a disproportion between the pres- sure within and that without the blood-vessels may give rise to hemorrhage in the cord. When the pressure of the atmosphere is rapidly lessened (in going out of caissons where the air is com- pressed, used in the construction of bridges, or out of diving- bells), symptoms have been seen which indicated spinal apo- plexy, but this has not yet been confirmed by autopsies. A considerable increase of the blood-pressure acts in a similar way ; such increase occurs in the case of excessive cardiac action, or in a more passive way it is due to impediments to the circulation in diseases of the heart and lungs, to sudden severe bodily exertion in lifting heavy burdens, in severe spasms, etc. 294 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Another group may be formed of those causes which lessen the resistance of the walls of the blood-vessels, and thus give rise to bleeding. Here should be mentioned the aneurysmal dilatations of minute vessels, as found by Griesinger and Liouville; the fatty degeneration, thickening, multiplication of nuclei, etc., in the walls of the small arteries, which are often found in micro- scopical examination of the diseased cord; perhaps also the chronic processes of softening and inflammation in the cord, and tumors of the cord (especially the soft myxoma and myxosarco- ma), in the interior or vicinity of which bleeding so often occurs. We must include here also the bleeding which in rare cases accompanies hemorrhagic affections (scorbutus, hemorrhagic small-pox, etc.), or acute infectious diseases (typhoid, yellow fever3 malarial diseases, etc.) Pathological Anatomy. The bleeding is mostly confined—in many cases exclusively so—to the gray substance, and in it attains very various dimen- sions. It may involve the gray cornua or the entire transverse section of the gray substance, and may extend to various dis- tances longitudinally. Bleeding in the white substance is much rarer, and is almost always combined with bleeding in the gray. Two sorts of extravasation may be distinguished by their vis- ible characteristics, which may coexist, but in origin and appear- ance are essentially different. 1. The hemorrhagic {or apoplectic) clot.—We find a clot of blood, of variable size, as big as a pea, an almond, or at most a nut; often showing through the pia as a bluish lump, while the pia is pressed up and often burst by the pressure, so that blood is found in the subarachnoid space. The clot itself is composed of blackish red blood, coagulated, and sometimes fluid in the centre. The substance of the cord is broken down to a corre- sponding distance, and forms a sort of ragged wall around the clot. An envelope of white substance commonly surrounds the clot; it is tinged with blood (red or yellowish) to a greater or less distance, so that the boundary between the clot and the sound SPINAL APOPLEXY. 295 tissue is largely obliterated. The clot sends out processes to various distances in the gray substance, and between the bundles of white fibres. The clot is almost always greater lengthwise of the cord ; the globular form is usual only in very small extravasations; con- siderable portions of the gray columns are commonly affected, pro- ducing what is called a tubular hemorrhage. One single clot is what is usually found, but several, or many, sometimes occur. The cervical and upper dorsal region is by far the most fre- quently affected, though of course not always. The microscope shows a great number of blood-corpuscles in all stages of decomposition and change; pigment granules and pigment crystals, fibrin, broken-down medullary elements, glob- ules of myelin, and usually granular corpuscles also. The clot undergoes a series of further changes in time; it either thickens and slowly dries up to a crumbly, caseous lump, the origin of which is denoted by its color and the presence of crystals of haematoidin, or the process of softening and fluidifi- cation occurs, so that at the last a hard capsule of connective tissue is found filled with serous or atheromatous contents. Smaller extravasations may doubtless be absorbed, for the most part, and leave behind only a small cicatrix of connective tissue, colored ochre-yellow by deposits of crystalline pigment. Secondary disease of the cord is very often found in the neighborhood of the clot. This most frequently consists of soft- ening, which extends to various distances up and down, often to nearly the whole length of the cord. Hemorrhagic softening of the gray substance is especially frequent, by which it is changed into a porridge-like mass, sometimes reddish black, sometimes of a chocolate color, and sometimes of an ochre-yellow (see the drawing in Cruveilhier); in these cases there probably always exists a primary central myelitis. But simple white softening also occurs in the neighborhood of the clot; it is to be recog- nized by its characteristic appearance to the naked eye, and microscopically by the numerous granular corpuscles, broken- down nerve-fibres and ganglion-cells, the vessels in fatty degen- eration, and the proliferation of neuroglia. In older cases we find secondary ascending and descending degeneration of the 296 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. posterior and lateral columns, presenting the same characteristics as in other limited disease of the cord (Goltdammer). 2. Hemorrhagic infiltration or softening ; inflammatory hem- orrhage. This likewise occurs in the gray substance exclusively, and is either limited to certain cornua or extends over the entire section, but rarely spreads to the white substance. It has been seen with an extent of a few centimetres, and again, reaching the whole length of the cord. The gray substance is changed to an atheromatous mass, red- dish brown, dotted with darker, blackish red points, and small coagula; the blood is intimately mingled with nerve-substance. Around about the place, at various distances, the cord is tinged unevenly of a rusty or ochre color. The microscope shows essentially the same elements that exist in the clot, but with a greater prevalence of granular corpuscles ; traces of growth of connective tissue and of histological changes in the nerve-fibres and ganglion-cells are also found. The latter can usually be traced in the gray matter far beyond the limits of the hemorrhagic infiltration ; they comprise soften- ing, accumulation of granular corpuscles, thickened and swollen axis-cylinders, like strings of beads, enormously swollen ganglion- cells (Charcot), abundant proliferation of connective tissue, excess of blood in the smallest vessels, some of which are en- larged into ampullae (Liouville), while in other cases their walls are thickened and degenerated—in a word, acute central mye- litis. Of the further changes occurring in such hemorrhagic infiltra- tions nothing precise is known, for autopsies are usually made at an early period. Capillary hemorrhages proper—small punctated extravasations, easily recognized —are rather common; they are not specially important, and give rise to no clinical symptoms. They constitute, however, a frequent element in important processes, softening, and the like. In their most developed form they are simply equivalent to hemorrhagic infiltration. Eichhorst has lately examined under the microscope a remarkable case of haematomyelia with widely-distributed capillary bleeding, and has given a careful description. We are not able, however, to agree with him in considering this case as a primary hemorrhage, as there existed paraplegia, accom- panied by fever, gradually extending upward, and in a few days leading to death. SPINAL APOPLEXY. 297 Changes in the spinal meninges are not specially essential accompaniments of intra-medullary hemorrhage. There is al- most always hyperaemia, corresponding to the seat of hemor- rhage ; rarely ecchymoses. The peripheral nerves and muscles often undergo a marked degenerative atrophy; this depends on the seat of lesion, and probably on the destruction of the trophic centres of these or- gans. The alterations in the other organs are the same as in the other forms of severe spinal paralysis (see the chapter on Myeli- tis). Symptoms. Although the number of observations is somewhat small, yet it is possible to draw a tolerably fair outline of spinal apo- plexy. The attack begins quite suddenly in many cases, and with fulminant symptoms ; the patient is struck with violent pains and sudden paraplegia, and falls without loss of consciousness. The hemorrhage often occurs in sleep, and the patient awakes paralyzed. But the disease does not always begin so very suddenly, be- ing often preceded by premonitions, which either consist of the symptoms of spinal congestion (pain in the back, excentric pain and parsesthesia in the limbs, great weariness and prostration, hyperaesthesia of the skin, etc.), lasting perhaps for days and weeks, or the symptoms of acute central myelitis (general mal- aise, fever, violent pains, formication, the sensation of a girdle, of heaviness and numbness, distinct weakness in the extremities, weakness of the bladder, etc.), and these usually last hours or days, until the apoplectic paraplegia appears. One specially characteristic feature of spinal apoplexy is the way in which a complete and severe paraplegia will develop in the course of a few minutes or an hour; this is usually intro- duced by a violent pain, either localized or extending over the entire spinal column, but usually disappearing after the palsy has become complete. 298 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Such patients are found by the physician with complete and absolute palsy of the legs, or the palsy may extend upwards over the trunk and even to the upper extremities; then the respira- tory muscles are palsied, and the patient becomes a picture of helplessness, breathing painfully and imperfectly with the aid of the diaphragm. The paralyzed muscles are perfectly lax, offer- ing not the slightest resistance to passive movements. In rare cases the paralysis is incomplete, some movements being left, or there is paresis only. In one case a single upper extremity has been seen palsied (Bourne- ville); hemiplegic paralysis is also rare, and always affects the upper extremity more than the lower. All this depends on the position and extent of the hemor- rhage. The motor paralysis is accompanied by anaesthesia more or less complete in respect to all possible sensory impressions ; this has the same distribution as the motor paralysis. It is obvious that this disturbance may vary in degree, and is subject to ex- ceptions ; but a certain amount of anaesthesia is seldom or never absent. Paralysis of the bladder and rectum is equally regular; at first there is complete retention of the urine, requiring the em- ployment of a catheter, and afterwards various forms of inconti- nence ; the stools are evacuated involuntarily and unperceived. Marked vaso-motor paralysis has been found in well-observed cases. Levier found a rise of temperature in the paralyzed lower half of the body (flexure of the knee), which equalled 0.2—0.5— 1.0 — 2.0° Centigrade as compared with the axillary measure- ments ; a symptom which, if it be of long duration, points not merely to a simple severance of the vaso-motor paths, but also to a destruction of the vaso-motor centres in the cord. Levier found the cutaneous perspiration absent in the paralyzed parts. The reflex actions vary much according to the seat of lesion ; they are completely suspended when the gray substance is wholly destroyed to its lowest point; if the seat of the hemor- rhage is higher, they may also disappear at the first moment, owing to the shock, but soon return, and may become much exaggerated. In a few cases priapism is given as one of the symptoms. SPINAL APOPLEXY. 299 While the lower half of the body is thus severely affected, the upper half may be perfectly normal and healthy, the arms may act normally, consciousness, intelligence, the functions of the cerebral nerves remain quite intact. At the most, slight febrile symptoms appear during the first few days. It is somewhat striking that the symptoms of irritation are so much in the background. Pain in the back seems the most frequent, and maybe localized or extensive ; the spine is little or not at all sensitive to pressure, a high degree of such sensitive- ness being probably limited to myelitis. Although symptoms of motor irritation, as twitching and partial spasms, are observed in the first moments of the hemor- rhage, yet at a later period they become very inconsiderable, and spasmodic symptoms are almost entirely confined to the non- paralyzed parts, thus marking the progress of the fundamental lesion or the supervention of secondary affections. Paraesthe- siae may be wholly absent in the paralyzed parts ; the patients do not feel their limbs, or only feel them as a dead weight; in other cases tingling or similar symptoms are felt in the paralyzed regions. In the succeeding days and weeks these symptoms increase in a very troublesome way. The first threatening symptom is usually the rapid appear- ance and the steady progression of gangrenous bed-sores on the sacrum, the trochanters, the heels, and other places exposed to pressure. This untoward event may occur in a few days, often in its most acute form. The urinary excretion is altered, the discharge soon becomes bloody, purulent, albuminous ; the severe palsy of the bladder leads directly to alkalescence of the urine, cystitis, and pyelitis with their sequelae. It follows, of course, that these severe disturbances are always accompanied by marked fever. Chills occur, pyaemic and septi- caemic symptoms are developed from the bed-sores, and rapidly consume the patient's strength. The paralyzed muscles become atrophic, sometimes very rapidly; and the atrophy is accompanied by a loss of faradic excitability, or the appearance of the reaction of degeneration 300 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. in the muscles. A few muscles become rigid or contracted, especially when secondary changes in the cord occur at a late period; spontaneous spasmodic jerkings, with exaggeration of reflex action, usually precede the appearance of these symptoms. But if the lesion is located high, the nutrition of the muscles and their electrical excitability may remain nearly intact, as in the case of Goltdammer. The reflex actions disappear by degrees, often quite rapidly and completely ; this is especially the case in central myelitis, when it spreads downward. It is usually hard to recognize the symptoms of secondary myelitis; violent pains, twitching movements and jerks, the formation of contractures—all this often in parts not affected by the palsy—such are the symptoms which belong to this affection. It is evident that this description applies in full only to the more severe cases, with la.rge effusion, but must undergo various modifications according to the seat, size, and cause of the hemor- rhage. It seems superfluous to attempt a full presentation of these ; the reader will be able by reflection to see for himself the special symptoms of a small limited hemorrhage ; for instance, that in the anterior cornua it will produce mainly symptoms of local paralysis, in the posterior cornua perhaps very incon- siderable symptoms, etc. It should in particular be stated that in many such cases, with small hemorrhage, the symptoms are so indecisive, so destitute of characteristic traits, as to furnish no means whatever of forming a diagnosis of hemorrhage. This is in entire accordance with what we know of spinal pathology. Hayem gives the name of chronic spinal apoplexy to the cases in which the hemorrhage is an accompaniment of existing chronic spinal disease. He quotes the cases of Massot (progressive muscular atrophy), Nonat (chronic central myelitis), Lancereaux (peri-ependymal myelitis). In all these, the symptoms of bleeding were more or less acute in their appearance. In our opinion, a hemorrhage in the cord cannot be chronic. Such cases are simply instances of the supervention of an acute complication (hemorrhage) upon a chronic spinal disease; not at all of a chronic form of spinal hemorrhage. SPINAL APOPLEXY. 301 As to the characteristic symptoms as dependent on the locality of the bleeding, we will content ourselves with a few words. If the lumbar region is affected, the symptoms of palsy and anaesthesia are restricted to the lower extremities, bladder, and rectum ; reflex actions are absent; rapid atrophy of the muscles with reaction of degeneration, bed-sores at an early period, will rarely fail to be present. If the thoracic region, the symptoms extend higher up on the trunk. The expiratory muscles are palsied, and those which compress the abdomen; reflex actions may be retained for a time ; atrophy of the muscles is tardy. If the cervical region, all four extremities are affected. A portion of the inspiratory muscles is palsied; pupillary symp- toms may be present; the reflex processes and nutrition depend on the downward progress of the lesion. If the bleeding occurs above the origin of the phrenic nerves, a rapid death by asphyxia is inevitable. In a few cases (Monod, Ore, Breschet—quoted in Levier) the hemorrhage has been found restricted to one lateral half of the cord, with the characteristic symptoms of Brown-Sequard's spi- nal hemiplegia (paralysis of the side corresponding to the lesion, anaesthesia of the other side). Course, duration, termination.—The course depends on the size and location of the hemorrhage, and in part also on the immediate cause. In severe cases, especially of diffuse central bleeding, the fatal termination occurs very soon through paraly- sis of respiration ; or secondary changes, acute gangrenous bed- sores, pyscmia, and septicaemia soon cause death amid fearful suffering. Charcot believes that a true haematomyelia is always fatal, but we cannot assent to this. If the bleeding is small, the case may be protracted a very long time, until at last death occurs from bed-sores, cystitis, fever, marasmus, and other complications. Partial recovery often occurs ; the lesion in the cord becomes cicatrized, and is restored to as normal a condition as is possible. Motility and sensibility return, at least in part; the bed-sores heal, the vesical palsy disappears, and the general health is 302 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. good. But usually some muscles or groups of muscles remain paralyzed and atrophied. Complete cure is doubtless rare, and only possible when the clot is very small. It is difficult to prove that it has taken place, although reports of cases and autopsies are very decidedly in favor of it. The duration must vary greatly. Rapid cases terminate in a few minutes, hours, or days, while less severe ones require weeks, months, or even years before death appears, or a moderate degree of improvement is gained. Diagnosis. This is chiefly based on the sudden and very rapid invasion of paraplegia without much motor irritation, upon the immedi- ate severity of the symptoms, and the very severe and protracted course of the disease. The decision may be supported by the existence of a reasonable cause, by certain prodromic symptoms, the absence of fever, and the elevation of temperature in the pal- sied parts. The diagnosis may, at any rate, be difficult in slightly marked or complicated cases, and the disease may be confounded with various others which resemble it. It is hardly possible to mistake it for cerebral apoplexy. The retention of consciousness, the absence of all symptoms of paral- ysis of cerebral nerves, the paraplegic form assumed by the dis- ease, the paralysis of the sphincters, etc., must guard us from this. And even in difficult cases, such as certainly occur, we shall not fail to make a correct diagnosis if we carefully attend to the symptoms. The diagnosis from meningeal hemorrhage will usually be easy (see above); in the latter there are active symptoms of irri- tation, hyperaesthesia and pain, violent spasmodic symptoms, while paralysis is less prominent; the disturbances of sensibility are quite slight, and the course of the attack is rapid and favor- able. In haematomyelia the severity of the paralytic symptoms is very striking, while the phenomena of irritation are quite in SPINAL APOPLEXY. 303 the background; bed-sores appear quickly; the disease is severe, often fatal, and often leaves incurable palsy behind. The chief difficulty is that which attends the diagnosis from acute central myelitis, especially as the hemorrhagic form of the latter is included in spinal apoplexy. In both cases there is a destruction of the central gray substance, and the only point of distinction consists in the rapidity with which the symptoms develop. The paraplegia requires hours or days for development in simple myelitis, in haematomyelia minutes or quarters of an hour. The same is true, of course, in hemorrhagic myelitis. We may say that the greater the rapidity of development, the more prominent is the element of hemorrhage. In distinguishing central myelitis from spontaneous haematomyelia, we must at- tend to some other points; myelitis begins with symptoms of irritation, pain, slight spasm, the vertebrae are sensitive to pres- sure, fever may be present, and anaesthesia and paraesthesia, par- tial palsy and weakness of the bladder precede the occurrence of severe paraplegia. The ascending spread of central myelitis may also be contrasted with the stationary nature of the symptoms in hemorrhage. By the aid of these points we may distinguish haematomyelia from central myelitis, and in the latter we may separate the simple from the hemorrhagic form. Poliomyelitis anterior acuta (or acute spinal paralysis) in adults is often quite like haematomyelia. It may, however, be sufficiently distinguished by the usual presence of fever at the commencement, the entire absence of all sensory disturbances, the absence of palsy of the bladder and of bed-sores. The diagnosis from ischoemic paraplegia will usually be easy ; although at the beginning it much resembles hemorrhage, yet severe ischaemic paraplegia occurs only in cases of obstruction of the aorta, and the latter may easily be recognized by the pathog- nomonic symptoms of absence of the femoral pulse, and dis- turbed circulation in the legs, etc. The diagnosis of the level of the seat of hemorrhage is made by attending to principles already stated. 304 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Prognosis. Although we by no means agree with Charcot's view of the usually fatal character of haematomyelia, yet the prognosis is almost always very serious. Large central hemorrhages are always fatal. The same is true when the seat is at a very high level. If the first few days and weeks pass without bringing very severe complications, the prognosis becomes gradually more hopeful. But complete recovery is rarely to be expected. But even when the disease appears favorable, and the symp- toms are slow in developing, a turn for the worse is always pos- sible. Besides the formation of bed-sores, the chief thing to fear is the ascending spread of central myelitis. Small circumscribed hemorrhages are certainly less dangerous —if they can be recognized at all during life. For the rest, a prognostication cannot be made in any case without a careful weighing of all circumstances. Treatment. The prophylactic measures are inferrible from the etiology. Such causes as can be reached will be attacked. Retained or suppressed menses, a cessation of hemorrhoidal bleeding, heart- disease, congestion of the cord, etc., will also receive careful attention. It is especially needful to inquire whether the symp- toms are related to a central myelitis, in which case all means will be used, including large bleedings, cold applied to the back, powerful derivation, mercury, iodide of potassium, etc. For the hemorrhage itself, little can usually be done ; by the time the physician arrives, it will (unless very considerable) usu- ally have ceased of itself. It will, however, be proper to take measures for preventing a recurrence or an extension to other parts of the cord, especially when signs of plethora, of excited action of the heart, of severe spinal congestion are present; we should then proceed with vigor to the employment of local and general bloodletting, free application of cold, maintenance of a WOUNDS OF THE CORD. 305 quiet position upon the side or abdomen, with the internal use of digitalis or ergot (or still better, subcutaneous injections of ergotin), purges, application of warmth to the extremities ; these are the remedies here applicable, and from which the proper selection must be made in each case. Afterwards we have to treat the sequelae. Secondary myelitis must be checked by the use of such means as are indicated in the appropriate section. But the chief object will lie in the pre- vention of severe trophic disturbances, cystitis, bed-sores, etc., which are the most threatening complications. Nothing but the most careful and self-sacrificing attention can accomplish this ; for directions see the General Division of this work (p. 192 et seq.) If the first weeks pass without serious results, we may at- tempt to promote the resorption of the extravasation and the repair of secondary myelitis by iodide of potassium. For the same purpose we would advise the use of lukewarm baths, warm springs, and brine baths, or a moderate cold-water cure, and above all, the scientific application of galvanism. The latter is also the chief remedy for the palsies, atrophies, and anaesthesias which remain even after comparatively favor- able cases. Special indications may of course arise in each case, which need not be enumerated here. 4. Wounds, Crushing or Tearing of the Cord {Acute Trau- matic Lesions). Ollivier, loc. cit. I. p. 246.—J. Hahn, Paraple*gies par cause externe ou traumatique. These. Strasb. 1866.— Leyden, loc. cit. I. pp. 310 and 321 ; II. pp. 84 and 139.—M. Rosenthal, 1. c. p. 331.—E. Gurlt, Handbuch der Lehre von den Knochenbriichen. II. 1. 1864.— Lente, Recovery from Fracture of the Spine. Amer. Journ. Med. Sci. 1857. Oct. p. 361.—Ruehle, Greifsw. med. Beitr. 1863. I. p. 12. — Vogt, Liihmung der vasomotorischen Unterleibsnerven nach Riicken- marksverletzung. Wiirzb. med. Zeitschr. VII. p. 248. 1866.—Quincke, Einige Falle excessiv hoher Todestemperatur. Berl. klin. Wochenschr. 18G9. No. 29.—Fronmueller, sen., Die Riickenmarkszerreissung. Memorabil. 1870. No. 12.— M'Donnel, Fracture of the Spine. Dublin Quart. Journ. 1871. Vol. 51. p. 215.— W. Mueller, Beitr. zur pathol. Anat. und Physiol, des R.-M. Leipzig, 306 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 1871. Beob. l.—Nieder, Lowered Temperature in Injury of Spinal Cord. Med. Times. 1873. I. p. 154.—Steudener, Zur Casuistik der Herzwunden (Schuss auch durchs R.-M.). Berl. klin. Wochenschr. 1874. No. 7. We here include a large group of disturbances, in the full consciousness that the bond which unites them is somewhat loose. All, however, have one thing in common ; they possess an acute traumatic lesion of the substance of the cord, which leads to a destruction of the organ, usually limited as to its longi- tudinal extension, of variable extent in the transverse direction, and inevitably followed by a traumatic myelitis, similarly local- ized. This circumstance imparts to all these lesions (they in- clude wounds by cutting, stabbing, and shooting, compression, crushing, and tearing of the cord) a great general resemblance, which from a practical point of view justifies their association in one group. Etiology. Severe traumatic lesions of the cord are hardly possible, un- less the bony envelope, the spinal column, is injured at the same time. There are but few spots (in the upper cervical and the lumbar regions) where the instrument of offence or the foreign body can reach the cord without injuring the spine, by passing in through the vertebral fissures. It may be regarded as a very rare occurrence for severe trau- matic lesions of the cord to take place without considerable in- jury to the bones or the soft parts. By far the most common and important causes of these lesions of the cord consist of fractures and luxations of the vertebrae. All injuries which occasion these fractures or luxa- tions may, therefore, be regarded as remote causes of lesion of the cord. Wherever fracture of a vertebra occurs, with displacement ot the fragments towards the vertebral canal, wherever in luxation the vertebrae are so transposed as to narrow the vertebral canal, there it is inevitable that severe lesions of the cord, compression and crushing, or even local destruction and tearing apart, should WOUNDS OF THE CORD. 307 occur. Owing to the width of the spinal canal and the loose attachment of the cord, a considerable intrusion is necessary before the latter is likely to be injured ; and yet the lesions we have mentioned are among the most common sequelae of frac- tures and dislocations of the vertebrae. Hence the great danger connected with these surgical events. We have no space here, nor are we called upon, to enter upon any details respect- ing the causes and the occurrence of vertebral fractures and luxations, the displace- ments which occur, their degree and direction, and their consequences. The reader is referred to the proper works on surgery, especially the exhaustive treatise by Guilt. It is sufficiently evident that lesions of the cord may occur in cases of appa- rently spontaneous injury to the vertebrae, such as the sudden breaking down of carious bone. That these traumatic lesions may occupy any conceivable sit- uation is plain; they have been observed from the atlas and axis, the fracture and dislocation of which are usually so rapidly fatal, down to the lumbar spine and even the sacrum, in any of which regions the cord or the cauda equina may be more or less in- volved. In the second place, we would mention gunshot injuries of the cord, which form an important chapter in military surgery. They are probably always complicated with gunshot fracture of the vertebrae, and the lesion of the cord is due either to the latter or directly to the entrance of the ball into the medulla. These cases, therefore, always involve complicated fractures of the ver- tebrae, with wounds which are often gangrenous, contain various foreign bodies, etc.; in short, all possible unfavorable circum- stances. Not every shot which strikes the spine is equally dangerous to the cord; the lesion is not rarely confined to meningeal hemor- rhage, concussion, etc., which are infinitely less dangerous than actual wounds of the cord. Stabs and cuts of the spinal cord are rarer. Blows from knives, swords, and daggers have been repeatedly observed to enter the cord, the point of the instrument having entered the canal either by dividing the vertebral arches or by passing through the intervertebral spaces. The injury may vary in extent; the point may have merely entered, or the cord may be 308 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. cut through in various ways, partially or wholly. The foreign body (point of a sword, broken knife-blade) may then remain sticking in the cord or vertebrae. In like manner, in fractures, pointed fragments of bone may injure the cord and maintain a permanent irritation. Finally, severe concussion of the body, such as is produced by a heavy fall on the back, rump, or feet, or by the striking of heavy bodies upon the back, has been observed in a few cases to be followed by considerable lesions of the cord (extravasation, destruction, etc.) without injury of the vertebral column. Thus, Fronmueller found a complete mashing of the dorsal medulla of the extent of three and one-half centimetres in a person upon whose back a heavy beam had fallen without injuring the spinal column. These cases may also be counted in with the severest forms of spinal concussion, and can only be distinguished from the latter by the coarse anatomical lesion. Parrot once found the cord of a new-born infant torn apart by excessive traction during labor. Pathological Anatomy. The lesions of the spine and other neighboring parts which cause or accompany injury to the spinal cord need not occupy us further; we refer our readers to the text-books on surgery and pathological anatomy. In the cord itself we observe various phenomena : 1. Simple incised or punctured wounds. At first a wound of various size and depth, filled and closed with curdled blood ; the edges of the cut often projecting over the pia. A foreign body (point of a knife or dagger, splinter of bone) is often found in the wound. The size of the wound differs: it involves various portions of the transverse section of the cord, one or the other white column, more or less of the gray substance; often one lateral half is severed, rarely the whole (J. L. Petit, Vogt). In a few days, and at subsequent periods, the edges of the wound are still further protruded, are colored a brown-red and more or less covered with pus ; their vicinity is hyperaemic more or less softened; filled with little extravasations of blood; puru- WOUNDS OF THE CORD. 309 lent infiltration or actual abscess of the cord is rarer. The menin- ges, at the same time, are reddened and inflamed, covered with iibro-purulent exudation, and abound in capillary hemorrhages ; at a distance they are opaque, thickened, adherent; the spinal fluid is increased, turbid, reddish. It has often been demonstrated in animals, and is probable, though not sufficiently proved, in the case of man, that in favor- able instances the edges of the wound heal, and a cicatrix of connective tissue repairs the injury. It is not }Tet certain how far the nerve-elements are restored. 2. Crushing of the cord produces a so*f tening and disintegra- tion corresponding to the size of the crushing body, usually associated with hemorrhage, but not always with tearing of the meninges. The medullary substance is changed into a soft black- red or chocolate-colored mass, sometimes rather grayish, com- posed of blood and debris of nerve-substance, showing its color through the pia, which is suffused with blood to a greater or less extent. The crushed spot is usually flat, constricted, and thin. Great hyperaemia presently appears in the parts adjoining, with progressive inflammatory softening ; the medulla swells, the outlines seen in section become obliterated, the consistency of the medulla diminishes; it imbibes at first a reddish, after- wards a yellowish tint, and is full of small extravasations. The microscope shows in the immediate vicinity many granular-cor- puscles, detritus of myelin, decomposed blood-corpuscles, pig- ment, and blood-crystals; also inflammatory swelling, and after- wards break-down of nerve-fibres, axis-cylinders, and remnants of ganglion-cells ; in short, the ruins of the medullary substance mingled with the products of its own acute traumatic inflam- mation. After a few weeks, a thin, gray-yellow, semi-fluid mass is found at the place which was crushed, partially enclosed in a structure of young connective tissue; the swelling of neigh- boring parts continues, they are closely adherent to the mem- branes, their color is grown paler, and is now a grayish yellow; a distinctly demonstrable simple softening is prolonged to some distance above and below. The lower portion of the cord is 310 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. especially apt to be found softened throughout its whole extent. Actual abscesses are seldom found. The characteristic secondary degeneration of the posterior and lateral columns, ascending in the former and descending in the latter, is a pretty regular oc- currence. If the wounded man lives longer, the destroyed medulla is by degrees absorbed, and in its place a sort of cicatrix is formed of young connective tissue, abounding in fluid, which grows harder and encloses here and there cystic spaces of various size. A full regeneration of the nerve-substance is not known to occur in man. 3. Complete severance of the cord is recognized by the fact that the two ends of the cord are separated by a space which may amount to three centimetres or more, in which case the pia is, of course, also torn, while the dura may remain uninjured, or nearly so. The space is filled with a semi-fluid mass, partly composed of blood, at first dark, afterwards rather of a chocolate or gray color. Inflammatory softening occurs, as after crushing, and extends more or less upward and downward. If the patient lives long enough, the commencement of cicatrization and junction of the ends may be observed. 4. Hemorrhagic destruction of the substance, caused by simple concussion, is quite like a hemorrhagic softening with all its consequences. The secondary changes in the other organs of the body, bed- sores, cystitis, disease of the kidneys, etc., are the same as in other forms of severe spinal paralysis, and will be more fully described under myelitis. Symptoms. For the sake of distinctness in the presentation, we make two groups, the one {a) containing comparatively slight injuries of the cord, the simple incised and punctured wounds ; the other (b) embracing all the more serious lesions, squeezing, crushing and tearing of the cord. It need hardly be said that between these two classes there exist transitions, and numerous analogies, WOUNDS OF THE CORD. 311 both as respects the anatomical changes and the symptoms, course, and termination of individual cases. a. The symptoms which indicate that an injury by cutting, or stabbing, in the neighborhood of the spine, has penetrated the cord, will be at first those of partial or total interruption of con- duction in the cord, which extends to the portions behind the seat of injury, and is not merely confined to the district of the nerve-roots which lie at the point of injury. This interruption of conduction may vary in extent and dis- tribution, according to the seat and extent of the injury. Almost all the experiments in the physiology of the cord consist in the infliction of such simple injuries by section, and all varieties of symptoms may be imagined in connection with them. At the moment the injury is received, there is usually a motor paralysis of various extent in the form of paraplegia, or spinal hemiplegia, or hemiparaplegia, or even paralysis of the trunk, and all four extremities. With this is usually asso- ciated sensory paralysis, due to the injury, and correspondingly of very various extent. It may be paraplegic, or may be lim- ited to one side, and in the latter case is upon that opposite to the lesion and the motor palsy; it may be quite circumscript; it may affect certain qualities of sensation only, as the sense of touch, the muscular sense, etc. In cases of very restricted lesion, hyperaesthesia (in the form of a girdle, or otherwise distributed) is often found. If the injury is of any considerable extent, paralysis of the bladder and rectum is always present; at first with complete retention of urine, which soon gives place to equally complete incontinence, while the evacuation of faeces takes place involun- tarily and unperceived. Close examination usually detects also vaso-motor palsy (elevation of the temperature of the skin, in- creased redness) in the regions affected by the motor palsy. The reflex actions are usually totally suspended at the first moment under the shock of the injury, but soon return, and may become exaggerated. This depends, of course, upon the seat of lesion. If we add to this the girdle-pains which are usually present, corresponding with the seat of lesion, and due to injury of the 312 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES.' roots, and the symptoms which depend on injury of the bones and soft parts, we have a pretty complete picture of the condi- tion of the patient during the first few days after the accident. This, however, is soon complicated by the symptoms of sec- ondary traumatic myelitis. Usually the inflammation is trans- verse in its distribution, covering nearly the whole breadth of the cord, but having little extension in the longitudinal direction. The fever usually lasts but a few days. Striking symptoms of irritation now commonly appear ; pains encircling the trunk like a girdle, active pains in the paralyzed parts, hyperaesthesia of various extent in the skin, also spasmodic conditions, twitching and contractures of single muscles and groups. The palsy at the same time increases rapidly in the transverse direction without extending much upwards, i. e., it seizes by degrees upon the motor paths passing the injured spot, which were at first unaf- fected (the sensory and vaso-motor paths, bladder, rectum, etc.), without any considerable change in the upper limit of the lesion. The reflex actions are decidedly increased, but may at a later period cease entirely, when the process has extended to the bot- tom of the cord. If foreign bodies remain in the wound, the symptoms of irritation reach a still higher point, with very severe pains, violent spasms and contractures. At a later period bed-sores, with all their consequences, ap- pear—pyaemia and septicaemia, cystitis, etc. According to the height at which the lesion is situated, other symptoms may arise to complicate the case ; we need not men- tion them all. The higher the injury, the more prominent are the disturbances of respiration, and the more threatening their import. b. The symptoms which, accompanying severe lesions of the spine or other places, indicate that the cord is crushed or torn, are usually those of complete and very severe paraplegia. The posterior portion of the body is absolutely paralyzed, with cor- responding complete anaesthesia, limited quite sharply above; the reflex actions are depressed or suspended, seldom increased ; the bladder is paralyzed to a severe degree, causing retention of urine and frequently an enormous distention of the organ; the intestine is paralyzed, producing meteorism ; the rectum is para- WOUNDS OF THE CORD. 313 lyzed, with involuntary evacuations; the vaso-motor paths are paralyzed, with elevated temperature in the posterior half of the body, and in many cases, in men, more or less severe and persist- ent erections of the penis ; the excretion of urine is lessened or suppressed, etc. To this add (to complete the picture) the symp- toms due to fracture of the vertebrae, or the like, as pain, immo- bility, displacement, etc. All these symptoms follow naturally from the lesion of the cord. The motor, sensory, and vaso-motor palsies are direct consequences of the interruption of con- duction in the cord. The suppression of reflex acts which is found even where the reflex centres are not directly injured, is the result of the severe shock suffered by the cord; after the lapse of some hours or days the reflex centres recover, the reflex actions reappear, and may even exhibit considerable increase if circumstances permit. The same is true of the vaso-motor centres, especially for those which preside over the evacuation of urine, situated in the lumbar cord; the shock, com- bined with the crushing, paralyzes these centres first, whence the complete retention of urine in the excessively distended bladder, which exists even in cases where the lumbar cord is not the seat of the crushing lesion. If the centres recover, occa- sional complete evacuations of the bladder occur quite involuntarily, and usually unperceived; thus, Steudener found a powerful contraction of the bladder occur- ring regularly as soon as the catheter in the urethra irritated the fossa navicularis— a phenomenon which is in perfect accordance with physiological facts observed by Goltz. At a later time the urine begins to drip continually. The priapism which is so frequent an occurrence in severe fractures of the verte- brae is far more difficult to explain. It is most common in connection with crushing of the cervical portion, rarer with that of the dorsal region, and never occurs with fractures from the third lumbar vertebra dowmwards. In many cases the erection has been observed directly after the injury; ejaculation at the same time has oc- curred in a few cases. The erection is either powerful, or lax and incomplete; it is either not felt at all, or is painful; at a later period it may diminish, and may be again produced by catheterism or other irritations. —It is not hard to form a plausible theory of the occurrence of this phenomenon, based on known facts; though it must be confessed that the subject is obscure in several respects. It is best explained by the assumption of an irritation, at the point of lesion, of those paths leading from the brain, the duty of which is to ex- cite the centre for erections in the lumbar cord. If it be objected that the centres in the lumbar cord are usually paralyzed at the outset, and that the complete paral- ysis of the bladder is in contradiction with the assumption, it may be answered that the symptom of priapism is common, in proportion to the remoteness of the lesion from the lumbar cord, and in proportion to the probability that the latter region retains its activity; and further, that the excitability of the centres for erection need not be equal to that of the centres for the bladder; and that we are 314 ERB.—DISEASES OF TnE SPINAL CORD AND ITS ENVELOPES. ignorant of the precise condition of the latter centres and their reflex excitability, in cases of permanent erection. If we take into view the symptom of ejaculation, which can certainly be nothing but a symptom of irritation, the assumption of irri- tation of the paths which give rise to erection will be found the more plausible. We cannot see how in such cases priapism can be regarded as a phenomenon of paralysis, unless it be of vaso-motor paralysis. At a later period—and perhaps at the beginning in many cases—there is no doubt that reflex irritation (as that origin- ating in a distended bladder, the introduction of a catheter, bed-sores, etc.) may give rise to, and sustain, the erections. If the above group of symptoms should allow the slightest doubt of the existence of a severe lesion of the cord, if the case should at first be taken for one of severe simple concussion, a few days' delay will usually bring full evidence of the real condition. At that time fever appears ; the symptoms of acute traumatic myelitis become more and more distinct; bed-sores appear, and in- crease rapidly and steadily ; if the lumbar region is crushed, there is rapid atrophy of the leg-muscles with loss of electrical reac- tion ; the urine becomes bloody, purulent, ammoniacal, etc. The temperature, especially when the cervical region is crushed, often rises continuously and to an excessive height (43°-44° C. [109° to 111° Fahr.], Brodie, M'Donnel, Quincke, and others)—the rise which occurs in the neuro-paralytic agony. In other cases, when the dorsal portion has been injured, the temperature has been abnormally low for some days before death (Nieder). For the interpretation of these symptoms we refer to page 128 et seq. Thus the most severe cases are rapidly brought to an end by complications—such as palsy of respiration, disturbances of cir- culation, pyaemia, neuro-paralytic agony, and so forth. The disease is by no means, however, always so severe; there are cases of partial crushing, where a fortunate accident has saved a portion of the transverse section from destruction, of which the result is partial paralysis (Ollivier, Obs. 25 and 26). The entire process is milder and less dangerous. This is not the place even to touch upon all the possible cases of such partial lesion; we need only say that the literature of the subject of fractures of the vertebrae contains cases of all possible degrees of severity. The symptoms differ, of course, in correspondence with the level at which the lesion may be seated. WOUNDS OF THE CORD. 315 If the cervical portion is affected, death usually occurs at once, if the lesion is at the height of the first or second cervical vertebra, e. g., in luxation of the odontoid process; and death is almost as speedy when the lesion is above the origin of the phrenic nerves. All four extremities are then paralyzed, while the respiration is so difficult as only to be maintained by the forced and anxious action of the auxiliary muscles of respira- tion ; the speech and voice are weak, and swallowing is difficult. If the cervical enlargement below the phrenic nerves is the seat of lesion, the expiration is chiefly affected ; the legs are wholly paralyzed, the arms more or less completely so; the sensibility of the arms may be partially retained ; reflex actions are retained, often exaggerated ; M'Donnel even saw co-ordinated reflex actions (the left hand, in a state of absolute palsy, made a movement to seize the genitals during the act of catheterization); priapism is very frequent; life may be retained for a considerable time. If the lesions are in the dorsal region, the arms are free, and the trunk is palsied, up to an uncertain height; the legs are more or less paralyzed, often unilaterally, with crossed anaesthesia; the expiration is less impeded, the voice and speech are some- what affected ; the reflex actions are retained and exaggerated in the subsequent course of the disease; the bladder and rectum are paralyzed ; priapism is somewhat rare ; bed-sores follow. In lesion of the lumbar region the arms and a great part of the trunk are free. The legs, bladder, and rectum are totally paralyzed ; respiration is not impeded ; reflex actions of all sorts are totally extinct; no erections ; rapid atrophy of the muscles, and extinction of their electrical reaction. The symptoms of lesion of the cauda equina are quite similar; but the freedom or the implication of certain nerve-paths, especially those belong- ing to the lumbar plexus, often enables us to refer the seat of lesion to the cauda equina.1 1 Cf. Erb, Ueber acute Spinallahmung bei Erwachsenen. Arch. f. Psych, u. Ner- venkrankh. V. p. 785. Beob. VI. 316 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Course, Duration, Termination. There are hundreds of physiological observations which show that improvement, and even cure, may occur in the first and slighter form of lesion (simple incised wounds of the cord). Goltz and Freusberg have kept dogs alive for many months, even when the dorsal cord had been completely severed by a cut; they observed, however, no occurrence of regeneration. An absoluteby fatal termination, therefore, even in man, can hardly be predicted; indeed, there are numbers of cases of un- doubted lesion of the cord, in which a comparative cure was effected and life was retained for many years. Such are the cases of cure of a probable punctured wound, given by Ollivier, and of various incised wounds, by Brown-Sequard and others. These, however, are the exceptions, which must not be looked for unless in slight injuries. If such is to be the result, the symptoms of myelitis do not become severe, they soon pass off, and the outer wound closes ; the symptoms of palsy are relieved in part, and in part remain, so that a more or less complete cure is by degrees obtained. The importance of the functional repara- tion of the lesion, urged by Schiff (p. 64 above), can hardly be overlooked. Usually, however, the secondary myelitis continues to increase, the paralysis increases, bed-sores, with their unfortunate conse- quences, appear, and the fatal end is reached after more or less protracted sufferings. The second and more severe form is almost always fatal. When the cord has been thoroughly crushed or torn in any part it is hardly possible to conceive of regeneration; and even if life be re- tained, in a number of cases, for weeks or months (M'Donnel, two months; Steudener, fifteen weeks; Page, in a case of severance of the cervical cord between the fifth and sixth vertebrae, even fif- teen months), yet the ultimate result is pretty certain, and occurs with the usual symptoms of severe spinal palsy. It is a matter of course that death may occur in a few hours or days after the injury by paralysis of respiration, shock, or similar occurrences. Is a cure ever effected ? and is it possible in any severe spinal WOUNDS OF THE CORD. 317 lesion ? The opinions of physiologists are divided upon this point (see above, pp. 64, 65). There are no convincing proofs in the case of man. In the instance given by M'Donnel, a sort of cica- trix was found at the close of two months, but not a trace of nerve-tissue could be found in it. Ollivier's observation (No. 18), and Lente's case, are strongly in favor of the repair of lesions of moderate severity. Diagnosis. It is not difficult to recognize an injury of the cord by the preceding symptoms. In case of simple injury to the meninges, by puncture or in- cision, the occurrence of meningeal apoplexy might give rise to the mistaken diagnosis of an injury of the cord. The former will easily be recognized by the symptoms of irritation, which are prominent at the outset—pain, spasmodic phenomena—and by the slighter degree and the greater diffusion of the paralysis; and finally by its rapid and favorable course. In severe injuries of the cord, the existence of spinal apoplexy may be suspected; but it is of no importance to determine it, as a crushing of the cord is doubtless always attended by haemato- myelia, and the symptoms and course of the two diseases are essentially similar. Cases of severe concussion of the cord may usually be re- cognized by the absence of a clear demarcation of the anaes- thesia and the palsy, by the subsequent course, the absence of bed-sores, etc. If dislocations of the vertebrae can be proved to exist, the crushing of the cord will become more probable. Prognosis. This will readily be inferred from what has been said. It is very dubious, even in the slightest cases of injury, and we should be prepared for a fatal result through secondary myelitis ; but there is still some hope. In all severe cases of crushing and tearing of the cord, death is almost absolutely certain, sooner or later. But there are excep- * 31S ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. tions, as has been before said, in the case of slight and very partial lesions only. Treatment. The first thing to be attended to is a careful treatment of the external injuries (wounds, fractures, and luxations of the verte- brae), for the details of which we refer to the hand-books of sur- gery. The injury to the cord introduces a very important element of danger in all these cases ; in most instances it is the cause of death; we ought, therefore, to make every effort to relieve it or to promote functional recovery. In addition to the ordinary surgical methods, we shall often have to consider the propriety of trepanning the spinal column for the relief of compression of the cord, the removal of fragments of bone, replacement of the ends of the fractured bone, etc. We need not, however, discuss the value or the feasibility of trepanning, or its indications, for which we can refer to the work of Gurlt. And yet we believe the operation is indicated wherever there is good reason to hope for gaining anything in the treatment of the dislocation which caused the lesion of the cord ; and such gain would be more probable in fractures of the arches of the vertebrae, as fragments of the bodies can hardly be reached. We can scarcely ever expect any direct result, as the injury to the cord is not from simple compression, but usually from crushing or tearing. Yet the removal of dis- placed fragments will at least increase to some extent the chances of life. We should not, therefore, hesitate, in so almost hopeless a case, to undertake an operation not of itself very dangerous, if there is any possibility of relief. The physician must carefully weigh all the chances; it is certain that in all severe cases the operation will do little harm, and perhaps some good. In the second place, we have to consider remedies for trau- matic myelitis, local (or if necessary general) bleeding, cold, ergotin, and belladonna, frictions with mercurial ointment, etc. (See the Treatment of Acute Myelitis.) By far the hardest task will consist in the personal attentions to the patient, those, namely, which are required for the preven- SLOW COMPRESSION OF THE CORD. 319 tion of bed-sores and cystitis, which usually destroy life. Two contradictory requirements are usually present: absolute quiet, for the surgical injury, and frequent change of posture, for the prevention of bed-sores. We must try to do what we can with water-pillows, air-cushions, pillows pushed in alternately on op- posite sides, cushions stuffed with chaff, great cleanliness, posi- tion on the face, etc., as circumstances dictate. The treatment of the vesical symptoms, the fever, marasmus, pains, etc., depends on general principles. We should compare the treatment of acute myelitis. 5. Slow Compression of the Cord {Chronic Traumatic Lesion of the Cord). Compare the works of Ollivier (I. p. 387), Hasse (p. 735), Jaccoud (Des paraplegies, etc.), Brown-Sequard (Paralysis of the Lower Extremities, etc. 1861), M. Rosen- thal (p. 313), Leyden (I. pp. 213-311; II. p. 147). Also Charcot, De la compress, lente de la moelle ep. Lecons sur la mal. du syst. nerv. II. Sur. II. fasc. 1873.—Bouchard, Compress, lente de la moelle. Dictionn. ency- clop. des sc. medic. II. Ser. Tom. VIII. p. 664. 1874.—C. Hawkms, Cases of Cancerous, etc., Disease of the Spinal Column. Med. Chir. Transact. XXIV. p. 45. 1841.— Vogel und Dittmar, Deutsche Klinik. 1851. Nr. 38.— Traube, 5 Falle von RUckenmarkskrankheiten. Charitg-Annalen. IX. 2. p. 129. 1861 — Ruehle, Zur Compression des R.-M. Greifsw. med. Beitr. I. p. 5. 1863.— James Young, Case of Temporary Paralysis. Edinb. Med. Journ. May, 1856.— Ogle, Case of Paraplegia, etc. Transact. Path. Soc. XIX. p. 16. 1868.—A. Joffroy, Cas de fract. de la colonne vert. Arch, de Phys. I. p. 735. 1868.— Leudet, Curabilite des accid. paralyt. consSc. au mal vert. Mem. de la Soc. de Biol. 1862-1863.—Michaud, Sur la mining, et la myelite dans le mal vertSbr. Paris, 1871. — Charcot, Anat. pathol. et trait, de la parapl. liee au mal de Pott. Gaz. med. 1874. No. 49.—A Courjon, Parapleg. dans le mal de Pott. Paris, 1875.—E. Rollett, Wien. med. Wochenschr. 1864. Nr. 24-26.—De Giovanni, Storia di un caso di paraplegia, etc. Riv. clin. di Bologna, 1870. No. 12.— Leyden, Ueber Wirbelkrebs. Charitg-Annalen. XI. 3. p. 54. 1863.—M. Rosen- thal, Wiener med. Presse. 1865. Nr. 42-45; Zeitschr. f. prakt. Heilk. 1866. Nr. 46-51. Tripier, Du cancer de la colonne vertebr. Paris, 1866.—Th. Simon, Paraplegia dolorosa. Berl. klin. Wochenschr. 1870. Nr. 35 und 36. Definition.— Numerous as are the conditions which we em- brace under this title, yet all have this in common, that a power acting from without upon the cord {and the nerve-roots) coin- 320 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. presses it very slowly and gradually in a limited longitudinal extent, giving rise to a series of characteristic symptoms which in all cases may be recognized by their essential features, and often are the first to call our attention to the commencement of a severe affection. These symptoms, however, are not usually produced by the pressure as such, or exclusively, but by the subacute or chronic transverse myelitis which develops almost invariably at the point of compression and by the secondary degeneration of the cord, extending upwards and downwards. The essential lesion is, therefore, a circumscribed transverse myelitis, the so-called myelitis from compression; and we should not devote a separate section to it, were it not that it forms a connecting link between very various morbid states origi- nating in the spinal column and its contents, and that the symp- toms of myelitis from pressure compose a very important feature, common to all those forms of disease. Etiology and Pathogenesis. Any circumstance which very gradually narrows the spinal canal, usually in the way of organic growth, and thereby leads to a slowly increasing local compression of the cord, may become a cause of myelitis by compression. We have already mentioned an important part of these causes, viz., meningeal tumors. To avoid repetitions, we would refer to what has been said above (see page 262 et seq.) upon this point. We here repeat that a gradual compression of the cord may be occasioned not solely by the so-called neoplastic tumors proceeding from the spinal membranes, but equally well by meningeal tumors formed by inflammatory and hemorrhagic pro- cesses, parasites, and the like, and by tumors which originate in the perimeningeal tissue. All these tumors have one thing in common, that their expansion is very soon checked by the nar- rowness of the canal, and that they then begin to exercise an increasing pressure upon the cord. It is self-evident that this pressure may affect the cord in various ways and from different SLOW COMPRESSION OF THE CORD. 321 sides, and may thus produce a great variety of symptoms, but the essential conditions remain the same. It may be questioned whether the intra-medullary tumors, those developing within the substance of the cord, ought to be counted among the causes of compression. They do not act from without, and therefore differ somewhat in their symptoms. Tt is characteristic of them that the cord is gradually compressed from one point of its transverse section, with myelitis as a gene- ral accompaniment; for which reason the characteristic initial symptoms relating to the compressed roots are absent, and those of compression of the cord begin at once. For all details we refer to the section on tumors of the cord, and premise only this remark, that all sorts of intra-medullary tumors may produce the symptoms of myelitis by pressure—as glioma, sarcoma, myxoma, tubercle, syphilitic gummata, cysts (hydromyelus and syringomyelia), etc. By far the most important cause is that furnished by diseases of the vertebral column. The most frequent of these, and also the most frequent cause, on the whole, of myelitis from com- pression, is caries of the spinal column (Pott's Disease, Spondy- larthrocace). We need not describe this particularly, for it is fully treated of in the text-books of surgery ; our present object is confined to inquiry as to the manner in which it may give rise to a slow compression of the cord. In the first place, the wasting and sinking of the bodies of the vertebrae produce kyphosis, which may give rise to a bend- ing and narrowing of the vertebral canal, with compression of the cord. This is certainly very rare, and only occurs in exces- sive kyphosis. Enormous angular kyphosis may occur without any symptoms of compression of the cord; and on the other hand, the paraplegia accompanying kyphosis often disappears altogether without the least change occurring in the latter ; and finally, there are cases of vertebral caries without any kyphosis, which are nevertheless accompanied by paraplegia. The kypho- sis is not, therefore, the sole nor even the chief cause of compres- sion of the cord. In most cases this compression is produced by the inflamma- tory exudation which accompanies the caries. The masses of VOL. XIIL— 21 322 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. pus produced by caries, and in particular the fungous granula- tions, accumulate between the dura and the bodies of the ver- tebrae and press the dura inwards ; they produce a pachymenin- gitic growth and thickening of the dura, causing a contraction of space in the vertebral canal (Charcot, Michaud; see also the very artistic illustration in Ogle). The dura is thickened; its outer layers especially are changed to a proliferous mass of young fibro-plastic tissue, partly undergoing caseous metamorphosis, which either surrounds the dura at one point like a ring, or presses it from one side against the vertebral canal to the extent of ten, fifteen, twenty millimetres or more. The nerve-roots at the place are more or less implicated, thickened, swollen, in- flamed, etc. Simple caseous pus-deposits may become a cause of pressure, or the protruding intervertebral cartilage, or sepa- rated and displaced fragments of bone. In the second place, carcinoma of the vertebrae should be mentioned as a frequent cause of compression, chiefly observed in old persons. The primary as well as the secondary disease may act in this way ; the latter quite usually follows primary cancer of the breast, but also that of any other organ. Not all cancers of the vertebrae produce spinal symptoms ; that depends, of course, upon their location, size, and the direction taken in growing; but when cancer attacks the arches of the vertebrae and the nerve-roots which pass between them, when it has at- tacked, softened, and thoroughly rotted the entire bodies of ver- tebrae, when it presses in to the vertebral canal, seizes on the spinal membranes and grows directly against the cord itself, then the characteristic spinal symptoms usually appear, and the form of compression known as paraplegia dolorosa, with most acute pains, is developed. There are several diseases of the vertebrae, much inferior in im- portance to the preceding, which may occasionally lead to com- pression of the cord. Such are exostoses of the vertebrae growing into the canal; osteoma ; syphilitic new formations of the bone ; also dry arthritis of the vertebrae, when it leads to considerable swelling of the articular processes, osteophytic growths, deposi- tion of bone, etc. Here must be mentioned also the thickening SLOW COMPRESSION OF THE CORD. 323 of the odontoid process of the axis, anchylosis of the vertebrae, and all similar affections. Finally, it remains to be said that external tumors of all sorts, growing towards the vertebral column, and entering the vertebral canal by any natural or pathological opening, may give rise to pressure of the cord. Such are echinococci, sarco- mata, aneurisms, etc. All these causes (with the partial exception of intra-medul- lary tumors) have one element in common, namely, that they push on very gradually against the cord, reaching fir st the nerve- roots and meninges, irritating and afterwards compressing them, and thus giving rise to a group of most characteristic symptoms, which belong to the first period of development. The cord itself is then attacked ; it is exposed to a gradual compression which interferes with and interrupts the conduction. Nor is this all, for after the compression has lasted a longer or shorter time (usually a very short time—sometimes even before paraplegia exists — Charcot, Michaud) inflammatory changes appear; myelitis is developed, at first confined to the seat of compression, but usually extending over the whole transverse section of the cord. With the compression and its concomitant myelitis, very characteristic symptoms are associated, belonging to a second stage of the disease. In most cases these symptoms seem to be connected with the appearance of myelitis. The question whether compression may exist alone without myelitis, and may of itself produce the paraplegic symptoms, or whether pressure-myelitis is a necessary condition, is somewhat a superfluous one. It is certain that compression—especially if it be acute—is capable by itself of giving rise to the seve- rest paraplegia, which, if the compression be speedily and suc- cessfully removed, may disappear in a comparatively short time, as in the oft-quoted cases of Ehrling and Brown-Sequard. It is, however, equally certain that in the very great majority of cases every protracted compression of the cord is very soon compli- cated by pressure-myelitis; it does not seem probable to us that this myelitis is the result of an ischaemia produced by compres- sion, an. ischaemic softening, but we consider it as the direct consequence of the irritation of compression acting upon the 324 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES elements of the tissue. Finally, it seems equally certain that in many cases the mere irritation of tumors pressing against the spinal membranes (carcinoma, etc.) is enough to produce mye- litis without actual compression. We therefore see that the pathogenesis of the symptoms commonly known as compression of the cord may be of several sorts; they may arise through com- pression alone, or through compression and the consequent mye- litis, or finally through myelitis alone. In conclusion, if the compression is not soon relieved, and if myelitis is once established, secondary degeneration and scle- rosis of the cord supervene, as in the case of every transverse myelitis (see farther on, No. 19), invading in a strictly regular way the various divisions of the cord above and below the point of compression. These in their turn lead to other definite symp- toms, which may be considered as forming a third period of the disease. Pathological Anatomy. The pathologico-anatomical changes which belong to the pri- mary lesion (vertebral disease, tumors, etc.) cannot be described here for want of space ; the reader is referred to the text-books of pathological anatomy and surgery. We have mentioned a few chief points under the etiology, and it remains here only to describe what is directly concerned with the cord and its appen- dages. The meninges are often hyperaemic, opaque, thickened, adher- ent to the neighboring parts ; often covered with deposits of va- rious thickness, which have much to do with the production of compression ; often, however, they are remarkably little changed, are smooth, and simply pushed a little from their usual position. The nerve-roots are almost always more or less involved in the morbid processes. They may be closely united with the tumor or the exudation, or may appear one with it; at first they are usually swollen, hyperaemic, inflamed, their fibres are in a state of fatty degeneration and beginning to break down, and this may be traced into the cord (neuritis); at later periods the LOW COMPRESSION OF THE CORD. 325 roots are atrophied, pale, gray, degenerated, and nearly reduced to a connective tissue abounding in nuclei. In carcinoma of the vertebrae, especially, the nerves and nerve- roots are reddened, swollen, fuller of fluid; rarely atrophied, and still more rarely directly involved in the cancerous growth. Sim- ple contact with the malignant tumor is sufficient to produce severe neuritis. The substance of the spinal cord is more or less flattened and thinned at the point compressed, is often reduced to a slender cylinder, hardly the size of a quill, or to a flat, ribbon-shaped string. The compression is sometimes greater from the front, sometimes from behind, sometimes from one side, and thus the cord gets a distorted, irregular look. The place compressed va- ries extremely in length; above and below it the cord is some- times of its usual thickness, and sometimes rather thickened in a club-shape. The consistence of the compressed spot is usually lessened at first (inflammatory softening), but afterwards may be increased (sclerosis). The place is anaemic, pale, often presenting no distinct change to the naked eye ; usually, however, the out- lines seen in cross-section are quite indistinguishable, the medulla is cloudy, or, at a later stage is gray and translucent. Microscopical examination shows—if the compression has lasted some time—a considerable increase and thickening of in- terstitial connective tissue at the place, and mingled with this are many granular corpuscles, often also corpora amylacea, while the walls of the vessels are thickened and in a condition of fatty degeneration ; the axis-cylinders are often swollen, while some are broken down or have disappeared; in the ganglion-cells of the gray substance there may be observed swelling, the forma- tion of vacuoles, pigment-deposit, and often a breaking down and disappearance (Michaud, Joffroy). In a word, there is chronic transverse myelitis, chiefly interstitial, extending over the greatest part or the whole of the transverse section. The myelitic changes extend beyond the place crushed, and may be observed above and below at various distances, with diminishing intensity. At a short distance from the spot, these changes usually appear confined to clearly defined portions of the transverse section, and 326 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. in these may be followed up and down almost the whole length of the cord. These are the well-known secondary degenerations (Tuerck, see farther on, No. 19). Above the compression, the pos- terior columns are affected, higher up the fasciculi graciles alone, and in the latter the disease often ascends as high as the medulla oblongata. In the lower segment the lateral columns alone are affected, and chiefly their posterior part; the dis- ease descends in this to the conus terminalis. The change may often be recognized in fresh pre- parations with the naked eye by the translucent, grayish, or slightly yellowish tinge of the tissue, but more usually the altered tissue cannot be recognized with certainty until the cord has lain some time in chromic acid, when it acquires a lighter color. With the microscope, interstitial proliferation of connective tissue, and degenera- tion of nerve-fibres are to be seen. In a few cases the degeneration has been seen ascending in the lateral columns also, usually but for a short dis- tance (Michaud). Commonly the degeneration is not uniform in the two sides. The illustration (Fig. 5) gives a good view of the typical distribu- tion of these alterations. The myelitic process often extends to great distances in the gray substance also, especially downward, but in this situation requires close microscopic examination to detect it; the charac- teristic signs consist of sclerosis of connective tis- sue, thickening of the arterial walls, atrophy and disappearance of the nerve-elements, pigmenta- tion, etc. This process is important in explain- ing many later symptoms. In severe cases all these processes make prog- ress ; there are consecutive changes in remote parts of the body (muscular atrophy, degenera- tion of peripheral nerves, cystitis, bed-sores, etc.), which hasten the fatal result. Pig. 5. Compression of the Dorsal Mrdul'a. Diffuse myelitis at the point of compression (*); the right half is more compressed than the left. Above, secon- dary ascending degen- eration in the fasciculi (rraciles (1—3); below, descending degenera- tion of the lateral col- umns to the lumbar cord (5—7). After Mi- chaud. SLOW COMPRESSION OF THE CORD. 327 In more favorable cases it is possible for restoration and full recovery to occur ; this is certainly true in vertebral caries, and would doubtless apply to other cases if the cause of compression were removed. In such an event there must be a regeneration and restoration of nerve-elements, at least in part, at the point of compression. The processes, however, have not yet been fully studied. Charcot and Michaud have examined such a case in which recovery had occurred ; the seat of compression was very distinct, its transverse section was much smaller than that of other portions of the cord, and it looked gray, as if degenerated. The microscopical examination showed the presence of much con- nective tissue, among which there were a great many nerve-fibres, normal in appearance, though slender ; they must certainly have been diminished in number. In the gray substance, which was much reduced in size, there were found some, though not very numerous, ganglion-cells. Little is known of the more delicate changes in these processes of restoration; it is probable that the axis-cylinders of some nerves are not destroyed, and clothe them- selves with a fresh medullary sheath when the pressure is re- moved. Further examination of the subject is to be desired. Symptoms. It is important to remember from the outset that two chief groups of symptoms are to be distinguished in compression of the cord, upon which may be based a division of the disease in two stages. In the first group are included all the symptoms proceeding from lesion of the parts situated externally to the cord, espe- cially the nerve-roots, meninges, bones, etc. They may also be designated as prodromal symptoms (symptomes extrinseques, Charcot). This group furnishes the symptoms which are usually decisive of the differential diagnosis of the various causes of com- pression, while those of the second group are nearly the same in all cases, with the exception of such variations as depend on the level at which they occur in the cord, or the portion of the trans- verse section which is occupied. This second group embraces all the symptoms which are de- 328 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. rivable from compression of the cord itself, and from the myelitis caused by pressure (symptomes intrinseques, Charcot). They are nearly alike under all possible causes, as above stated. The succession and development of the symptoms of these two groups will give the characteristic signs of the disease. This being premised, the general symptoms are as follows. After those of the primary disease (as Pott's Disease, vertebral cancer, etc.) have existed for some time, or even before they have been observed, the first evidence that the contents of the verte- bral canal are attacked consists in certain symptoms of irritation of all the organs contained in the canal, the periosteum, menin- ges, and especially the roots of the spinal nerves. Pain of vari- ous sorts and degrees of violence, pains in the form of a girdle, excentric neuralgias in almost any spot (but holding constantly to that spot), open the scene; a great hyperoesthesia of those portions of skin which correspond to the distribution of the pain may be added, but often disappears to make room for a corre- sponding anaesthesia, often limited to a few islands of skin—or both conditions may subsist together. Severe pain in the back, local stiffness of the spine, great sensitiveness of the spinous processes, are seldom absent. The neuralgic pains are often accompanied by herpetic or bullous eruptions of the skin. To these are afterwards added (especially when the lesion occupies the cervical or lumbar enlargement) states of motor irritation in the districts of the nerves whose roots are first implicated, as twitching, spasm, tonic spasm, and contracture; weakness and paralysis is soon added, confined to certain muscles or groups of muscles, to one extremity or the other, and often accompanied by great atrophy and loss of electrical excitability. It must be observed that these sensory and motor symptoms are located in the same, or adjacent nerve-districts, and therefore may be re- ferred to a single source of disease. If the original causal lesion then declares itself by such signs as progressive kyphosis, congestive abscesses, pain strictly local- ized in the spine, external swellings of various sorts, etc., the diagnosis of the disease may be considered as already made out. This prodromal period may differ very greatly in duration; it SLOW COMPRESSION OF THE CORD. 329 may last months or years; its symptoms always precede for some time those of compression of the cord; they are absent only in case intra-medullary symptoms are prominent, when the symptoms of pressure may be the very first to be noticed. The latter, belonging to the second stage of the disease, con- sist at first of a paralysis, of more or less rapid development, usually in the form of paraplegia, more rarely in that of hemi- plegia, and in the latter case usually developing into paraplegia. The first symptoms of paralysis are often preceded for a time by paresthesia in the lower half of the body; tingling, f urriness, sensations of burning or cold, girdle-sensations, etc., are described by the patient. The order in which the sensory and the motor symptoms appear depends on the direction from which pressure is first felt; those which first appear may exist some time before the other set follows. Those of the motor class, however, very soon become more marked than the other set; the preponderance of motor paralysis is quite a characteristic trait in the picture of myelitis from pressure. The paralyzed muscles are first com- pletely relaxed and softened, the joints are relaxed, and obey every passive movement without resistance. At the same time there is considerable increase of the reflex actions, both cuta- neous and tendinous, in the paralyzed lower extremities, except when the lumbar swelling is the seat of pressure; the slightest irritation gives rise to the fullest reflex movements, convulsive twitching, and the like, in grotesque contrast with the absolute motor paralysis. The paralysis of the bladder and rectum is often delayed, but if there is any considerable compression, it is sure to occur; the symptoms are the well-known ones of involuntary discharge. As the disease progresses, the muscles, at first quite lax, be- come by degrees tense and rigid, and are attacked by twitchings, or transient tonic spasms; contractures appear, at first tempo- rary, afterwards permanent; the lower extremities continue in a permanent position of extension, which afterwards gives place to flexion. At the same time there is an additional increase of reflex action; the tendinous reflexions especially gain in inten- sity, every slight dorsal flexion of the foot produces the most active clonic movement of both lower extremities, often a con- 330 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. vulsive tremor, etc. The nutrition of the muscles may remain intact for a time, or they may emaciate. At this point the cases divide ; those of a less severe sort remain for a long time of about the same severity ; slight im- provement gradually appears ; the anaesthesia is the first to diminish ; the functions of the bladder are better regulated ; the power over a few movements returns, increases by degrees; in short, the improvement may go on step by step to full recovery. In severe cases, however, the symptoms become worse; the paraplegia remains complete ; bed - sores appear on various places, cystitis, fever, general marasmus follow, and amid inde- scribable sufferings the patient sinks into his grave. Let us now analyze the symptoms, and attempt to refer them to the existent anatomical lesions. The most constant and most important of the prodromal symptoms is without doubt that of pain. It has a great deal that is characteristic; it is confined to very distinctly marked nerve-root districts, being in the beginning often localized in a line or a point; it is neuralgiform, lancinating, and often (in con- nection with marked neuritis) rather of a burning character. It is very distinct in carcinoma of the vertebrae, where it occurs in severe paroxysms, especially by night, is soon beyond the con- trol of narcotics, and gives the patient fearful torments. A vari- ety of eruptions of the skin often appear in the district of the cutaneous pain. Without doubt these pains should be referred to the mechan- ical irritation, and most especially to the consequent neuritis of the sensory roots; this irritation is brought about by the in- crease of the compression, the sinking together of the vertebrae, and the narrowing of the intervertebral foramina. As all these matters may differ in each case, it is readily seen that the degree and extent, intensity, character, and commence- ment of the pain may differ greatly in individual cases. We refrain from entering further into the details. It is without doubt to the same cause—mechanical and inflam- matory irritation of the sensory roots—that the hyperaesthesia is due which we observe in many cases, found usually in the parts where the pain is distributed, and varying greatly in character. SLOW COMPRESSION OF THE CORD. 331 A further lesion of the roots is indicated by the anaesthesia occurring in their district of distribution, which may assume the form of a zone, or be restricted to certain cutaneous nerves, or to quite isolated spots of skin, according to the number of fibres compressed. The symptoms of motor irritation and paralysis in the initial stage are referable to quite analogous states of the anterior roots. Tremor, spasms, cramps, permanent uniform painless contrac- tures occur here, and alternate with paresis or paralysis of cer- tain muscles and groups of muscles, or coexist with them. The location of these disturbances varies according to the seat of lesion ; they will be noticed at an early period if the compression acts upon the roots passing off from the cervical or lumbar swell- ing, because in that case considerable disturbances at once ap- pear in the extremities. The fact that the motor and the sensory disturbances are referable to nerve-roots occupying nearly the same level in the cord is one which has been observed in many spinal diseases, but is especially distinct in this. If the compression and neuritis of the anterior roots becomes severe, the now complete paralysis of the corresponding muscles is followed by progressive atrophy, and with the atrophy there is very closely associated a corresponding diminution and loss of faradic excitability, which, as will be seen upon closer exami- nation, is only a portion of the reaction of degeneration. It hardly need be said that in these paralyses from pressure on the roots the reflex actions are always extinguished, and that this circumstance is not without value in the diagnosis. In the second stage the symptoms of motor paralysis are the first and the most prominent. In fact, paraplegia is often enough the first symptom that indicates the severity of the dis- ease. It may develop with more or less rapidity; a few hours or days are often sufficient, but usually weeks are required ; the patient feels his legs growing heavier, he drags them in walking ; the toes catch at the least obstacle ; his knees double under him, and so walking and standing become impossible ; at last there is a complete loss of all movement, even in the lying posture. The muscles remain perfectly lax, soft, and non-resistant under pas- 332 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. sive movement. Their electrical reaction is unchanged ; their nutrition is at first quite unimpaired. All this is perfectly intelligible when referred to the gradually increasing compression of the cord, with its accompanying mye- litis ; the slight initial symptoms of weakness may without hesi- tation be referred to compression, while a more rapid increase of paresis, a relatively rapid development of paralysis, is undoubt- edly due to myelitis. At a later date, of course, the proportion of the influence of the two elements upon the origin of the com- plete paralysis cannot easily be estimated. As the disease is always circumscript at the beginning, the nutrition and electric reaction of those muscles whose nerves originate in the inferior (intact) portion of the cord will remain perfect until a descending affection of the gray substance threatens their functions. As in most cases the compression takes place from the front of the cord (Pott's disease), it is readily seen that the motor dis- turbances will be the first to appear, and will for a long time outweigh the sensory. In a minority of the cases, the compression is limited to one- half of the cord, leaving the other more or less intact. The paralysis then takes the form of spinal hemiplegia or hemipara- plegia; if the compression of the affected half is pretty complete, it may be associated with a crossed anaesthesia, and give rise to the characteristic unilateral lesion (see below, No. 14). Usually, however, after a longer or shorter time, the myelitis will extend over the entire transverse section, and complete the paraplegia. The paralysis not infrequently begins in the form of a cervical paraplegia, i. e., the upper extremities are first and completely palsied, while the lower are nearly or wholly free at first. This condition may be due to the fact that the lesion occupies the level of the cervical enlargement, and in this place first attacks the anterior roots for the upper extremities ; in this form of palsy, muscular atrophy and absence of reflex actions form a characteristic feature. Or, if the lesion is situated in the upper part of the cervical cord, it may happen that the motor paths in the antero-lateral columns which belong to the upper extremity are at first exclusively attacked by the compression, and those for the lower extremities at a later period. This might perhaps SLOW COMPRESSION OF THE CORD. 333 be explained by supposing the former to lie nearer the surface of the cord than the latter, and thus to be sooner affected by pres- sure and myelitis. In this case the reflex actions are retained in the upper extremities also. Finally, in a few rare cases, a so-called recurrent paralysis has been observed, that is, an upward extension of the paral- ysis above the point of compression ; e. g., in compression of the dorsal region, extension to the upper extremities. This is explained by the ascending myelitis, which often occurs, and in some cases by the very rare occurrence of ascending degeneration of the lateral columns, which may extend to the cervical enlarge- ment (Michaud). The sensory disturbances are not usually so marked as the motor, at least in the beginning. The development of paraplegic symptoms is often preceded for a varying period by paresthesias (tingling, formication, burning, etc.), which may cover the whole body, and often continue without a break, or recur during the later course of the disease. They are sometimes due to compres- sion of the posterior columns, and sometimes are signs of com- mencing myelitis in the posterior columns and the gray substance. The same cause may be assigned for the pains, wThich often appear during the later course of the disease ; these have not the lancinating, neuralgiform character, but are rather an intense, dif- fuse sense of pain, burning, boring, pressure, etc., extending over the whole of the lower extremities. I have repeatedly observed them in the paraplegia of vertebral caries, and Michaud ascribes them to the myelitic irritation of the gray substance. Charcot describes also an abnormal irradiation of pain and paraesthesia, a peculiar dysesthesia, which is produced b}>- vari- ous sensory irritations ; it is a singular painful vibrating feeling in the lower half of the body, the same for all sensory impres- sions ; this sensation must also be referred to the disease of the gray substance. Symptoms of anesthesia are most constant, though they may vary greatly in amount; the anaesthesia is usually incomplete, and not rarely presents a certain contrast to the severity of the motor paralysis ; Courjon states that the sensibility is never quite destroyed in vertebral caries, though this certainly occurs 334 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. in other forms of paralysis from compression. A retardation of sensory conduction is also often observed. All these symptoms are very simply explained by the different degrees of compres- sion and of myelitis, by the greater or less implication of the gray substance, etc. There is very little said of vaso-motor paralysis in the existing reports of cases; only Hawkins states that he has observed a constant elevation of the temperature of the paralyzed half of the body in a case of compression of the dorsal medulla. It is con- ceivable that the slow.progress of the interruption of conduction in the cord may give the vaso-motor centres, situated in the lum- bar region, time to develop sufficient activity to avoid serious vaso-motor disturbances. Paralysis of the bladder is usually a subordinate feature of compression-myelitis, especially when seated above the lumbar enlargement; it then seldom appears early or in a severe form. This depends on the seat and severity of the lesion, the integrity of the centres in the cord, etc. ; all shades of severity may be observed. The severest cases are those which accompany a pres- sure-myelitis of the lumbar medulla. The same is true of paral- ysis of the rectum. The condition of the reflex functions is especially interesting; an exaggeration of their activity is one of the most constant symptoms of pressure-myelitis, provided that the portions of gray substance which preside over the reflex actions are not dis- eased. The first thing which attracts notice is the increase in the cutaneous reflex actions, the lightest touch upon the skin pro- vokes a vigorous reflex jerk; if the skin is pressed or pinched more strongly, active and powerful movements of the entire extremity are made, which often extend to the other inferior extremity, or, in their severest form, terminate in a convulsive twitching and shaking of the limbs, which may continue some time. The reflex actions originating in other parts are also in- creased ; every evacuation of the bladder or the rectum, the introduction of a catheter, etc., is accompanied by active, often painful, jerkings of the limbs. Irritation of the skin of the inner SLOW COMPRESSION OF THE CORD. 335 surface of the thigh, or of the urethra, has been seen to produce reflex erection of the penis. The tendinous reflexions, however, are most markedly devel- oped in such cases, and it is in myelitis from pressure that they are to be best studied. The lightest tapping of the patellar ten- don or the tendo Achillis, the tibialis posticus, the tendons of the flexors of the knee, gives rise to reflex actions; the same is often accomplished from the periosteum of the bones and from various fasche ; powerful pressure of the patella downwards pro- duces reflex clonus in the quadriceps ; the slightest dorsal flexion of the foot produces that clonic tremor of the lower leg, which in its highest degree extends to the whole leg, and then to the other leg, and terminates with an intense tremor of both legs, lasting some time. Nothnagel has recently stated that all these reflex actions may, in favorable cases, be inhibited and arrested by a powerful pressure upon one of the great nerve-trunks of the lower extrem- ities. It can hardly be doubted that this increase of reflex activity must be referred to two circumstances : first, interruption of the conduction to the brain, which interferes with the function of the fibres for inhibition of reflex action; and secondly, hyperaemia and inflammatory stimulation of the gray substance. It is not at present possible to determine the part taken by each of these circumstances in increasing the reflex action. It is interesting that a reflex action originating in a tendon, the centre for which is situated in the compressed region, may become extinct, and may afterwards reappear when the motility has returned and the pressure-myelitis is cured. I have observed this in a case of kyphosis of the lumbar region, in which the upper part of the lumbar enlargement was evidently compressed. As long as the paraplegia continued, the tendinous reflexions from the ligamentum patellae and the adductor tendons were completely extinct, while in the whole sciatic region they were considerably increased. After four months the paralysis disappeared, when the reflex actions from the ligamentum patella? and the adductor tendons re- appeared. Another step in the disease of the cord is indicated by rigid- ity of the muscles. We have seen that at first they are com- 336 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. pletely relaxed. In a few days, however, or more usually in a few weeks, or still later, the muscles begin to be attacked by twitchings and slight spasms; they assume a condition of ten- sion, oppose to passive movement a gradually increasing oppo- sition, and at last contractures appear, at first transient, then permanent, which affect the disease in a characteristic way. Usually these are at first contractions in extension; the legs lie stretched stiff and straight side by side, the feet in the position of varo-equinus, the knees stiff and pressed together. At a later period, especially in vertebral caries, contractures in flexion al- ways occur ; the hip and knee-joints are strongly bent, the knees drawn up, the heels to the buttocks, the legs often crossed and locked. At first the contractures are comparatively easy to reduce, but return whenever the traction is taken away; after- wards they resist all external force. It appears quite certain that these motor symptoms are refer- able to disease of the lateral columns, that they belong to the descending degeneration and sclerosis of the postero-lateral col- umns. They seem to be more marked in myelitis from pressure than in most other forms of the disease. Trophic disturbances are not very prominent in myelitis from pressure, as long as certain sections of gray substance (in the cervical and lumbar medulla) are not directly affected. The nutrition of the muscles then remains intact a long time, and so does their electrical reaction ; at the most we observe emaciation, caused by want of activity and by the general depression of the nutritive processes. The case is otherwise when the lumbar or cervical enlargement is affected, or when the secondary myelitis of the gray substance extends upwards or downwards to those parts ; the consequences, then, are rapid and great emaciation of the muscles, loss of faradic excitability, and the appearance of the reaction of de- generation. In a few cases, affections of the joints and skin have been caused by pressure-myelitis. Bed-sores are usually confined to the severer cases. The same is true of cystitis and other consequences of retention of urine. After this review of the chief symptoms, we have to say a few SLOW COMPRESSION OF THE CORD. 337 words of the variation in symptoms which is due to the differ- ent seat of the compressive lesion. The case- is most complicated when the lesion occupies the cervical part of the cord. And here, again, we can form two subdivisions, according as the cervical enlargement, or the part of the cord above it, is the seat of compression. In the latter case (compression of the upper part of the cervi- cal cord), the disease not rarely begins with pain in the occiput, stiffness of the whole neck, obliquity of the head, inability to nod and turn the head, and so forth. The paralysis often begins and continues in the upper extremities (paraplegia cervicalis), while the lower are wholly or comparatively free. At a later time there is palsy of all four extremities. The reflex actions are retained in the upper extremities. Other symptoms, however, now appear, which are quite characteristic of this seat of lesion, and are due to implication of the nerve-paths there situated. Such are: oculo-pupillary symptoms, either paralytic myosis (from paralysis of the corresponding paths in the cervical me- dulla), or spastic mydriasis (from irritation of the corresponding paths), either unilateral or bilateral; respiratory disturbance, from implication of the respiratory paths ; gastric disturbances, repeated vomiting, difficulty of swallowing, continued hiccup, to be explained by implication of the vagus, spinal-accessory, and phrenic. In many cases a striking and permanent retarda- tion of the pulse has also been observed, down to 48-20 beats in the minute, accompanied by fainting-fits with complete cessation of pulse ; these symptoms have been referred to irritation of the vagus (Charcot, M. Rosenthal); and finally, epileptic attacks have often been seen when the compression was situated at this point. If the cervical enlargement is compressed, the initial symp- toms of pain, anaesthesia, spasm, palsy, atrophy, are localized in the upper extremities; these are also the first to be affected, and the lower extremities follow later. The absence of reflex phenomena, and the atrophy which soon invades the upper ex- tremities (see above, description of Pachymeningitis Cervicalis Hypertrophica, p. 221 et seq.), constitute decisive proof that this is the seat of disease. In this form, also, one or several of the VOL. XIII.—22 338 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. above-named symptoms may appear (changes in the pupils, dis- turbances of respiration, retarded pulse, etc.), and complete the picture of the disorder. The portion most frequently the seat of compression is the dorsal region. The symptoms are very characteristic : girdle- pains, intercostal neuralgia at various levels of the trunk, para- plegia up to the corresponding level, reflex actions in the lower extremities retained and increased, nutrition of the muscles and their electrical excitability intact, etc. If the lumbar region is affected, the paralysis is confined to the lower extremities, the bladder, and rectum ; the initial symp- toms are localized in the lower extremities; reflex actions are absent, the muscles are permanently relaxed, are mostly atro- phic, exhibit the reaction of degeneration, etc. The paralysis of the bladder and rectum is complete, and severe at an early period. It scarcely need be mentioned, that the diagnosis of the loca- tion may be sustained and confirmed by various symptoms con- nected with the vertebrae—kyphosis, swelling, painfulness, etc. If only one lateral half of the cord is compressed, the charac- teristic symptoms of Brown-Sequard's unilateral lesion appear: motor paralysis and hyperaesthesia, and increased temperature on the side of the lesion, bounded above by a zone of anaesthesia, while on the opposite side of the body there is (crossed) anaes- thesia. (See below, No. 14.) Course, Duration, Termination.—All depends on the nature of the primal lesion. In meningeal and intra-medullary tumors (see the section on these) the disease almost always goes on with- out stopping to its termination; death comes sooner or later, after months or years, and always amid the painful accompani- ments of severe spinal paralysis—bed-sores, cystitis, fever, ma- rasmus, etc. The same is true in cases where vertebral carcinoma or other malignant tumors are the cause of compression, except that in these the fatal result is usually much more speedy. But it is otherwise in vertebral caries, which is by far the most common cause of spinal compression. In most of these, the course is comparatively favorable. A good many perish by SLOW COMPRESSION OF THE CORD. 339 the ordinary process of severe paraplegia, bed-sores, pyaemic fever, etc.; but the disease usually runs on more slowly to its end, with remissions and exacerbations, often after an apparent cure, if the vertebral disease is lit up afresh by an accident, a surgical injury, a severe cold, etc. In more favorable cases, the paraplegia remains unchanged and uniform for a considerable time (two, five, to ten months, one to three years); bed-sores do not appear, or, if they do, are healed. Finally, a slow improvement begins ; a few movements can at times (for example, when in the bath) be executed by the paralyzed parts; then they are resumed permanently, grow stronger, the contractures disappear, sensibility improves, the function of the bladder is again controlled by the will, the excess of reflex action diminishes. The patient then succeeds in stand- ing, and by degrees learns to walk, at first with crutches, then with a stick, and then without help. Thus he may be completely restored; but a number of months is always required for the pur- pose. Such kyphosis as is present may remain without any change ; evidently nothing has occurred but a diminution of the exudation in the spinal canal, by which a resumption of use, and repair of structure, has been rendered possible. The result is not always so completely favorable. Restora- tion may remain imperfect; partial paralyses and contractures, local atrophy and anaesthesia, weakness and clumsiness in the use of the limbs, remain. Such persons are always in danger of a relapse, and any external injury may arouse the sleeping dis- ease. Diagnosis. The entire group of symptoms, their beginning and succession, usually enable us to decide with ease that a slow compression of the cord exists. Of characteristic importance are the initial root- symptoms, which give warnings for a long time previous; and afterwards, the more or less rapid occurrence of paraplegia with increased reflex action, with muscles at first entirely lax, after- wards more rigid, etc. The only point which usually presents difficulties is that of 340 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. the cause of the compression. In many cases it will be quite im- possible to ascertain the cause, as in small exostoses of the ver- tebrae, in meningeal tumors, etc. In the ordinary cases, the points of diagnosis will be furnished by the external circumstances, those belonging to the primary disease as such, although these will not always insure a correct decision. We will give some instances. Potts disease usually presents the symptoms in their typical form, and the actual cause of them cannot be ascertained unless other symptoms, especially characteristic of spondylitis, are present—the gradual formation of kyphosis, especially if angu- lar ; painfulness of movements of spine ; great tenderness of spi- nous processes when touched ; severe pain when the electrodes of a galvanic current are placed close to the diseased vertebra (M. Rosenthal); abscesses of congestion; youth on the part of the patient, especially if he be scrofulous; in older persons, a pre- vious traumatic lesion, etc. In vertebral carcinoma, the violence of the initial pains is usually regarded as characteristic, but there are so many excep- tions to the rule that this circumstance ought to be allowed, at most, only to establish a suspicion. The girdle-pains and other pains of excentric origin are often of fearful violence, and occur in paroxysms, especially by night. Great hyperaesthesia usually exists in the painful region, together with all other possible root- symptoms. The localization of the pain in the back close to the vertebral column is said to be characteristic (Gull). If, in addi- tion, there exist a local pain in the vertebrae, progressive, round curvature of the column, symptoms of compression of the cord, an external prominence and general cachexia, the diagnosis be- comes plainer, and the more so if a primary cancer can be shown anywhere else (as, for instance, in the breast)—the search for which should be a first duty. Yet it is possible to confound this affection, in its first stages, with almost any other one which com- presses the roots. In respect to meningeal tumors we have mentioned the most important points above (p. 262 et seq.); they are usually charac- terized by slow development, and also, to some extent, by the absence of every symptom of vertebral disease. SLOW COMPRESSION OF THE CORD. 341 In regard to the intra-medullary tumors we shall speak more in detail farther on (see No. 18). It is doubtless extremely hard, in most cases, to distinguish them from cases of circumscript trans- verse myelitis of spontaneous origin. We merely remark here that the initial symptoms of irritation of the roots are usually absent, and that they open with symptoms of compression and myelitis caused by pressure. The diagnosis of the rarer causes of compression of the cord— gout of the vertebrae, exostoses, syphilitic new formations, aneu- risms, etc.—is made from the signs which are applicable to these diseases, though their uncertainty is well known. Prognosis. This follows easily from what we have stated, and depends in the first instance upon the fundamental disease. Carcinoma of the vertebrae, tumors of the meninges, exostoses, etc., are never recovered from. If they lead to compression of the cord, the prognosis is very bad, or absolutely fatal, and the most that can be hoped for is some modification of the duration of the disease, depending on the original cause and the greater or less rapidity of its progress. Cases due to compression by syphilitic formations, perimenin- geal exudations, and vertebral caries, are curable. The question whether restitution and repair of myelitis from compression is possible must be answered decidedly in the affirmative. Wher- ever the cause of compression is capable of removal, the cure of the paraplegia may be expected. This seems to be far from uncommon in Pott's disease. Among six cases of paraplegia from vertebral disease which have come under my observation in the past year, five, including two adults, have been cured or decidedly improved, and only one has terminated fatally. A similar result is reported by a great many (Leudet, Charcot, Courjon, and others). Accordingly, the prognosis of such paraplegias is to be stated as compara- tively favorable, with a certain reservation. A good recovery may be especially looked for in young, pretty well-nourished persons, in whom the disease of the bone has not assumed con- 342 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. siderable dimensions, or led to large abscesses of congestion, and who also are not very scrofulous. Complete recovery, with the exception of the permanent deformity of the spinal column, seems to be a possible thing. In many cases, however, we must be content with an imperfect recovery. Treatment. Little can be said of this. In cases of severe lesion (carci- noma, exostosis, meningeal tumor, etc.) there is simply nothing to do, and we must be content with a symptomatic treatment for the relief of pain and other discomforts, and for prolonging the patient's life as much as possible. The only object which repays treatment is formed by the cases of spondylarthrocace; a steady persistence in the use of rational means will often lead the disease to a more favorable course and gradual recovery. It is not our object here to enter into details regarding the treatment of vertebral caries, but only to cast a passing glance upon it. First of all, the spine should be kept in repose as nearly as possible, for which purpose rest in bed for months on the face or back is necessary. Apparatus for support or protection of the spine may be very useful in cases where movement is unavoida- ble, or is required for other reasons, or, finally, when the im- provement has made a certain degree of progress, and the spine requires still further care. The physician must be earnestly warned of the danger of those mechanical manipulations which are so often employed by ignorant orthopedists and bandagers for straightening the spine and relieving the curvature. It is quite certain that kyphosis is not usually the cause of para- plegia. In general, a tonic treatment is to be recommended—good, abundant diet, such as is specially suited to scrofulous patients, fresh air, iron, quinia, cod-liver oil. For the disease of the bone itself, preparations of iodine are much in favor ; iodide of potas- sium, or still better, iodide of iron, and externally, painting with tincture of iodine, or friction with strong iodine ointment. In SLOW COMPRESSION OF THE CORD. 343 proper cases, leeches or cups may be applied to the spine. Derivatives, vesicants, moxae are great favorites. The white-hot iron has lately been repeatedly advised as peculiarly efficacious in Pott's disease (by Charcot, and others). Every two weeks, on each side of the curvature, from two to four eschars are to be made of the size of a half-mark piece (sixpence sterling), and passing through the entire skin. Strikingly good results have been observed from this treatment even in late stages of the dis- ease. Brine-baths or warm sea-baths may support this treatment in many cases. For the myelitis from pressure little can be done until the cause of compression is removed. In the cases, which have been before described, where the cause is not removable, we had better not undertake any treatment for the relief of myelitis. In vertebral caries, also, we should do best to put off this branch of the treatment until the compression begins to dimin- ish ; but inasmuch as this point cannot be defined, and as the hope of doing good is likely to influence us at an early date, we shall usually find ourselves justified in employing the customary remedies for the relief of chronic and subacute myelitis (cf. be- low, Treatment of M}^elitis). These include local bloodletting, derivatives, frictions with mercurial ointment, the exhibition of iodide of potassium, pencilling with iodine, etc. When the process of regeneration has begun, there are various remedies which may possibly hasten it, as the continued use of nitrate of silver, iodide of potassium, iodide of iron, quinia, strychnia (used with the utmost caution), moderate hydropathic measures, and most especially the galvanic current. Ollivier (p. 481) gives a case, in which galvano-puncture was apparently fol- lowed by good results. I have acquired the impression from my own experience that a moderately strong galvanic current, applied in the stabile way to the point of lesion, decidedly favors the restoration of the spinal functions. I place the poles upon the spine, one above, the other below the seat of disease, and pass a weak current, at first in one direction and then in the other, for two or three minutes in all, once a day. I have never seen this do harm. Patience and perseverance are of course required for this. 344 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. The symptomatic treatment of the chief special symptoms (pain, spasm, atrophy, bed-sore, cachexy, cystitis, etc.) is gov- erned by general rules. When a cure is effected, the patient should be strictly warned against fresh injuries, which might bring on a relapse of his com- plaint. 6. Concussion of the Spinal Cord — Commotio Medulle Spi- nalis. Abercrombie, Diseases of the Brain and Spinal Cord. German tr. by G. v. d. Busch. 1829. p. 520.— Ollivier, L. c. I. p. 488.— Leyden, L. c. II. p. 92.— Holmes, System of Surgery. Vol. II. p. 238.— Clemens, Die Erschutterung des R.-M. und deren Behandlung durch Elektricitat. Deutsche Klinik. 1863-65.—Lidell, On Injuries of the Spine, including Concussion of Spinal Cord. American Journ. of Med. Sci. Oct. 1864.—Erichsen, On Railway and other Injuries of the Ner- vous System. German tr. by Kelp. Oldenburg, 1868.— Webber, Recovery after Four Years' Paralysis, following Railway Injury. Boston Med. and Surg. Journ. July 18, 1872.—Morgan, Injuries of the Spine, Result of Railway Concussion. Med. Press and Circular. Jan. 1873.—Scholz, Ueber Ruckenrnarkslahmung und deren Behandlung durch Cudowa. 1872. p. 76.—Erichsen, On Concussion of the Spine, Nervous Shock, and other Obscure Injuries of the Nervous System. London, 1875. / Introduction and Definition.—Under the term, "Concussion of the Spine," we include those cases in which, energetic trau- matic influences (falls, blows, collision, etc.) have given rise to severe disturbances of the function of the cord, without any considerable visible anatomical changes in the latter. Slight changes, small capillary extravasations, etc., probably exist in such cases, but they do not seem to constitute the proper es- sence of the disease; for the most part, the anatomical change is quite negative, and we do not yet know what changes, if any, constitute the basis of the concussion proper. In the preceding chapters we have considered cases in which severe traumatic injuries have given rise to coarse anatomical lesions—hemorrhages, crushing, hemorrhagic softening of the cord, etc. We have now to deal with cases in which this does not occur, and yet there are severe spinal symptoms. Whether these two classes of cases are different only in degree, and may CONCUSSION OF THE CORD. 345 gradually run into one another, we will not try to decide ; but it does not seem very probable to us. We rather incline to the view that the concussion of the cord is a very peculiar kind of disturbance, and that more or less of it is usually present in those severer lesions, but concealed to some extent by the symp- toms. We may here assume a similar relation to that which exists between concussion and contusion of the brain ; the for- mer being a condition unaccompanied by any certain and con- stant anatomical changes, and the latter involving crushing and destruction of brain-tissue. We may here include with safety the conditions which have been named shock of the spinal cord. The diagnosis is in many cases so uncertain, and the want of satisfactory evidence from autopsies so great, that the history of the disease is still surrounded by darkness. We shall, there- fore, be as brief as possible, consistently with the great practical importance of the subject. Etiology and Pathogenesis. The most usual cause consists of a fall of moderate height upon the feet, buttocks, back, and less frequently on both arms outstretched and stiff. I have observed the symptoms in two ladies, produced by a fall on the ice and on a polished floor; a fall on the buttocks caused by slipping down stairs is often men- tioned as a cause. A blow from a heavy body in motion, striking the spine or trunk, acts in quite the same way. A sudden shock to the whole body produced by the sudden cessation of a rapid motion—as occurs in a collision between vehicles—is a common cause of concussion ; of late years railway accidents have played a very prominent part in such injuries, the rapidity of their movement essentially increasing the force of the shock. They sometimes seem to produce quite special forms of concussion, and have been carefully studied, especially in England, where the suits for damages against the railway cor- porations have given them a very great practical importance. The action of any of these mechanical causes may be limited 346 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. more or less to a portion of the cord, when the spinal column has been directly struck; but it may extend to a great part or the whole of the cord, if the shock has been indirect, or has affected the entire system at once. Severe symptoms do not always follow directly upon the accident; they are often delayed for weeks or months, and may not appear until some other in- jury has been received. We must then assume that the shock has only produced a certain tendency to disease of the cord. All these mechanical causes may produce a more or less con- siderable lesion of the soft parts or the spinal column ; which is quite a matter of accident. Besides the mechanical causes, there are others capable of producing symptoms very like those of concussion of the cord, which we will not omit. Clemens speaks of excessive coitus, conjoined with unusual excitement, or suddenly interrupted, or practised in the upright posture, as a not infrequent cause of a certain sort of concussion of the cord, said to be indicated by sudden weakness, collapse of muscular force, and subsequent severe spinal symptoms. Violent mental excitement, especially fear or anger, is con- sidered to play a similar part, and the paretic symptoms which often follow such excitement are referred to the cord ; but the nature of the connection is quite obscure, and seems to us to be effected rather by congestion or myelitis, than by a change re- sembling concussion. Finally, there is no doubt that a stroke of lightning often causes a general shock, in which the spinal cord participates, and which causes speady death. The person struck often re- covers, but with paralysis, paraplegia, etc., for various periods of time, for which no anatomical basis has been found. A sort of concussion is, therefore, supposed to be experienced in such cases by the central nervous system, and in a few cases by the cord especially. We cannot form an exact idea of it at present. The pathological anatomy of concussion of the cord is ex- tremely imperfect. In many cases which are examined at an early period, nothing at all is found in the cord, or at most one or two small unimport- ant extravasations of blood. Leyden reports a case which ended CONCUSSION OF THE CORD. 347 fatally in five days, in which the most careful examination dis- closed no alteration of the cord. In other cases anatomical changes are found, which are not severe enough to be considered causes of death ; large and small clots, crushings, softenings of the cord in various places, etc. In cases which terminate in death after a long time, chronic inflammatory changes may be found ; it is supposed nowadays that chronic meningitis and myelitis, and various forms of gray degeneration and sclerosis, may gradually develop out of con- cussion ; but this is not determined with sufficient precision. It is, therefore, rather rash to entertain a decided opinion re- garding the proper nature of concussion of the cord. It seems to be certain that the anatomical report is a negative one. The most common view, therefore, is that which supposes only molec- ular changes in the finer nerve-elements to have occurred, giving rise either to an immediate and complete functional paralysis of the latter, or forming the commencement of further disturbances of nutrition, which at a later time may result in degenerative inflammation. H. Fischer1 has recently attempted to develop, in a complete form, another view of the cause of shock and concus- sion. He considers that which is known to surgeons as shock to be nothing more than a traumatic reflex paralysis of the vascular nerves ; the concussion of the brain simply a shock localized in the brain, a traumatic reflex paralysis of the cerebral vessels. Scholz has applied this view directly to concussion of the spine. We cannot see that Fischer's argument is convincing ; it is hard to understand why, in so severe a shock, the vascular nerves alone should be paralyzed, to the exclusion of the other nervous elements; we rather believe that the latter are affected to at least as great a degree. This of course shakes the foundation of Scholz's application of Fischer's hypothesis to the cord. For the present our opinion is that the molecular disturbance is the chief element in concussion. Such anatomical changes as may be present in individual cases are accidental and not essen- tial adjuncts. It is perfectly evident that concussion of the cord must very often be complicated with contusion, hemorrhage within its substance, etc. 1 Volkmann's Samml. klin. Vortr. Nos. 10 and 27. 348 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. A very interesting statement has been made by Erichsen!—although it is not at present quite easy to interpret—to the effect that persons who are sleeping at the moment of a railway accident do not, as a rule, receive a concussion of the nervous system. Those sitting with their backs to the direction from which the shock comes, are the most severely injured. The same author draws an excellent com- parison between the effect of a violent mechanical impression upon the cord, and the loss of magnetism in an iron bar which is struck with a hammer. Symptoms. The phenomena of concussion of the cord may yary very much ; there are many circumstances which influence it, such as the nature and the severity of the traumatic lesion, the degree of individual resistance, perhaps also neuropathic influences, the external circumstances as regards the care received, and the rest taken, with a variety of other matters. In fully developed cases the essential point lies in the pres- ence of a sudden, more or less complete loss of the spinal func- tion ; if the concussion is local, this may be confined to the parts below the point of shock ; if diffuse, it may extend to the greater part of the body. We observe accordingly a more or less exten- sive paralysis and anaesthesia, coldness, cyanosis, weakness of the pulse, disturbance of respiration, retention of urine, etc. In some cases there is a gradual and imperceptible shading from slight weakness and relaxation to the severest palsy. After some minutes, hours, days, or even weeks, movement and sensation return slowly; often there is no other phenomenon developed until recovery is complete; more often, however, a sort of stage of irritation follows, to which chronic inflammatory spinal disease may be added; the latter may under some cir- cumstances last a long time and result badly. Not every case, however, begins with severe symptoms ; there exists a class of cases which ought, without doubt, to be included here, which, commencing with the most trifling symptoms, after- wards develop into a serious chronic spinal disorder. The result is the production of a great diversity among the individual cases of concussion of the cord. For convenience we present here the following principal groups in outline : 1 On Concussion, etc. p. 120. CONCUSSION OF THE CORD. 349 a. General and very severe symptoms at the instant of in- jury. Death in a short time. Severe form of shock. The patient, after receiving some severe injury or other, is found completely paralyzed in all his extremities, with distinct anaesthesia, great prostration, often, though not always, with dis- turbance of consciousness, with involuntary evacuations. The pulse is very small, weak and slow, the skin cool and pale, or slightly cyanotic, the respiration disturbed, dyspnoic, etc. In a few hours or days death occurs amid general prostra- tion, increasing collapse, and paralysis of the respiration and circulation. In this class must be included the cases of severe injury to the cord which end fatally in a day or two without any visible lesion (as crushing) which should necessarily involve death. These disturbances are plainly due to a severe molecular con- cussion of the substance of the cord, whereby its internal nutri- tion is impaired and arrested. b. Severe symptoms at the moment of receiving the injury. Cure in a short time. Slight shock. Immediately after the accident the patient is found, usually in full possession of consciousness, complaining of severe and general pains in his body or in the lower half of it. The lower extremities, less commonly the upper also, are more or less severely paralyzed; usually there is anaesthesia also, but the latter is not always present, and often is but slight. The blad- der is not always paralyzed. There are no symptoms of spasm. If such a case is seen within a moderate time after the accident, the reflex function, especially that connected with the tendons, may be found exaggerated, and the electrical reaction in the paretic parts may be increased or depressed. In a few days improvement appears ; the patient regains the power to stand and walk, but slowly, hesitatingly, feebly, and with tremor. The pains disappear; improvement makes rapid progress, and in a few weeks the recovery is complete. As an example of this form I repeat the following case in brief. Johann Schaefer, set. 55, day-laborer, four weeks ago fell a distance of twenty feet from a tree, landing on his feet and buttocks. He was not unconscious, but was paralyzed immediately, and had to be carried home. The following symptoms 350 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. were there observed: violent general pains in the loins and legs. Legs quite para- lysed and immovable for about a week, when improvement gradually commenced, so that the patient can now walk a couple of steps. The sensation of the legs was always good ; no anaesthesia was observed. Evacuation of the bladder always nor- mal. Stool retained the first day, afterwards regular. The pains have disappeared by degrees, but the legs still tremble and are stiff. Present condition.—The patient can scarcely walk two steps, and does it slowly, hesitatingly, dragging his feet, but without ataxia. Standing on the toes or on one foot is very difficult. Both legs tremble when he stands. Sensibility of the lower extremities quite normal. Cutaneous reflex functions retained. Tendinous reflex function strikingly active. No distinct atrophy of the legs. The electrical excita- bility of the nerves and muscles of the lower extremities is remarkably depressed, without qualitative change. Sphincters and upper extremities quite normal. No change in the back and vertebral column. Region of sacrum somewhat sensitive to pressure. The galvanic treatment (to the spinal column and legs) was wonderfully success- ful ; after a few sessions the patient was able to walk quite well, and was discharged cured after twenty-two (daily) sessions. The electrical reaction was again almost normal. c. Severe symptoms at the first; followed by a protracted ill- ness of some years'* duration ; recovery in most cases. Shortly after the accident, the patient displays great weak- ness, which rapidly increases to a paralysis of various extent, often embracing all the extremities. With this are associated acute pains, more or less diffuse, often chiefly located along the spine, in the back of the neck, and loins. Paresthesia occurs; cutaneous anaesthesia is not usually very marked. Retention of urine and retardation of pulse occur. In many cases an impli- cation of the brain is indicated by unconsciousness and vomiting at the first; or by an increased irritability of mind afterwards. Slow and gradual improvement occurs; great weakness of the extremities, slight atrophy of the muscles, acute pains and great sensitiveness remain. The extremities are cool and livid, the vertebral column is painful to pressure, and often excessively sensitive. The patient is obliged to learn to walk by slow de- grees. After a long time—often years—a condition which ap- proaches recovery is attained; but the patient always remains irritable and sensitive, and has to guard against injury. The following may serve as an illustration: CONCUSSION OF THE CORD. 351 Miss X., aged twenty, in April, 1872, slipped and fell on a polished floor, com- ing down on her seat. She immediately felt a severe pain in the back of the neck and loins, with great weakness, but was able to go into another room. In a quarter of an hour she vomited, the pains increased, there was severe paresis of the entire body, so that she could not even raise her head. All efforts to move were extremely painful, and she was excessively sensitive to light. Vertebrae very sensitive to pres- sure ; numbness of hands and feet, oppression of the chest, weak and slow pulse; such were the leading symptoms at first. U.hic retained only during the first day. In the third month she begins to be able to lift her head a short time; the feelings of proecordial distress disappear; afterwards the movements of hands and feet are recovered. At the beginning of September the patient can walk a few steps, if supported. Improvement very slowly progressing. At the beginning of June, 1873, I found the patient a fresh, healthy girl in appearance, but with very excitable nerves. In walking—for which a slight support is required—a marked slowness and difficulty in performing the motions strikes the observer. Her back seems weak, and vacillates in various directions. In a few minutes she sinks upon her knees, and is forced to sit down. Standing is accom- plished tolerably well for a considerable time. Sitting without a support for the back is possible only for a short time. No ataxia. Given movements are easily executed with the legs, but without force. Arms and head quite free from symp- toms. No difficulty with the bladder, no sense of constriction, no palpitation of the heart. Sensibility normal everywhere; slight numbness is said to be felt occa- sionally in the soles. Spinal column straight, easily moved. The spinous pro- cesses of the cervical and upper dorsal vertebrae, and those of the lumbar vertebrae, are very sensitive to pressure. Galvanic treatment is carefully commenced, and is followed by a rapid and progressive improvement. By the middle of August the patient can walk quite securely without a stick. She then makes use of the cold-water treatment in Switzerland, from which she returns with fresh improvement. Another five weeks' course of galvanic treatment is also attended by good results. The patient was fully cured in the course of the year 1874, and in 1875 was married. d. Very slight symptoms at the beginning; a severe progres- sive spinal disease develops after a longer or shorter time. Re- sult doubtful. At the first moment—e. g., if a railway collision—the symp- toms are very insignificant. The patient has a sensation of hav- ing been severely shaken, a momentary weakness, perhaps some confusion of mind, but soon recovers, picks himself up and walks about, dismisses apprehension from his mind, and goes on his journey. On the next day, or several days later, or even after weeks 352 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. and months, more threatening symptoms set in, perhaps pre- ceded for a considerable time by very slight and unnoticed premonitions. A general depression of strength, sleeplessness, slight mental indisposition, tendency to shed tears, etc., may be noticed ; the patient cannot attend to his usual business ; pains appear in the back and limbs, and gradually increase. Out of these symptoms a group gradually develops, which is very far from being identical in given cases, but which in general presents the following as its chief features : increasing weakness of the legs, which may reach different degrees of severity; the gait is uncertain, straddling, stiff, and dragging; uncertainty in standing, indications of disturbed co-ordination are often present. Stiffness of the back and the general attitude. Back painful, especially when moved ; some of the spinous processes extremely sensitive. Girdle-sensation, paraesthesia of all sorts, anaesthesia of various degree and location, and often hyperaesthesia. Weak- ness of the bladder, diminution and loss of sexual power. Im- paired general nutrition, pale sallow complexion, changed ex- pression of countenance. Marked atrophy in certain muscles and groups of muscles, often quite extensive. Disturbances of circulation, bluish complexion, cold extremities, etc. With these are usually conjoined symptoms which point to a disturbance of the cerebral functions ; broken, poor sleep, timid- ity and irritability, weakness of intelligence, impairment of memory and of power to work, change of character, constriction of the head, increased irritability of the senses, etc. These are essentially the marks of a very slow meningo-my- elitis, associated with more or less considerable disturbances of the cerebral functions. The subsequent course of the disease usually fluctuates a good deal. Periods of apparent improvement and comparative health alternate with those of downward progress. On the whole, a gradual loss usually occurs; a favorable result is sel- dom seen; but cases occur in which, after a very long time, the disease has considerably improved, or at least has ceased to make progress. This category is largely composed of the cases which Erichsen has so admirably described; they have been observed more fre- CONCUSSION OF THE CORD. 353 quently of late, especially as a consequence of railway accidents, and have acquired a great practical importance in connection with the latter {railioay-spine of the English). They may, how- ever, equally well follow other severe concussions of the body, and especially of the back. Clemens describes a similar case, in which, after a fall from a scaffolding, atrophy and paralysis began to appear three-quarters of a year after the accident. The two last observations by Scholz are excellent instances of this form of concussion. There are various cases of progressive mus- cular atrophy originating in surgical injury which might be in- cluded here. Diagnosis. It is a matter of no small difficulty to establish a concussion of the cord with certainty, since the symptoms, especially at the beginning, possess a very close resemblance to those of slight hemorrhages or contusions of the cord. The entire group of concussions of the spinal cord is still somewhat doubtful and undefined, and by many is only retained in order to serve as a receptacle for certain cases which cannot otherwise be easily interpreted. We shall make an attempt at a stricter definition. The distinguishing character of concussion is the fact that, in consequence of some one of the above-mentioned causes (espe- cially a traumatic lesion), severe disturbances of the functions of the cord occur, while at the same time the entire course of events shows the absence of any severe anatomical lesion, such as often actually follow such accidents. The case may then take one of two forms: either (1) severe disturbance quickly appears, most severe immediately after the injury, and is followed in a comparatively short time by improve- ment, disappearance of the grave symptoms, until recovery is complete; or (2) no symptoms appear at first, or at most only trifling ones, the functions of the cord are comparatively free, the idea of a severe anatomical lesion of the cord seems inadmis- sible, and yet after a longer or shorter time severe and increasing disturbances do follow, which indicate a profound affection of VOL. XIII.—23 354 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. the cord. In both cases we shall be compelled to assume the existence of molecular changes due to the traumatic lesion. Either class, however, may give rise to mistakes. Cases of the first class may be mistaken for crushing and contusion of the cord, with haematomyelia and haematorrhachis. The symptoms of all these may be very much alike at the begin- ning ; but it is not impracticable to draw the diagnosis. Concus- sion agrees with crushing and tearing and with haematomyelia, in the severity of its initial symptoms, its paralysis, etc. ; but its course is much more rapid and favorable. This point is entirely decisive. When, therefore, an apparently severe paraplegia comes to a favorable ending in a few days or weeks, without bed-sores, etc., we should assume the existence of concussion. The rapidity of recovery and the favorable termination belong to haematorrhachis and to concussion; but the initial symptoms are different, being usually more severe in concussion. In hae- matorrhachis the preponderant symptoms are those of pain and spasm ; the paralysis is slighter; in concussion the opposite is usually the case. The hypothesis of a concussion may be favored by the follow- ing circumstances: distribution of the paralysis over the entire spinal region without the corresponding disturbance of respira- tion and the rapidly fatal result which are the regular conse- quences of crushing of the cervical region; paleness and coolness of the skin, small, retarded pulse, absence of dislocation or fracture of the vertebrae, absence of pain and stiffness of the back at the commencement, etc. Cases of the second class are not essentially distinct from those of myelitis or myelo-meningitis with a slow beginning, and are to be known only by the cause—the immediate and un- questionable connection of the symptoms with some traumatic or similar cause. The concussion should then be regarded only as the cause and starting-point of an organic disease. We believe that the points of view we have taken will enable the reader to form at least a more correct judgment and a clearer definition in many cases of concussion of the cord. Much re- mains to be done in this respect; the first thing consists in col- lecting accurate reports of cases, avoiding, more carefully than CONCUSSION OF THE CORD. 355 has hitherto been done, the intermixture of other sorts of lesions. The diagnosis will have to remain very obscure in many cases; it will of course be the most difficult, where with the concussion there exists at the same time some severe lesion, as crushing or bleeding of the cord. In such cases it will often be impossible to make an accurate diagnosis ; but in many a careful sifting of evidence will perhaps succeed in distinguishing the two classes of injury. The diagnostic evidence will here consist in the dis- appearance of the symptoms of concussion from a part of the body—a reduction, as it were, of the functional disturbance to that point where it is properly commensurate with the anatomi- cal lesion. Prognosis. In the severest forms of concussion of the cord, known as shock, the prognosis is always very grave. The lighter cases of this sort mostly recover; if improvement rapidly occurs, and good care is taken of the patient, the prognosis will be quite favorable. It is, on the whole, not very bad, when compared with the severit}^ of the brief initial symptoms. At all events, cases with severe initial symptoms seem to be the very ones which warrant a favorable prognosis as compared with those whose development is slow (Erichsen). But even in protracted and sluggish cases, the prognosis is not absolutely unfavorable. If distinct myelitic or meningitic symp- toms appear, the prognosis must be made as for these diseases ; but even in the latter case, an attack which originates from con- cussion in a comparatively well person admits of a more favor- able prediction than one of spontaneous origin. But when the improvement ceases, when after one or two years of rational treat- ment it makes no further progress, recovery is hardly to be ex- pected. If there is a severe anatomical lesion along with the concus- sion, such a lesion determines the prognosis when the danger of shock is over. 356 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Treatment. According to the form assumed, the treatment must vary. In many cases the most urgent indications are those for treat- ment of shock. We must first make a most careful examination, must observe the pulse, the respiration, etc. A quiet and easy place to lie, warmth to the body, covering with warm clothes, rubbing the skin, are the first things to attend to. Then, in most cases, stimulants must be given in full doses ; we should select, according to circumstances, wine, coffee, tea, hot spirit and water, cognac, and the like ; or such drugs as aromatic spirit of ammo- nia, ether, musk, camphor, etc. In severe and threatening cases, strong cutaneous irritation is indicated, large sinapisms and vesi- cants, the faradic brush, etc. It must be decided by further ex- periments whether the subcutaneous injections of strychnia em- ployed by Leyden will be serviceable. Bloodletting, formerly very popular, must always be used with care in such cases; we may employ it in certain cases of robust persons, of full habit of body, if their pulse is strong, the temperature normal or increased, the spinal column decidedly painful at one point, or if we suspect some anatomical lesion, etc. We shall rarely have reason to use general bloodletting; the local will usually suffice. In the second place, we shall have to treat symptoms of reac- tion. Here, too, absolute rest in a suitable position is required ; if the patient does not bear lying on the side or face, he may lie on his back upon a couch tilted down at its foot (Erichsen). According to the violence of the symptoms, we shall then have to use the ordinary remedies for hyperaemia of the cord, for slight meningitis and myelitis—cold, moist or dry cups, derivation to the skin and intestine, ergot, iodide of potassium, etc. A careful watching of the period of convalescence is necessary after these symptoms have passed away. The patient must care- fully avoid all injurious things; especially, he must strictly abstain from bodily and mental excess of work, sexual excesses or excitement, colds, unusual jarring of the body (as by long drives, driving in bad roads, etc.); and he must be careful to get enough sleep. Recovery can often be favored by careful friction SPINAL IRRITATION. 357 with cold water, by moderate use of the galvanic current (ascend- ing and stabile through the spinal column), or peripheral fara- dization ; by the careful use of chalybeate spring-baths abound- ing in carbonic acid (Cudowa, Schwalbach, etc.); also, by the internal use of tonics, iron, quinia, cod-liver oil, etc. Strychnia should not be resorted to until all the symptoms of irritation are past. Patience is necessary, as many of these cases last a des- perate while. It remains to speak of the treatment of the seauele, tedious and often severe, which follow so many cases of concussion of the cord. In most of these cases the treatment of chronic myelo- meningitis will be appropriate. Quiet, and a well-ordered life, are of the first importance, and after this we may attend to the administration of special remedies, according to the usual princi- ples—of which the chief will be the galvanic current, derivations to the skin, and iodide of potassium. Erichsen praises the effi- cacy of a combination of corrosive sublimate and quinia. The preparations of strychnia and iron will not be called for until a later period, when things have taken a favorable turn. The mineral springs are of especial importance in these cases ; a pro- per selection is difficult to make, in the present state of our knowledge. Thermae, especially the hotter ones, seem decidedly injurious, while moderate and careful cold-water cures seem dis- tinctly useful. Scholz praises the Cudowa springs as the chief resource in most cases of concussion of the cord; he states the indications somewhat thus : Cudowa is indicated in all pure, un- complicated cases of concussion; in the later periods it is espe- cially indicated when there are few inflammatory symptoms, even in marked paralysis and anaesthesia. Cudowa is nearly useless for distinct meningitis. In all circumstances, the treatment of these severe and pro- longed cases requires great care and skill. 7. Functional Irritation of the Spinal Cord—Spinal Irr Ha- lation. Stiebel, Rust's Magazin. XVI. p. 550. 1823.—C. Brown, On Irritation of the Spinal Nerves. Glasg. Med. Journ. No. 2. May, 1828.—T. Pridgin Teale, A Treatise 358 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. of Neuralgic Diseases dependent upon Irritation of the Spinal Marrow, etc. 1829. —Hinterberger, Abhandlung fiber die Entziindung des R.-M. u. s. w. Linz, 1831.— w. and D. Griffin, Observations on Functional Affections of the Spinal Cord, etc. London, 1834.—Ollivier, 1. c. II. p. 209.—Stilling, Physiologische und pathol. etc., Untersuch. fiber die Spinalirritation. Leipzig, 1840. — Tuerck, Ab- handlung iiber Spinalirritation. Wien, 1843.— G. Hirsch, Beitr. zur Erkenntniss und Heilung der Spinalneurosen. Konigsberg, 1843.—Eisenmann, Zur Spinal- irritation. Neue med.-chir. Zeitung. 1844. No. 1.—A. Mayer, Ueber die Un- zulassigkeit der Spinalirritation als besondere Krankheit. Mainz, 1849.—Die Lehre von der sog. Spinalirritation in den letzten 10 Jahren. Archiv der Heilk. I. I860.—Romberg, Nervenkrankheiten. 3. Auflage Bd. I. p. 184. 1853.— Wunderlich, Handb. der Pathologie und Therapie. 2. Aufl. III. p. 28. 1854.— Axenfeld, Des nevroses. Paris, 1863. p. 284.—Radcliffe, Reynolds' System of Medicine. II. p. 640. 1868.—Beard and Rockwell, A Practical Treatise on the Uses of Electricity, p. 350. 1871.—Hammond,!, c. p. 397. 1873.— Leyden, 1. c. II. p. 3. 1875. Introduction and Definition.—A good deal of change has taken place in the views entertained respecting the existence, the pathological position and significance of the group of symptoms which has been so well known by the term "spinal irritation" since the time of Brown (in 1828). Sometimes greatly overrated, its importance and frequency exaggerated beyond limit, and used as a common term for many most heterogeneous forms of disease in which pain of the back and sensitiveness of the verte- brae happened to be present, spinal irritation has been considered one of the commonest of diseases ; while again, at the time when pathological anatomy was made the sole judge of everything, it was entirely denied recognition, or regarded as at most a frequent and rather meaningless symptom, so that it has almost passed from the memory of the present living generation of physicians. No one, however, who has had much practical experience and who understands how to observe, can have failed to see that there is a considerable number of cases which by no means deserve to be confounded with hysteria, as has commonly been done ; and which, on the other hand, do not agree with the other forms known to us, especially the ordinary spinal complaints, while they exhibit a sufficient mutual resemblance and agree- ment. Such cases occur chiefly in the female sex. They are charac- SPINAL IRRITATION. 359 terized by a great irritability of the sensory functions, with motor weakness and debility, in which one of the most constant symp- toms is pain in the back and great sensitiveness of many spinous processes to pressure. In these cases the group of symptoms, as a whole, and the general course, unite to exclude with certainty any coarse anatomical lesion of the nervous system. These diseases, which are distinguished by the great incon- stancy of the symptoms, and a great variety in the localization and the apparent nature of the case, but which possess certain essential features in common, we will name "spinalirritation," and we justify the use of the term by claiming that the disease it represents is sufficiently characteristic in form. It must be ad- mitted that the term is only a symptomatic one, as long as the pathological anatomy is so completely in the dark. We would state plainly, that the idea of spinal irritation involves its own complete series or group of symptoms ; and that all other known forms of disease, especially all organic diseases and tangible anatomical lesions, must be excluded. Thus we throw out all those cases which have so much confused our ideas of spinal irritation, in which the simple presence of spinal pain and tenderness have been supposed to prove the existence of spinal irritation. Spinal pain occurs in numberless diseases— hysteria, intermittent fever, many affections of the thoracic and abdominal organs (compare Tuerck's instructive presentation); but this does not imply that spinal irritation is present in these diseases. In hysteria, the entire series of symptoms often occurs, and so do, not infrequently, all other possible neuroses (intercos- tal neuralgia, migraine, spasm of the diaphragm, etc.). Never- theless, spinal irritation does occur in an isolated form, and deserves separate consideration. It is the duty of diagnosis to establish in each case the independence or the secondary nature of the disease. We have no more right to refuse to spinal irritation the claim to a separate existence, simply on the ground of the want of a known basis of anatomical lesion in the cord, than we have to do the same in acute ascending paralysis, in tetany, and many other diseases which betray an equally imperfect knowledge of pathological anatomy. 360 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. At all events, we believe that in the statement we are going to make, we shall present forms of disease with which practition- ers are well acquainted, and for which neither the diagnosis of "hysteria," nor general "nervousness," nor any known ana- tomical form of disease, sufficiently accounts. Etiology. The female sex is very much predisposed to the disease. The number of women suffering from spinal irritation is far greater than that of men ; yet the disease occurs in men also. Youth is also decidedly liable; very much the greater number of cases occur between the fifteenth and the thirtieth year. Finally, hereditary neuropathic tendency plays a very considerable part. Among the direct causes it is usual to enumerate everything which excites and weakens the nervous system, and depresses its power of action. This includes strong psychical impressions, great excitement of the feelings, fright, grief, care, unfortunate love, violent passions, etc.; also excessive bodily exertions, severe marches, watching by night, work by night, etc. ; in like manner, great sexual excitement and excesses, onanism in excess, con- tinued and frequent sexual excitement without gratification ; and finally, bad food, imperfect formation of blood, exhausting dis- eases, losses of blood and fluids. All these things may pro- duce spinal irritation. Intoxication with alcohol or opium, traumatic agencies, cold, etc., are also named as occasional causes. At the time when every patient with pain and tenderness of the spine was considered to have spinal irritation, numberless diseases of the peripheral organs, and especially those of the intestine and uterus, were considered as giving rise to a symp- tomatic form of spinal irritation, as it was called. Such a thing is now no longer spoken of. As we do not yet know what takes place in the cord in cases of spinal irritation, and as the pathological anatomy of the dis- ease does not at present exist, it is hard to form a reasonable idea of the nature of the action of all these causes. We gladly omit all statements regarding the pathogenesis of the disease. SPINAL IRRITATION. 361 Symptoms. The development is usually gradual. Slight pain and dis- comfort in the back appear, especially between the shoulder- blades—at first only upon unusual occasions, during excitement or fatigue ; by degrees they become more permanent and require less and less to produce them. To these are added all kinds of excentric pains, increased nervous irritability, loss of general power, etc., and all this increases until the disease is fully dev- eloped. Often, however, the development occurs quickly—in a few days, especially when very powerful influences have acted upon predisposed persons. The disease then presents the following general aspect: The patient is oppressed by a more or less troublesome sense of illness ; a general malaise, increased psychical irritability, has seized upon her. In most cases she complains especially of pain in the back, situated in various spots, but most frequently be- tween the shoulder-blades, next in the back of the neck, less fre- quently in the loins. It grows more severe when any movement or exertion is made, and in the exacerbations of the disease. An examination usually discovers at the spot mentioned a great sensitiveness to pressure, tapping, the passage of a hot sponge, electricity, and other irritations. This sensitiveness may be so great that the lightest touch calls forth loud expressions of pain, the weight of the clothes becomes intolerable, and leaning the back against anything impossible. The skin of the affected portions of the back is usually very hyperaesthetic, but the spi- nous processes themselves are usually very sensitive to pressure. The degree and character of the pain differ greatly in individual cases ; the pain is commonly described as a more or less severe sense of aching, which often lasts a considerable time beyond the effect of the irritation. Hammond describes, in addition, a deep- seated pain of the back, which, he says, is produced by pressure on vertebrae which are not sensitive, by movements of the spinal column, by standing, etc. To this are added a crowd of other symptoms ; but what most troubles the patient is the pain felt in various parts of the body: 362 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. neuralgiform pains, now in the upper extremities, or the occi- put, or face ; now in the trunk or viscera, assuming the form of various visceral neuralgiae ; again in the lower extremities, pelvic region, bladder, or genitals; pain often of great violence and severity, sometimes fleeting, sometimes more permanent, and often brought back by slight causes. With these pains paresthesie are often connected; tingling, formication, a sense of burning and heat, often of cold also ; but these are less prominent. The same is true in a still greater degree of actual anesthesia; it seems to be very seldom ob- served. Marked disturbances of motility are regularly observed— above all, great weariness and exhaustion upon slight efforts ; the patient has lost all endurance in walking, can walk but a lit- tle way, and presently not at all, on account of the intolerable pain the act occasions. Most patients therefore find it agreeable to lie on the back, and usually continue thus. Manual occupa- tions, such as knitting, sewing, piano-playing, writing, etc., are more and more restricted, and at last are quite suspended, chiefly owing to the pain produced in the back or limbs. No real paral- ysis usually exists ; all movements are possible, but provoke vio- lent pains; and there is no power of endurance. The nearest approach to palsy consists in a moderate general paresis, occur- ring in but few cases ; proper paralysis is not one of the symp- toms of spinal irritation. On the other hand, much is said of spasmodic symptoms; fibrillary twitchings, spasms of some muscles, choreoid move- ments, singultus, etc., are often observed. Even permanent con- tractures, epileptic attacks, etc., are said (probably without truth) to have been observed as consequences of spinal irritation. Vaso-motor disturbances are also very frequent; most pa- tients exhibit an abnormal irritability of the vessels, and easily turn red or pale ; most of them suffer from marked coldness of the hands and feet, which are often of a bluish, cyanotic color. Functional disturbances of the vegetative organs, of a great variety of forms, are also very common; eructations, nausea, even vomiting occur ; palpitations of the heart are very frequent; disturbances of breathing, spasmodic cough, etc., are less com- SPINAL IRRITATION. 363 mon ; while vesical spasm, increased desire to urinate, abundant discharge of pale, clear urine, are more frequent, but actual palsy of the bladder and rectum does not seem to occur. Finally, a symptom, which seems quite a regular one, is that of increased psychical irritability and depression, with more or less sleeplessness; there is often some dizziness, noise in the ears, inability to read continuously, owing to the appearance of muscae and disturbances of vision, etc. The physiognomy of the disease is thus seen to be very com- plex. In fact, individual cases also differ greatly. We may try to divide them into three classes, according as the symptoms point to the upper, the middle, or the lower parts of the cord as the chief seat of suffering. If the upper portions are principally affected, the pain of the back and spinal tenderness are chiefly localized in the cervical vertebrae. The prominent symptoms are those referred to the head, giddiness, sleeplessness, disturbances of the senses, pains in the occiput, and pains in the district of the brachial plexus ; nausea, vomiting, palpitations, hiccup, etc., are not rare; motil- ity in the upper extremities is usually impaired. If the dorsal portion is affected, the chief symptoms in addi- tion to those in the spine are intercostal neuralgia, gastralgia, nausea, dyspepsia, etc.; the lower extremities usually take a large part in the disturbances of motility and sensibility. If the lumbar portion is chiefly affected, the leading symp- toms are neuralgia in the lower extremities and the pelvic organs, spasm and weakness of the bladder, cold feet, weakness of the legs, etc. A certain generalization of the disease is not uncommon, when the spine is painful in several places, often quite gene- rally, and the disease is complicated by all kinds of peripheral symptoms. Course, duration, termination.—We have already described the way in which the disease begins. Its course is usually very fluctuating. Improvement and relapses alternate in the most irregular way ; the chief symptoms and the spinal tenderness are sometimes felt in one place, sometimes in another ; a relapse often occurs without any visible cause, and so does improve- 364 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. ment; it is here that we must be most on our guard against illu- sive successes. Many cases run a comparatively acute course, grow rapidly worse, and as rapidly improve and recover. In most cases, however, the disease is extremely slow and chronic, and its duration is stated in months and years; there are some patients who suffer more or less from occasional attacks all their life, and who are exposed to a relapse on the slightest occasion. Nevertheless, a cure may be regarded as the rule; if proper measures are taken and the causes avoided, this may be ex- pected in the majority of cases. Much patience will doubtless be required, and the many relapses may often greatly prolong recovery. Whether spinal irritation may in bad cases result in the de- velopment of severe spinal diseases, does not seem to us suffi- ciently ascertained. The observations are almost all of an elder date, and give no sufficient guaranty against the confusion of the first stages of severe spinal lesion with functional irritation of the cord. This question, therefore, can only be decided by further careful observations. The entire doctrine of spinal irrita- tion requires a renewed revision by means of careful and criti- cally sifted clinical observations. Until this is done, we shall not be in a position to entertain a better founded opinion upon the nature of spinal irritation than we now possess. We can scarcely doubt, it is true, that the structures within the spinal canal are the proper seat of the disease, and the entire list of symptoms makes it most probable that the cord itself is in a condition in wdiich it performs its functions badly. The assumption that the meninges are the first to be affected, and the nerve-roots and the cord suffer second- arily, has little support. But we possess no direct observations to show what sort of changes occur in the cord. The pathological anatomy of spinal irritation does not exist; the few autopsies which we possess are not always uniform, and some of them certainly do not relate to cases of this disease. We are therefore thrown back upon guesses and hypotheses regarding the real nature of the change SPINAL IRRITATION. 365 in the cord in spinal irritation. Such hypotheses are numerous, but we have not the time to spare for them. The contradictory views that are entertained by authors are well illustrated by the fact that Ollivier and (in part) Stilling also refer spinal irritation to hyperaemia of the cord, while Hammond affirms with the full- est conviction that it is due to anaemia of the cord, and especially anaemia of the posterior columns, and that the ultimate cause for it may possibly exist in the sympathetic (vaso-motor) sys- tem ; Beard and Rockwell assume at one time anaemia, at an- other hyperaemia as a cause, while Hirsch and many other wri- ters see in spinal irritation nothing but a so-called dynamic disease, a functional disorder of the cord,without organic change in it—an irritation which may be due to very various causes. All these opinions may be defended and attacked with power- ful reasons, but we need not try to sit in judgment on them, as the conclusion could only be that we know nothing definitely at present. The most probable seems to us to be a purely func- tional disturbance of certain nervous elements of the cord, in company with which hyperaemia and anaemia of the cord may probably appear when the vaso-motor paths are reached by the disturbance; but this whole question, it seems to us, awaits a solution. Diagnosis. It will not be very hard to recognize spinal irritation when the entire group of symptoms as above given is present; when the pain in the back and the sensitiveness of the spine are accompanied by many changeable excentric symptoms, motor weakness, great psychical irritability, or marked paralysis or anaesthesia; when no organic changes exist, and a remarkable disproportion between the intensity of the subjective symptoms and the objective can be demonstrated ; and where, finally, great fluctuations in the course of the disease are observed. We ought not to try to settle the diagnosis too soon, nor should we acquiesce in it until, after careful examination and estimation of all circumstances, the other possibilities have been excluded. In doing this we should bear in mind the following : 366 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. The diagnosis from hyperemia of the cord is so difficult, that cases were formerly often mistaken one for the other. The long duration of the disease will furnish the most important argu- ment in favor of spinal irritation ; in severe hyperaemia, paralysis is rarely absent. Hammond recommends as a test remedy a sub- cutaneous injection of strychnia, which is believed to do good in spinal irritation, and harm in hyperaemia. The distinction from meningitis spinalis will also often be difficult. But in the latter the stiffness and painful tension of the muscles of the back, the pain in the spine, which especially occurs during movement, the fever, late paralyses, etc., may fur- nish very useful diagnostic points, Meningeal tumors in their first stage, among the primary symptoms of which are found pain in the back and excentric neuralgia, will best be known by the stability of the symptoms, by their permanent localization in well-marked nerve-paths, and, at a later stage, by the paratytic symptoms. The diagnosis from myelitis will usually be made soon. In this disease only deep pressure on the spinous processes is pain- ful ; there is no circumscribed cutaneous hyperaesthesia in the vertebral region, but there is the girdli sensation, very early and marked anaesthesia and palsy, vesical paralysis, often painful contractures and spasms, which are absent in spinal irritation. The unfavorable termination of the disease, the absence of the general nervous condition so common in spinal irritation, are likewise in favor of myelitis. The distinction from hysteria will be impossible in many cases, as both diseases possess many similar features, and spinal irrita- tion not rarely occurs in connection with hysteria. The specific hysterical symptoms of globus, general spasms, definite forms of paralysis, etc., do not belong to spinal irritation ; and the pecu- liar mental traits so characteristic of hysteria—whimsical obsti- nacy, irritability, etc.—are also absent. A full consideration of the circumstances in each case will often furnish some decisive diagnostic points, while in other instances we shall have to admit the existence of both diseases together. From neurasthenia spinalis, which is described in the follow- ing section, and which has an undeniable general resemblance to SPINAL IRRITATION. 367 spinal irritation, the present disease differs by the fact that symp- toms of sensory irritation preponderate, that extreme sensibility of the vertebrae is present, and that the disease occurs chiefly in the female sex. (See the diagnosis of spinal nervous weakness.) The marks which distinguish spinal irritation from vertebral caries and other coarse lesions of the spine need not be stated here. Prognosis. This is generally held to be favorable, although such is not always the case. In all circumstances we should remember that the disease is usually chronic, may last many months and years, and relapses are very frequent. Life is in no danger; but most of the patients are doomed to a long and tedious illness, they are cut short in all their enjoy- ments, are plagued with tormenting pains, and so forth—circum- stances which certainly deserve mention in making a prognosis. Treatment. This is a difficult subject. The disturbance of nutrition in the cord is not so easily to be removed ; and the patient is usually irritable, changeable, weak of purpose, so that it is often very hard to secure the necessary persistence and energy in treatment. First of all, we must try to remove the causes. By reference to the list already given, it will appear what is implied by this. In the direct treatment, the chief object doubtless consists in improvement of the nutrition and tone of the nervous system, especially the spinal cord. The first thing to prescribe is, there- fore, in most cases, a general tonic regimen: good food in abundance, a not too sparing use of spirituous drinks (the Eng- lish recommend them in large doses, and Hammond orders stimu- lants such as brandy and rum). As tonics, quinia and iron, preparations of zinc, and cod-liver oil may be used. A great deal of fresh air is indispensable to all the patients; active and pas- sive exercise in the open air is therefore always indicated, but this should not be overdone, as frequent repose in the horizontal 368 ERB.—DISEASES OF TnE SPINAL CORD AND ITS ENVELOPES. posture is often necessary. When it can be had, the air of mountains and forests is to be sought; a moderate cold-water treatment supports these tonic measures, and will be especially valuable when applied in a high mountain climate. Strychnia (with other preparations of nux vomica) enjoys a special reputation with many physicians for the cure of this affection. It is given alone, or in suitable combination with other medicines. Thus, Hammond advises a combination of extract of nux vomica, half a grain (0.03), with phosphide of zinc, one- twelfth of a grain (0.005), given several times a day. A mixture of iron, quinia, and nux vomica in various forms seems often useful. Another important remedy is the galvanic current. Ham- mond ascribes great successes to it, and I have also observed some good results. The best plan seems to consist in passing an as- cending stabile current through the vertebral column, including the painful portions between the two poles. The current ought not to be very strong, and the duration of the applications must be short. The negative pole, acting directly on the painful ver- tebrae, has often been found to be of value. Many patients of this class will be benefited by the methods of general faradization and central galvanization. (See above, p. 181 et seq.) Finally, derivatives have long enjoyed a general reputation. The best place for application seems to be directly upon the affected spots, the most painful parts of the spine. Many wonderful reports are made of the successful application of blis- ters, tartar-emetic ointment, oil of turpentine, veratrin ointment, etc. A repeated and continued use of these remedies is, how- ever, often necessary. In less severe cases, dry cups suffice, and moxae or the hot iron will be resorted to very rarely. We should be careful about drawing blood from the spine, which was formerly so much in vogue. With most patients this does not agree ; though in some cases, when the person is very robust and of full habit, or when there are signs of congestion, it may be very suitable. A symptomatic treatment is required for the pains in the back and other neuralgiform symptoms. Hammond recom- mends opiates especially; the application of hot water or sand SPINAL NERVOUS WEAKNESS. 369 along the spine may also be tried ; also bromide of potassium, blisters, and other derivatives, faradization, galvanization etc. For weakness, electricity is of special value. 8. Functional Weakness of the Spinal Cord.—Spinal Nervous Weakness. —Neurasthenia Spinalis. Beard and Rockwell, Practical Treatise on the Uses of Electricity, etc. 1871. p. 294.—Russel, Cases of Paraplegia induced by Exhaustion of the Spinal Cord. Medical Times. Oct. 31, 1863; May 25, 1867.—A Bourbon, De l'influence du coi't et de l'onanisme dans la station sur la production de paraplCgies. Paris, 1859.—Leyden, 1. c. II. p. 22.—Erb, Bericht fiber die Versammlung mittel- rhein. Aerzte am 18. Mai, 1875, in Heidelberg. Betz' Memorabil. 1875. 5. Heft. Introduction and Definition.—Every physician encounters cases in the course of his daily practice, chiefly if not wholly originating in the higher walks of life, which may affect either one of the various departments of the nervous system. As a rule, there is no anatomical basis for them ; and certainly, any severe anatomical changes seem to be excluded by the entire nature and course of the symptoms observed. Such are the cases which have been classed together under the name of "nervous- ness," " nervosismus," " nervous weakness," etc., and are com- monly regarded with some mistrust by physicians. Beard and Rockwell have given a very good description of them, and have proposed the name neurasthenia (weakness of the nerves). It is desirable to examine these cases more closely, and form them into classes. Careful observation quickly shows that this nervous weakness is capable of assuming various forms, and affecting different parts of the nervous system. In some cases the entire nervous system is more or less affected ; in others the brain is chiefly affected, and in others still, the functions of the cord. It Is this latter, the spinal form of neurasthenia, that we wish to speak of. Abundant experience has shown me that these cases are not rare, and are of great practical consequence. For they cause much anxiety, not only to the patient, but also to the physician,. owing to the striking resemblance they possess to the first stage VOL. XIII.—24 370 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. of severe disease of the cord. It is of course important to decide this question as early as possible, as the prognosis of the two dis- eases must be very unlike. We therefore understand by spinal nervous weakness those diseased conditions in which marked and unquestionable dis- turbances of the functions of the cord exist, for which no consid- erable anatomical basis can be found or assumed; a disease, therefore, which must at present be classed among the functional disorders. Whether, and how often, this condition may lead to actual organic disease of the cord, cannot be known at present; from my experience I infer it to be rarely the case. The symptoms, how- ever, are not infrequently present during the early period of ana- tomical lesions of the cord, though probably always associated with other disturbances, which enable us to recognize the com- mencement of the real disease. It cannot be denied that this complaint has a close resem- blance in many respects to spinal irritation, the subject of the previous section ; and the opinion might perhaps be defended, that this disease is essentially, for the male sex, that which corre- sponds with spinal irritation in females. Nevertheless, charac- teristic differences will be seen as the description is given; I believe that the two diseases, though related, cannot be regarded as identical. It would be very desirable to lay out a better divi- sion and classification of these spinal "neuroses" by means of accurate clinical and symptomatic study, in order to promote the pathology of such an obscure subject. What follows professes only to be a first step in this direc- tion. Few accounts of the disease are recorded in print; I find an exquisite case briefly described in O. Berger;' Scholz" de- scribes one under another name ; that which Leyden describes as " spinal irritation from loss of semen" belongs for the most part to this class; so does much of what has been described as the results of spermatorrhoea, etc., in regard to which see Cursch- mann's excellent account in Vol. VIIL of this Cyclopaedia. 1 Zur Pathogenese der Hemikranie. Virch. Arch. Bd. 59. p. 335. 1874. J Ueber Riickenmarkslahmungen und deren Behandlung in Cudowa. p. 21. SPINAL NERVOUS WEAKNESS. 371 Etiology. A predisposition to this affection is most common in the male sex ; and males are attacked in much larger numbers. Youth and middle age are also most exposed to the disease. The chief contingent to this army of sufferers comes from neuropathic families, in which psychoses, hysteria, and other neuroses are well-known guests. The upper classes are also more affected than the lower, though the latter are by no means spared. Finally, all the direct causes of the disease (to be named presently) may increase the predisposition, or perhaps cause it. Among these direct causes, I am able from experience to name three as particularly active. Excessive mental efforts may often produce the spinal form of neurasthenia—such as are made in the pursuit of a profession, or in severe mental toil, especially by night; a similar effect is produced by grief and excitement, violent excitement of the affec- tions and passions, gaming, etc., in predisposed persons. A much more frequent and important cause is found in sexual excesses; onanism begun very young and long continued; ex- cessive coitus. I have often seen the entire series of symptoms develop in otherwise healthy men after very great sexual ex- cesses, and again disappear in a few weeks under suitable ob- servances. The standard of sexual "excess" is of course very varying ; but, for the individuals in question, excess usually begins with comparatively moderate performances. Excesses of a less degree, but protracted, are often also at fault, and the affection not rarely appears after the honeymoon. In predis- posed individuals, frequently repeated sexual excitement without gratification acts similarly; and the practice of having connection in the standing posture, mentioned by French authors, seems not less injurious. Excessive bodily effort seems to be a less potent cause; yet long forced marches, mountain climbing, etc., are often men- tioned as causes. The injury is most distinct when several of the above causes coexist—e. g., great mental and bodily overwork, with disturb- 372 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. ance of the nightly rest (hence, the disease is not infrequent among physicians); or when, amid great mental exertions, sexual excesses are indulged in, etc. It is not yet certain whether there are other causes ; but it is probable that severe exhausting diseases, bad food, and other circumstances which depress the powers of the nervous system, may be active in this direction. Symptoms. The description of these is based almost exclusively upon the patients' subjective complaints. The persons affected are usually young or middle-aged men; they complain chiefly of a set of motor disturbances, principally consisting of a striking weak- ness and rapid fatigue of the lower extremities. They have constantly the sensation of great exhaustion of the legs, such as well persons only feel after making considerable exertions of body; this is perceived even in bed in the morning. They are incapable of walking or standing for a long time; a continuance in the standing posture is especially apt to make them tired. After more severe exertions, the great fatigue is accompanied by occasional tremor of the legs, and such a remarkable stiffness of the members as a well man would only feel after a very severe march. Unaccustomed efforts, even of a very moderate degree, are remarkably apt to produce that peculiar muscular pain, the origin of which is so obscure. I refer to that well-known pain in the muscles which frequently occurs in well men after very active and unaccustomed muscular efforts, as when one rides, practises gymnastics, takes mountain walks, etc., after a long period of intermis- sion. It usually appears about twenty-four hours after the exertion, is associated with slight swelling of the muscle and sensitiveness to pressure, and is produced by every contraction of the muscle affected. The essential nature of the pain is not yet known. Such a pain occurs in patients of the present class, after comparatively very slight exertions. Similar symptoms of quick exhaustion and want of endur- ance are observed in the arms, but much less in degree than in the legs. With this is associated a variety of disturbances of the sen- SPINAL NERVOUS WEAKNESS. 373 sory organs. One of the most common is a peculiar pain in the back, seemingly localized in the muscles of that part, and appear- ing whenever certain movements are made, as of bending the spinal column forward or backward, or certain movements of the shoulder ; and often in breathing or swallowing. The pain is not very intense, and varies greatly in its occurrence and posi- tion, rarely remaining for any length of time in one place. It is increased or brought on by slight exposure to cold, a draft of air, and probably also by excesses in Baccho aut Venere. A diffused sensation of burning in the skin of the back is often observed, especially between the shoulder-blades ; this is usually accompanied by sensitiveness of some of the spinous processes, just as in spinal irritation. In other cases, pain in the loins is observed. In the extremities, especially the lower, this excessive feeling of fatigue often increases to that of slight shooting and tearing pain in the districts of certain nerves. These pains are usually not very severe, and pass away rapidly ; they chiefly occur dur- ing movement and after unusual exertion. Some of the muscles, also, are not infrequently stiff and painful. In such cases there are seldom or never any defined and violent pains of the well- known lancinating sort (see above, p. 75-6). Marked paresthesia is also very rarely spoken of; many complain of a slight numbness or formication, especially in con- nection with great cold of the feet. A medical man, or one who knows and dreads the symptoms, is apt to speak of this. Cold hands and feet are very commonly complained of ; they are probably due, for the^most part, to vaso-motor disturbances. The feet, in particular, are often icy cold, and can hardly be warmed, even in bed. The feeling of burning in the feet is rare, and if it occurs, is associated with an actual rise of local tem- perature. The disturbances of the sexual functions are usually very striking ; they commonly take the form of irritable weakness ; the power of erection and of performing the act are lessened ; the ejaculation takes place too quickly, and a repetition is impossi- ble. The act is usually followed by remarkable prostration, restlessness of the limbs, and the like; or the man falls into a 374 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. half-slumber and a profuse perspiration, etc. All the symptoms usually increase after the passion has been gratified, unless the greatest moderation has been used, or even after repeated sexual excitement. Pollutions or spermatorrhoea do not constitute a regular feature of the disease, unless they previously existed, and are to be considered as causes of the disease. Their occur- rence, however, often aggravates the trouble, and they are much dreaded by the patient. The functions of the bladder are usually quite normal; in some cases a little dribbling is spoken of. The sphincter ani acts properly. Trophic disturbances of the lower extremities, and bed-sores and the like, never occur. With these regular and common symptoms we often find a number of others which indicate a wide extension of the nervous weakness. Among these we should mention sleeplessness, not usually very troublesome, but often peculiar in form. The patient wakes, after a few hours' sleep, with a sense of great uneasiness in his limbs, and cannot fall asleep for some hours after ; in the morning he feels unusually prostrated. In some cases there is a certain sense of constriction of the head, timidity, often a re- markably womanish disposition, a tendency to weep, etc. I have seldom heard complaints of vertigo. The higher functions of the brain, memory, intelligence, etc., and the organs of special sense, remain perfectly normal. The power of mental work may be unimpaired, but is usually weakened by the patient's hypo- chondriacal depression. The vegetative functions are unimpaired, on the whole ; the disturbances most frequently observed are those of the digestive apparatus—dyspepsia, tendency to constipation, flatulence, etc. There is frequent complaint of palpitations, and a sense of con- striction. The general sense of illness is very great. Most patients are hypochondriacal in their feelings, are in dread of tabes, etc.; if a physician is the sufferer, he is apt to let his mind dwell on this anticipation, and to be made wretched by the thought. The general nutrition is usually somewhat impaired ; the pa- tient loses some flesh, gets a sallow look, and becomes a littlo SPINAL NERVOUS WEAKNESS. 375 anaemic. There is always great sensitiveness to cold and severe changes of weather. As compared with all these complaints, the objective symp- toms—and this is a decisive point—are excessively slight, in fact, almost wholly negative. The closest examination shows no trace of disturbance of motility; all movements are performed easily and securely; the finest and most complicated actions can be executed; the patient stands on one foot, or with closed eyes, quite perfectly ; only the power of endurance in muscular action is weakened. In like manner there exists not the least disturbance of sensi- bility. There is usually no sensitiveness of the spinous processes. The reflex functions of the skin and tendons are usually normal. There is no atrophy, no change of electrical reaction. The only distinct symptom that can be found is, in many cases, a moder- ate degree of anaemia, a changed, suffering expression. The closest objective study, therefore, discovers no change whatever that can stand in any relation to the patient's subjec- tive complaints. Of course, not all cases are alike, for many variations in the character of the disease occur ; various symptoms may be absent, or may be more distinct in one case than in another ; but the lead- ing features of the disease will probably be traced in most cases. I select from my list of recorded cases (of which I possess more than two dozen) the following one as an example: The patient, a wholesale merchant, aged thirty- five, belongs to a neuropathic family; two sisters were in the insane asylum; a brother has a tendency to melancholy and nervous complaints; he himself has been a long time " nervous." Married at twenty-three ; he has three children ; he says that he indulged a good deal in the sexual act, perhaps too much, but never observed any ill results from it. He has often been to bathe in the ocean, with temporary benefit. He has a great deal of work ; at least eight hours a day in his office, occasionally going into a close, damp warehouse. All the nervous symptoms have slowly increased; they have been about as follows for four weeks past: Great general sense of fatigue—this is very marked in the morning in bed; ina- bility to walk for a long time, or, if he does it, it is followed by great fatigue and active tremor of the legs. When moderate exertion of an unwonted sort is made, there are severe muscular pains on the following day (as lately, after skating for fif- teen minutes). No tottering or uncertainty of gait; no vertigo. Some sense of fatigue in the arms, uncertainty in writing. 376 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. No pains, no numbness or formication in legs or arms. No headache; only a frequent sense of pressure on the vertex. Intelligence and memory good ; depressed, hypochondriacal state of feeling. Occasional disagreeable feeling in the back, but no real pain. Suffers much from cold feet, which formerly was never the case. Great sensitiveness to cold; after exposure he feels slight shooting pains in the limbs. Sleeps badly; usually wakes about three o'clock and remains awake for two or three hours, with great prostration and restlessness of limbs. Vesical functions quite normal. Sexual functions distinctly altered in the last few weeks; sexual excitability increased, ejaculation too early, erection insufficient; after coitus a sense of exhaustion, with excitement and restless half-sleep. Tendency to shed tears; unusual timidity and want of self-possession ; noticeable confusion when he is conscious of being observed. Frequent palpitation, and some shortness of breath when he ascends stairs. Appetite and stools good. Objective symptoms.—An apparently strong and well-nourished man; internal organs all sound. Motility quite normal by objective tests. Stands with closed eyes very well. No disturbance of sensibility. Cerebral nerves all normal. Slight anaemia. He was ordered quinine and iron; cold friction in the morning ; movement in the open air; strong diet; moderation in business and sexual act; afterwards a period of residence in a high mountain region. Half a year later the patient returned from Switzerland and called upon me; he was considerably improved. The strength and endurance of the legs are decid- edly greater, and his temper is much more cheerful. He walks his four or five hours every day and seldom suffers from tremor, still less from pain of the muscles. He has no cold feet, and his sensitiveness to cold is less. He sleeps much better, though not perfectly well. Sexual functions the least improved of all. Head never troubles him. Temper much improved ; he has no disposition to weep. After another half-year the greater part of the morbid symptoms had dis- appeared. Course, duration, termination.—The disease usually begins in a very gradual and insidious way, yei sometimes it happens that it develops quite rapidly; some injury, a severe exertion, an excess, may bring the disease to an outbreak, when in the course of a few days or weeks it may reach a certain severity. In such acute cases there is during the first few days a marked and general sense of being ill, prostration, loss of appetite, etc. The symptoms usually increase gradually for weeks and months, and then remain more or less stationary. Great fluc- tuations, considerable transitory improvements, are rare; but slight fluctuations in the intensity of the symptoms are common. If a proper treatment and regimen are then adopted, gradual SPINAL NERVOUS WEAKNESS. 377 improvement occurs ; but months and years may pass before the last traces are removed. Intercurrent febrile affections often seem to have a favorable influence upon the disease and to hasten recovery. Traces of the disease may last many years. Relapses are not uncommon, and are often occasioned by fresh injurious exposures of a trifling nature. I am unable to state whether there are incurable cases, and whether the disease may last a great many years. At all events, cases occur of sufficient severity to compel the patient to give up business and avoid society, and to make his existence wretched. I am also in doubt whether the disease can pass into any tangible chronic form of spinal disease (myelitis, sclerosis, gray degeneration). I have not observed such an event, and have never had to modify my diagnosis in the direction indicated. But only continued experience can decide. Of the essential nature of the disease, I think we are not yet prepared to express an opinion. We are far too little acquainted with the pathology of many morbid processes of the cord, to allow ourselves to express a distinct opinion regarding the foun- dation of the disease here described. A few remarks may, however, be allowed. A spinal difficulty may naturally and reasonably be thought of, in connection with the symptoms described ; the simultaneous occurrence of sensory and motor difficulties in both legs, the vaso-motor disturbances, the pains in the back, and especially the disturbances of the sexual function, which are most easily explained by increased excitability and weakness of the centres in the lumbar cord, are so strongly in favor of the spinal location of the disease, that other possibilities (as, for example, that of an affection of the cauda equina) sink into the shade by its side. The hypothesis of a spinal affection certainly seems to us the most acceptable. Furthermore, the disease can only be afunctional disorder in the ordinary sense of the term. In favor of this we have the absence of all objective disturbances, the absence of all paralytic symptoms, and the usually favorable course. In such circum- stances it is hardly possible to suppose a considerable anatomi- cal change in the nervous or interstitial structure of the cord; 378 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. the most would be, perhaps, a disturbance of circulation, hyper- emia, or anaemia of the cord. The regularly accepted descrip- tion of these forms, however, does not agree with that of neu- rasthenia spinalis. I must admit that the hypothesis of anaemia of the cord is very plausible. But it is impossible at present to confirm this hypothesis in any way, and it must remain an open question. It seems most natural to recur to fine disturbances of nutri- tion in the cord, such as we are still obliged to assume in so many diseases of the nervous system. The term "irritable weakness" (reizbare Schwache) agrees best with this notion, and in our description the weakness is quite prominent. We do not know at all what may be the nature of the processes of nutrition which cause the symptoms. We, however, believe that we are certainly entitled to locate them in the cord, especially the lower portion, the lumbar region. The most obvious view is that which supposes that the physio- logical fatigue of the nervous elements, which always occurs after severe and protracted irritation, becomes exaggerated and assumes a fixed form. In such a case we may suppose that the fatigue of the nervous elements does not become repaired in the prompt manner which is usual under physiological conditions. Diagnosis. The decision will be based chiefly on the great disproportion between the acute subjective complaints of the patient and the almost negative result of objective examination. The absence of each and every disturbance of motility and sensibility, of all symptoms which indicate an anatomical lesion of the cord, must give probability to the supposition of a purely functional dis- turbance. If in addition there exist general nervous weakness, sleeplessness, psychical irritability, a neuropathic constitution, and other etiological elements (especially that of undue sexual stimulation), the supposition then becomes much more probable. A good deal of practical experience and accuracy in examination is always necessary, and a long period of observation will often be necessary before we are clear in our minds. SPINAL NERVOUS WEAKNESS. 379 A few remarks upon the points of diagnosis in reference to the better-known diseases of the cord will be useful here. From a commencing tabes, which is the disease most usually suspected, spinal neurasthenia can be distinguished with tolera- ble ease. The absence of lancinating pains, of paraesthesiae and disturb- ances of sensibility, of the girdle-sensation, of tottering when the eyes are shut or in the dark, of motor uncertainty, of ataxia, will suffice. The study of the tendinous reflex action will per- haps furnish an important point, if it should appear that this reaction is absent in the early stages of tabes. From active hyperemia of the cord we may distinguish spi- nal neurasthenia by the absence of pain, of cutaneous hyper- aesthesia, of symptoms of motor irritation, and probably also by the long duration of the disease. From passive hyperemia, by the absence of paretic symptoms, of the feeling of heaviness in the legs, and probably also by the causes of the disease. From incipient myelitis the diagnosis will be rendered possi- ble by the absence of paraesthesiae and anaesthesia, of paresis and paralysis, of weakness of the bladder, etc. The distinction from spinal irritation will often be less easy to make. If we consider that the latter is more characterized by symptoms of sensory irritation, that in it the dorsal pains, neu- ralgias, sensitiveness of the vertebrae, etc., are in the foreground, while in spinal weakness the motor disability, the sexual weak- ness compose the chief subjects of complaint, we shall usually be in the right way. It must be admitted that there are cases of ambiguous signification which stand, as it were, half-way between the two forms of disease, and possess somewhat of each. In no case can we state the diagnosis with certainty until after a most careful objective examination and a weighing of all cir- cumstances, and, if possible, an opportunity for watching the case some time. The prognosis is very essentially influenced by these circum- stances. It is favorable, as compared with that of organic dis- eases of the cord, which somewhat resemble it in symptoms. In most cases the patient recovers when the causes are re- moved and a suitable regimen of life is observed. Much time is 380 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. required for this, and the patient must submit for months, or even years, to many a deprivation of ordinary enjoyments. If he will do this, his powers, and especially those of the mind, may remain considerable, provided that great regularity of life is ob- served, and all excesses are avoided. In almost all cases, however, patients will have to suffer some loss of the former enjoyments of health ; they remain a long time —perhaps always—in the category of "nervous" persons, and must look forward to a relapse of their disease with every fresh exposure to injurious influences. If the hereditary tendency is very great, if there are unfavora- ble external conditions, permanent causes, the prognosis will of course be much less bright. The disease then continues, but without, as it seems, involving immediate danger to life. As re- gards the possibility of the development of anatomical lesions, we cannot at present render an opinion. Treatment. The causal indication must be satisfied, first and foremost. The excessive claims upon the nervous system must be decidedly forbidden, and in most cases it is really necessary to interpose a period of absolute rest from harmful occupations. The arrange- ments for this will differ in each case, according to the existing cause. Especial attention is required by the regimen and diet of the patient. He must live a regular and healthy life in every respect, and must continue this plan with the greatest perseverance. He must work little, and only at fixed hours, with frequent interrup- tions ; must go to bed early and sleep as much as he can ; must have an abundance of strong, easily digestible food, at not too great intervals ; spirituous drinks are allowable in moderation; much moving about in the open air (but never to the point of ex- haustion, and with proper alternations ; walks, mountain climb- ing, skating, gymnastics, etc.) is absolutely necessary ; patients who are very easily exhausted must sit a great deal out of doors in a good air ; the sexual act must be restricted as much as possi- ble, but need not be absolutely forbidden in most cases, or but SPINAL NERVOUS WEAKNESS. 381 for a time; sexual excitement without gratification must be avoided as much as possible. Of the plans of treatment for the direct relief of the disease, the use of a moderate cold-water cure, well graduated to the patient's strength and sensitiveness, deserves especial mention. Rubbing down with partly warmed water, gradually made colder, washing of the back, of the feet, and sitz-baths are the most suitable, and usually soon impart an increase of vigor and power. Douches and very cold applications should be avoided. I have found the mountain air no less efficacious in many cases; a considerable time passed among high mountains, gradu- ally going to higher stations, does such patients a great deal of good, and quickly improves the power of their lower extremities. It is well to combine this air-cure with a moderate water-cure, when possible. In selecting a place, its altitude, the quality of the service, and the convenience of the walks must be regarded ; there is no lack of very suitable places in Switzerland and Tyrol. The galvanic current has also an important place among the remedies for spinal nervous weakness ; it is applied to the back in the usual way (best in the ascending direction, stabile, with change of the position of the electrodes—current not too strong), and may also be applied directly to the legs, and perhaps to the genitals also. Most patients bear it well, and are improved by it Of drugs, almost the only ones in use to be recommended are the preparations of iron and quinia ; their forms and combina- tions m&y be very various. It is often useful to combine them, in the way recommended by Hammond (see the previous section), with small doses of nux vomica or strychnia; but. it is well to be cautious. According to circumstances, other tonics may be used. We shall often have to decide upon the choice and applica- bility of baths. For anaemic and debilitated persons, the chaly- beate baths will be indicated; patients who require much protec- tion, who are very sensitive to cold, should at first be sent to the thermal brine baths (Rehme, Nauheim, etc.), rather than to a cold-water cure. Sea-baths are a most excellent after-treatment for patients who are used to the water and have a good digestion. Under all circumstances, these cures must be followed out 382 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. steadily and repeatedly for a long time, for the complaint is very slow and does not yield to the first attack. Symptomatic indications, such as arise from the presence of sleeplessness, pain, spermatorrhoea or pollutions, impotence, di- gestive disorders, etc., should be treated with the customary remedies. 9. Inflammation of the Spinal Cord—Myelitis. Harless, Diss, inaug. de myelitide. Eilangen, 1814.—Klohss, De myelitide. Halae, 1820.—Funk, Die Ruckenmarksentzundung. Bamberg, 1825.—Albers, Beob. auf d. Gebiete d. Pathol. I. S. 73. 1836.—Ollivier, 1. c. II. S. 302. 3. Aufl.— Abercrombie, Krkh. d. Gehirns u. R.-M. Deutsch von G. v. d. Busch. 1829. S. 474.—Cruveilhier, Anatom. patholog. 1835. 42. Livr. 32 u. 38.—Marcel, Diag- nost. et nature du ramolliss. blanc d. 1. moelle epin. Gaz. m€d. d. Paris. 1854. No. 52.—Evan Reeves, Acute Myelitis. Edinb. Med. Jour. I. 1855, 1856. p. 305 and 416.— Oppolzer, Acut. Entziind. mit part. Ervveichung d. R.-M. Sjfitalszeit. 1860. No. 1-3.—Broion Sequard, Lect. on Diagn. and Treat, of thePrin. Forms of Paral. of the Lower Extrem. London, 1861.—Koehler, Monographic d. Meningit. Spinal. 1861. Beob. 17 u. 18.—Mannkopf, Fall von acut. Myelit Berl. klin. Woch. 1864. No. 1; u. Tagebl. d. 40. Vers. Deutsch. Aerzte u. Naturf. etc. 1865.—Jaccoud, Des paraplegics et de l'ataxie du mouv. Paris, 1864.—Armin. Levy, D2 myelit. spinali acuta. Diss. Berolin, 1863.—Frommann, Untersuch. fiber die normale u. patholog. Anatom. d. R.-M. I. 1864. II. 1867. —Engelken, Beitr. zur Pathol d. acuten Myelitis. Diss. Zurich, 1867.— P. A. H. Sachse, U^bar Myelit. etc. Diss. Berlin, 1867.— Voisin, Meningo-myelite aigue. occas. p. 1. froid. Gaz. d. hop. 1865. Nos. 25-30.—Harley and Lockhart Clarke, Fatal Case of Acute Progress. Paral. from Softening etc. Lancet. 1868. Oct. 3.—Keen, Softening of the Spinal Cord, etc. Amer. Jour, of Med. Sci. July, 1869. p. 128.—Ilasse, Krkht. des Nervensyst. 2. Aufl. S. 696.— Ham- mond, Diseases of the Nervous Syst. 3d edit. p. 456.—M. Rosenthal, Klinik d. Nervenkrkht. 2. Aufl. S. 296.— Leyden, Klinik d. Rlickenmarkskrkht. II. S. 115.—Dujardin-Beaumetz, De la myelite aigue. Paris, 1872.—G. Hayem, Des hemorrhag. intrarhachid. Paris, 1872.—Hayem, Deux cas de myel. aigue cen- trale et diffuse. Arch, de Physiol. VI. p. 603 1874. — C. Westphal, Ueber fleck- weise oder diseminirte Myelitis. Arch. f. Psych, u. Nerv. IV. S. 338. 1874.— Bernheim, Artikel: Myelite im Diet. Encyclop. des Sci. medic. II. ser. T. VIII. p. 674. 1874.—Duchenne (de Boulogne), Electris. localisee. 3e edit. 1872. p. 459.—Hallopeau, Etudes sur les mye'lites chron. diffuses. Arch, gener. d. med. 6. s6r. T. XVIII. u. XIX. 1871, 1872.—C. Lange, Fall von Myel. interstit. chron. Hosp. Tid. 14. Aarg. S. 35. Virchow-Hirsch, Jahrcsb. pro 1871, II. S. 77.— Frommann, Fall von Wirbelcaries u. Degenerat. des R.-M. Virchow's Arch. MYELITIS. 383 Bd. 54. 1872.—Rob. W. Tibbits, Case of Myelitis. Med. Times. 1871. May 13. —Hallopeau, Etude d. 1. scler. diff. periependymaire. Gaz. mod, 1870. Nos. 30-35.—Vulpian, Cas d. mening. spin, et d. sclerose corticale annulaire, etc. Arch. d. Physiol. II. p. 279. 18G9.—Martineau, Inflammat. aigue general. de 1. substance grise d. 1. moelle. Union med. 1874. Nr. 30.—Feinberg, Ueber reflect. Gefassnervenh'ihmung u. Ruckenmarksaffection nach Ueber- firnissen der Thiere. Virchow's Arch. Bd. 59. S. 270. 1874.—Schueppel, Fall von allg. Anasth. Arch. d. Heilk. XV. S. 44. 1874.—Troisier, Deux cas de lesions sci fir. de la moelle e*p. Arch. d. Physiol. V. p. 709. IS 73.—Joffroy, Faits experim. pour servir a l'histoire de la myelitc. Gaz. m6d. de Paris. 1873. Nr. 36.—Charcot, Sur la tumfifact. des cellules nerv. motrices et des cylindres axiles, etc. Arch. d. Physiol. IV. p. 93. 1872.—C. Lange, Bidrag til etc. Hosp. Tid. 16. Aarg., Schmidt's Jahrbb. Bd. 168. S. 238.—Raymond, Myel. de la region dorsale. Gaz. mCd. 1874. No. 9.—F. Raymond, Myelite de la reg. cer- vicale. Progres m6d. 1875. No. 17.—Gerin-Rose, Myel. aiguii generalisee. Union med. 1875. No. 90.—Langhans, Myelitis d. grauen Commiss. etc. bei Lepra anaesth. Virch. Arch. Bd. 64. 1875.—Hamilton, On Myelitis, etc. Quart. Journ. of Microsc. Sci. Oct. 1875. p. 334.—Pierret, Note sur un cas de myel. a rechutes. Arch. d. Physiol. VIII. p. 45. 1876.—Laveran, Obs. d. myfil. centr. subaigue. Ibid. VII. p. 866. 1875.—P. Baumgarten, Eigenth. Fall von Paralys. ascend, acut. mit Pilzbildung im Blut. Arch. d. Heilk. XVn. S. 245. 1876.— Lewin, Paraplegie in Folge von acut. Myelitis u. el. Behandlung derselben. Deutsche Klinik. 1875. Nr. 11.—See also the literature of multiple sclerosis, sclerosis of the posterior columns, lateral sclerosis, poliomyelitis anter. acuta et chronica, etc., in the succeeding chapters of this work. Introduction. Myelitis constitutes unquestionably the most extensive and important chapter in the pathology of the medulla spinalis. Amy one who possesses even a superficial knowledge of the sub- ject, will be able to appreciate the difficulties which confront us in the attempt to furnish a comprehensive and classical account of it. The material at hand bearing on inflammation of the spinal cord and affections that are classed with it, is immense and in the critical sifting and arrangement of this material we meet with difficulties that cannot be overcome. These are encountered chiefly in the domain of pathological anatomy, many and per- haps most of the questions which come within the limits of this department being still in process of development. It is as yet 384 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. impossible to define accurately the boundaries of inflammation of the spinal cord in both its acute and chronic forms, and to decide exactly what does and what does not fall within them. Some authors do not hesitate to class almost all the forms of acute as well as chronic disease of the cord, which will be de- scribed in the following chapters, under the head of Mamma- tion. They regard tabes dorsalis, the so-called lateral sclerosis, multiple sclerosis, progressive muscular atrophy, spinal paraly- sis of children, myelitis centralis, chronic atrophy of the cord, and secondary degeneration of it, as mere subvarieties or different localizations of one and the same inflammatory process. Others, on the contrary, hold that a number of these processes, such as simple and degenerative atrophy, softening, sclerosis, gray de- generation, and the like, are entirely distinct from and independ- ent of inflammation. Hence, the additions made by one party to the great mass of material bearing on the disease, are detached and diverted in different directions by others. It is as yet impossible to foretell when the elucidation of the facts and opinions will take place. Of late, however, all the anatomical and clinical investigations have aimed at this goal, and they have already thrown much light on some of the doubtful points. AVe need, above all things, searching histological studies of the diseased spinal cord, to enable us to comprehend the gene- sis and the histological development of the different processes. There is, moreover, great need of further elucidation and a more exact definition of the general pathological conception of inflam- mation, in order to show what should be comprised under the head of inflammation of such an organ as the spinal cord. It is especially necessary that we should learn how chronic inflamma- tion of the cord is to be defined, and how it is to be distinguished from, or in what genetic connection it stands to, the other forms of chronic disease, viz., atrophy, degeneration, softening, sclero- sis, etc. Not till these steps have been gained, will it be possible to determine positively what forms of disease are to be classed under the head of myelitis, and to describe accurately the clini- cal histories of the different forms. The necessities of practice, however, demand a dogmatic pres- MYELITIS. 385 entation of the subject, and the practical physician has a right to insist, that it should be in accord with the present state of our knowledge, however incomplete that may be, all disputed ques- tions being avoided as far as possible. This idea has guided and influenced us in the preparation of the following account of the disease. It is both short and incomplete, but in extenuation of the latter we must plead the difficulty of the subject, and of the former the shortness of the space allotted us. History. An accurate history of the growth of medical knowledge on the subject of myelitis would be almost the same thing as a his- tory of the pathology of the spinal cord in general. That does not enter into our present task. Nor is it at all necessary for us to investigate the question whether the ancients—Hippocrates, Aretaeus, Galen, and others—had or had not any definite con- ception of myelitis. There can be no doubt that they repeat- edly met with the disease, but they did not differentiate it sharply from other affections. We find in their works more or less recognizable descriptions of both the acute and the chronic forms of myelitis. Our more accurate knowledge of the inflammations of the spi- nal cord dates only from the end of the last and the beginning of the present century. Here, too, it was P. Frank (1792) who gave the impetus to more accurate investigations. Spinitis, rachi- algitis, and the like, were the terms then applied to the more acute forms of the disease. At a later period, the term "myeli- tis," which is now universally employed to designate inflamma- tion of the spinal cord, was introduced, mainly through the works of Harless (1814) and Klohss (1820). In the third decennium of this century, the epoch-making works of Ollivier (1st Edit., 1821) and of Abercrombie (1828) appeared and placed the subject of myelitis on a firmer founda- tion. These authors were the first to point out the intimate con- nection of softening with the acute form of the disease. After this the subject remained in statu quo for a long time. During the fifth and sixth decennia the attention of physicians was grad- VOL. XIII.—25 886 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. ually directed more to the chronic forms of the disease. Among the valuable contributions of this period, we must mention Tuerck's discoveries concerning the secondary degenerations, and Romberg's account of tabes dorsalis, but, above all, the admira- ble observations and investigations of Duchenne (of Boulogne). This last-named author described in a classical manner the clini- cal histories of chronic spinal paralyses, locomotor ataxia, pro- gressive muscular atrophy, etc. The development of the pathology of the spinal cord did not, however, receive any great impetus until the beginning of the seventh decennary, when it began to make rapid progress under the influence of improved methods of physiological and histo- logical investigation. In this accelerated development the sub- ject of myelitis played a prominent part. We must here extol especially the works of Brown-Sequard. The publications of Oppolzer, Levy, Mannkopf, and others, on acute myelitis, are also deserving of special mention, while the pathological ana- tomy of the subacute and chronic forms of myelitis was cleared up very greatly by the valuable contributions of Frommann (1864 and 1867). From this time forward wTe have to chronicle a rapid advance in the knowledge of the acute and chronic forms of inflammation of the spinal cord, which became the object of zeal- ous study in France and England, as well as in Germany. Broad foundations, on which to build up the edifice of acute myelitis, were laid by the works of Engelken, Charcot, Dujardin-Beau- metz, Hayem, Westphal, J. v. Heine, and others, but it was nevertheless the chronic forms of the disease which attracted the most earnest attention of scientific men. Our knowledge of these has been greatly advanced by the admirable works of Friedreich, Westphal, Leyden, Frommann, Th. Simon, and others, in Ger- many ; of Lockhart Clarke, Gull, and others, in England; and of Duchenne, Topinard, Jaccoud, Charcot, Vulpian, Hallopeau, Joffroy, Michaud, Pierret, and others, in France. The school of the Salpetriere, under the direction of Charcot and Vulpian, has unquestionably played the most prominent part in the furtherance of this development. We have to thank it for numerous admirable works, full of new discoveries and fruitful thoughts. Germany, too, has furnished during recent MYELITIS. 387 years a number of excellent works. (Compare the histories of tabes dorsalis, multiple sclerosis, and spinal paralysis of children.) Finally, we must also mention the claims of the electro-therapeu- tists, especially those of Germany, whom we must thank for many valuable advances, nofc only in the treatment, but also in the pathology of myelitis. In describing myelitis, it seems to us for many reasons expe- dient to distinguish two principal forms of the disease, viz., the acide and the chronic. These two forms run into one another in many points, but as a general thing they present noticeable dif- ferences, chiefly in regard to their course, but also in regard to their pathological anatomy and their clinical manifestations. The different forms and subvarieties of the disease, of which there are not a few, will be only briefly alluded to here, as we shall return more fully to them at a later period. A. Acute Inflammation of the Spinal Cord—Myelitis Acuta. Definition.—We understand by acute myelitis all the varie- ties of acute inflammation of the substance of the spinal cord, which rapidly lead to serious disturbances, and are usually, if not always, attended by fever. We have to deal here with rapidly developing inflammatory changes, which affect the connective substance as well as the ner- vous elements of the cord, but of which all the histological steps are not yet thoroughly understood. The usual result is a rapid destruction of the histological constitution of the cord, which almost always takes the form of softening, and is of course accompanied by abolition of the function of the affected part. In the present state of our knowledge, it is scarcely possible to make an accurate subdivision of the disease into parenchyma- tous and interstitial acute myelitis. Acute myelitis may present itself in different forms, according to its exact seat. It may also follow very different courses. It is true that the development of the disease and of the disturb- 388 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. ances of function caused by it, is in almost all cases very rapid, but of the cases which prove fatal, it is only in a small number that the subsequent course of the disease is as rapid as its com- mencement. On the other hand, a speedy recovery is very rare ; usually the disease runs a more or less protracted course, and either terminates in death or sinks into a chronic affection. Etiology and Pathogenesis. The comparative rarity of acute myelitis accounts in a mea- sure for our lack of knowledge concerning its causes. It is only in a small number of the cases that we can succeed in dis- covering a tangible cause, and even in them its mode of action usually remains enveloped in mystery. Many cases apparently originate spontaneously, without any exciting cause at all. In such cases the cord has been subjected to the action of irritants which are entirely unknown to us. Very little is known concerning the conditions which produce an increased predisposition to acute myelitis. The male sex seems to be more subject to the disease than the female. It is said that the greatest number of cases occur during youth and middle age, between the ages of ten and thirty years, but still there is a particular form of acute myelitis, the so-called spinal paralysis of children, which is essentially and almost exclusively a disease of childhood. Many authors hold that this form of the affection is connected with dentition, but the correctness of the opinion is questionable. It seems to us that it would be more correct to class sexual excesses, the practice of coitus in the erect position, severe bodily exertion and the like, with the predisposing than with the exciting causes of acute myelitis. Of the latter the simplest and the easiest to stud}?- are inju- ries, to which the spinal cord is so frequently exposed, and which may result from the most various external agencies. All sorts of injuries of the cord, such as those produced by punctur- ing and cutting instruments, by fractures and luxations of the vertebrae, contusions, etc., form the regular starting-point for the acute traumatic myelitis which we have already described in MYELITIS. 389 No. 4, Part 1, p. 305. This traumatic myelitis has also repeat- edly been the subject of experimental investigations. Next in order come the cases, in which a slow compression of the spinal cord is the starting-point of a myelitis. This com- pression maybe due to lesions of the most various sorts. (Comp. above, No. 5, Part 1, p. 319.) It is true that some of the com- pressing agents which come in question here, are more liable to excite the subacute and chronic forms of myelitis. When, how- ever, the agent which produces compression of the cord, is at the same time of an irritating nature, e. g., carcinoma, the inflamma- tory exudation in caries of the vertebrae, etc., changes are not infrequently produced, which unquestionably belong to acute myelitis. This brings us to those forms of acute myelitis which are due to the transmission of inflammatory processes from neighboring organs and tissues, without the intervention of com- pression of the cord. The principal, and practically the only important, disease belonging in this category is acute meningitis spinalis, which is almost invariably attended by more or less extensive implication of the cord itself. We have already spoken of this peculiarity in the chapter on Leptomeningitis Acuta, Part 1, p. 233. Catching cold is unquestionably one of the most important and most frequent causes of acute myelitis. The cases in which exposure to some one of the more severe causes of colds, such as sudden cooling of the overheated body, a fall into water, sleep- ing on the damp earth or in snow, etc., has been followed imme- diately by the symptoms of acute myelitis, are too numerous to leave any doubt of the potentiality of this cause. (See the obser- vations of Ollivier, Oppolzer, Voisin, and others.) Dujardin- Beaumetz believes that the frequency of the disease among bakers can be ascribed to the fact, that their work exposes them in an unusual degree to colds. The question whether excessive bodily exertion must also be classed among the exciting causes, cannot as yet be decided. Perhaps it acts onty as a predisposing cause. At all events, it seems to have a certain etiological significance, when combined with exposure to the causes of colds ; every war, and especially every winter campaign, furnishes examples which illustrate this, 390 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. The same may also be said of the different varieties of sexual excess. Acute myelitis is not unfrequently developed as a complica- tion or sequel of acute diseases. It has been observed in con- nection with typhus, the acute exanthemata, acute rheumatism, severe puerperal diseases, etc.; most frequently, however, in con- nection with variola (Westphal). In this last case the myelitis has set in at a variable period after the outbreak of the primary dis- ease, in a few rare cases not until several weeks afterwards. Baumgarten recently reported a remarkable case, in which infec- tion with bacteria (from malignant pustule) was in all probability the cause of an exceedingly acute myelitis. Among the chronic infectious diseases, syphilis can unques- tionably cause acute myelitis. A question may be raised as to whether we have to deal in this case with a specific luetic process, or with an ordinary non-specific myelitis of which the syphilis has been only a predisposing and distant cause. It is at all events certain, that myelitis running a rapid course, is observed with unusual frequency among syphilitic patients. Our own observations lead us to agree with Hayem, who claims that syphilis is an etiological agent of decided importance. Continued suppression of the menses, sweating of the feet, and hemorrhoidal bleeding play a more or less doubtful role in the etiology of acute myelitis. Violent emotions seem in many cases to have been really the starting-point of myelitis. At least some isolated cases have been reported (by Leyden, among others), in which the first symptoms of myelitis showed themselves immediately after some intense psychical movement, such as fear, anxiety, or anger. Finally, irritations and diseases of peripheral organs must also be mentioned among the causes of acute myelitis, although the cases in which they are really the agehs morbi are compara-^ tively rare. For instance, a certain proportion of the so-called reflex paraplegias, which are developed in connection with dis- eases of the urinary and digestive apparatuses and of the uterus, or with irritations and inflammations of the peripheral nerves, the joints, etc., should really be classed as acute myelitis. This fact and the pathogenesis of reflex paralyses have already been MYELITIS. 391 discussed In more than one chapter of this work, and we may refer the inquirer to them for further information.1 Here, we will only mention the fact that Feinberga has recently succeeded, by varnishing the skin of rabbits, in exciting an acute affection of the spinal cord, which at all events closely resembles inflamma- tion. He regards it as reflex in nature and secondary to the severe irritation of peripheral sensitive nerves, and ascribes it to paralysis of the vaso-motor centres. After all has been said, however, we must admit that we have very little positive knowl- edge concerning the pathogenesis of reflex paraplegias, and unfortunately our knowledge of the pathogenesis of myelitis due to other causes is equally deficient. The traumatic cases and those secondary forms due to extension of inflammation from neighboring tissues, are the easiest to comprehend. When, however, we seek to explain the manner in which catching cold or emotional disturbance produces myelitis, or the mode in which it is developed in connection with acute diseases, or with syphilis, etc., we can only bring forward more or less gratuitous theories, which it would be useless to discuss here. Pathological Anatomy. Frequently a spinal cord which is the seat of acute inflam- mation, presents very little or even absolutely no macroscopic change. There is not the slightest reason to doubt, that the disease has on innumerable occasions been overlooked at the autopsy. In fact, we can scarcely ever be absolutely certain that an acute myelitis exists, until a microscopic examination has been made. In the macroscopic examination the most striking peculiarity is the diminution in the consistence, the softening, of the cord (myelomalacie). This change is so constant, that softening has been generally, but very incorrectly, identified with acute in- flammation. That the two processes are not identical, is evident 1 See Vol. XI. and Vol. XII. 2 Virchow's Archiv. Vol. 59. p. 270. 392 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. on the one hand from the fact, that every softened cord is not inflamed, and on the other from the fact that inflammation of the cord does not always terminate in softening. It would be better consequently to discard entirely the use of the term "softening," to designate inflammatory processes. I must at all events pro- test most earnestly against the promiscuous employment of the name myelomalacia as a synonym for myelitis. That term should be reserved for processes of softening pure and simple. The inflammatory changes, which we will consider first, vary greatly as regards their localization in the spinal cord. Acute myelitis has its seat and starting-point most frequently in the gray substance, a fact which depends probably on the vascular richness of this portion of the cord. It may extend to a greater or less distance in a vertical direction, and may penetrate more or less deeply into the white columns. This is the form which, since the time of Albers, has been usually designated as myelitis centralis. It may spread very rapidly through the gray substance, and in a short time involve the greater part, or even the whole of the gray axis—diffuse central myelitis (Hayem). When the white columns are also involved to a marked extent, so that the entire cord is more or less implicated in the inflammatory process, the affection may be called myelitis diffusa. Strictly speaking, however, this is a rare oc- currence. Not unfrequently the entire thickness of the cord is affected for a longer or shorter distance. The diseased part may in such cases be several inches in length, but the inflammatory process is usually not equally intense throughout its whole extent. This is the form which is now ordinarily described as myelitis trans- versa. When the centre of inflammation is less extensive, so that it involves only a small portion of the cord both vertically and transversely, it is termed myelitis circumscripta. Here we have to deal with a small spot of inflammation buried somewhere in the substance of the cord. Not unfrequently, however, we meet with several of these small spots in the same cord. Cases have been observed (Westphal), in which the myelitis presented itself in the form of numerous foci scattered throughout the entire cord MYELITIS. 393 and separated from one another by healthy tissue—cases in which the disease was widespread, but attacked only circumscribed and scattered spots. This is called myelitis disseminata. Finally, that form of the disease which is secondary to menin- gitis, affects principally the peripheral layers of the cord, pene- trating more or less deeply and extending vertically to a variable distance—myelitis peripherica. The appearances presented by the affected spots vary greatly according to the stage of the myelitis, and in part also accord- ing to the special peculiarities of the process in the individual cases—always provided there are macroscopically demonstrable lesions. We must here distinguish different stages. 1. The stage of hyperemia and commencing exudation (red softening). We do not often meet with this stage of the disease at the post-mortem table. The opportunities to study it are fur- nished most frequently by those cases in which the inflammation is secondary to severe traumatic lesions, or by cases of myelitis centralis, which run a rapidly fatal course. At the affected spot a slight, and in rare cases a marked, swell- ing can be recognized. On section, the transverse markings are found to be blurred and indistinct, and the cut surface not unfre- quently presents a variegated, marbled appearance. The red color of the tissue, which is due to the hyperaemia, is usually very marked ; it may vary from a slight rosy injection to a deep red, reddish brown or chocolate color, when more or less numerous capillary hemorrhages are added to the often very intense hyper- aemia. The inflamed spots are almost always unusually moist and soft; they swell up above the level of the cut surface. The softening may be so great that the tissue is reduced to the con- sistency of pap. In very rare cases we observe a slight increase in consistency at this stage, probably on account of infiltration of the interstitial tissue with a firmer exudation. Hayem has reported an instance of this. In some few cases we can see with the naked eye, or with the help of a lens, a distinct deposit of 394 ERB.—DISEASES OF THE SPINAL" CORD AND ITS ENVELOPES. exudation in the affected spot; it takes the form of whitish or yellowish, clouded or glassy, colloid streaks or rings, which are imbedded in the septula or poured out around the vessels. The meninges in the neighborhood of the affected spot also frequently present the signs of hyperaemia and inflammation. In preparations hardened in chromic acid, the myelitic spots can usually be much more readily distinguished from the healthy tissue by their different (brighter yel- low) color, than in the fresh cord. The inflamed parts, moreover, harden slowly and badly, and on section they appear friable, crumbly and not coherent, and do not present sharply defined markings. The smaller spots of myelitis in particular, as well as the secondary degenerations, are very sharply and distinctly mapped out by this discoloration. 2. The stage of fatty degeneration and of resorption (yellow and white softening). As the disease progresses, the affected spot becomes constantly paler and more and more softened. Its color changes gradually from red to yellow ; this change is due partly to the diffusion and alteration of the coloring matter of the blood, partly to the fatty degeneration of the medullary sheaths and the formation of masses of fat-granules, and partly to the cessation of the hyperaemia. Through the influence of these three agencies, but particularly in consequence of the ac- cumulation of fatty detritus, the color becomes progressively whiter, and the entire substance assumes a creamy or milky ap- pearance. The softening has meanwhile made rapid progress, the medulla swells up very much above the cut surface, acquires a pappy or even a more fluid consistency, and often flows out of the sac of the pia entirely. This softening is caused principally by the fluid exudation from the vessels, acting in concert with the destruction of the nerve-fibres. This exudation may possibly present certain differences in different cases, which would account for the varying degree of the softening, or even for its entire ab- sence. Of this, however, we have no positive knowledge. At last nothing remains of the diseased spot but the vascular network and a portion of the hypertrophied septa, between which is a softened mass that can readily be pressed out, or which per- haps flows out without the help of pressure. In consequence of the progressive resorption of the nerve-substance and the fat- MYELITIS. 395 granules, the spot gradually assumes a more grayish color, and finally becomes smaller and depressed. Actual suppuration occurs very rarely in acute myelitis. When abscess of the cord does form, it is generally secondary to a severe traumatic lesion or to suppu- rative meningitis. In spontaneous myelitis, on the other hand, suppuration is ex- ceedingly rare, and has only been observed in a very few cases. 3. The terminal stage (formation of cicatrices or cysts, in- duration, sclerosis, etc.). The resorption of the softened masses continues until finally all the fluid portions have completely disappeared. Nothing remains but the vascular and connective tissue networks, which are in part thickened and hypertrophied; they form a more or less dense, shrivelled, grayish, semi-transparent cicatrix, which is often flecked with pigment. This cicatrix unites the portions of the cord that have remained healthy. In some rare cases a restoration of the nerve-tissue takes place ; after a certain length of time small, dark-bordered, regenerated nerve-fibres can be de- monstrated in the cicatrix. In this way also a restoration of function can be brought about, as happened in one of Charcot's cases. This fortunate result seems, however, to occur more read- ily in the subacute and chronic forms. Not unfrequently more or less extensive collections of fluid are left behind in the framework of the cicatrix, and lead to the formation of single or multiple, large or small cysts. They usu- ally contain a muddy fluid resembling milk, or more frequently, serum. In many cases, on the contrary, the interstitial, supporting framework becomes in course of time greatly hypertrophied and consolidated. It increases in thickness and density, the vessels become larger and their walls thicker; the previously softened spot becomes firmer and denser, gray and semi-transparent, and presents a marked contrast in color and consistency to the sur- rounding parts. Here we have the commencement of harden- ing, or sclerosis. When the interstitial growth of connective tissue persists, and extends in a slow but progressive manner to the neighboring parts of the cord, which were previously either healthy or very slightly changed, and when it propagates itself 396 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. there, leading to a gradual destruction of the nervous elements, we have before us the transition into chronic myelitis. This is a frequent occurrence. In almost all cases of myelitis which do not prove rapidly fatal, this transition takes place at some late period of the disease. The macroscopic examination, as a rule, reveals also an im- plication of the meninges in the inflammatory process. The signs of it are cloudiness of the membranes, infiltration with serum, cellular elements or pus (often only discovered at the microscopical examination), thickening, adhesions, capillary ex- travasations in addition to extreme hyperaemia, etc. The spinal fluid is usually increased, somewhat cloudy and reddish, but it is sometimes entirely unchanged. The condition of the roots of the nerves is regulated by that of the pia; they are sometimes softened, loosened and swollen, sometimes atrophic, gray, trans- lucent and indurated. In the later stages, in addition to the actual centre of inflam- mation, we often meet with the so-called secondary degenera- tions, of which we have already repeatedly spoken: ascending degeneration in the funiculi graciles, and descending in the pos- terior lateral columns, etc. In many cases of acute myelitis the disease does not last long enough for their development, but they are rarely wanting in the cases that become chronic. The transi- tion from myelitis to secondary degenerations can often be traced very accurately in successive transverse sections. The microscopical examination is, however, of supreme im- portance for the understanding of the pathological processes which take place here. The cord should be examined microscop- ically, both in the fresh state and after it has been hardened by the usual methods. The changes are seen to affect the nerve- fibres and the ganglion-cells, as well as the connective tissue framework and its vessels. In the first stage we find marked dilatation of the capil- laries and small arteries, and more especially of the small veins ; they are distended with blood, and not unfrequently enveloped in layers of white and red blood corpuscles arranged in the form of a sheath. Here and there larger collections of red corpuscles are found (capillary extravasations). The walls of the vessels MYELITIS. 397 are thickened and studded with fat-granules and granule-cells, presenting exudative and plastic infiltration. Hayem describes particularly a glassy, colloid exudation, which surrounds the vessels like a sheath in a layer of varying thickness, and which is also found disseminated elsewhere in the tissue. Baumgarten seems to have seen something very similar—a hyaline, firm, glassy exudation in the tissue of the gray substance, about the vessels and in the anterior longitudinal furrow—in his interesting case of acute central myelitis, which was probably due to infection with the poison of anthrax. Marked changes are always found in the neuroglia. The fibres of the reticulum are thickened and swollen, the network is much denser and more distinct, and it is in part filled with nuclei and cells. The glia cells themselves are swollen and in- creased in number; they often contain several nuclei, and are sometimes, like the thickened connective tissue septa, infiltrated with colloid masses. Even in this stage we generally find granule-cells in greater or less numbers, partly in the immediate neighborhood of the vessels, partly scattered irregularly in the interstitial tissue and its meshes. The changes in the nerve fibres are also very striking and im- portant. The fibres, in general, present irregular contractions and enlargements; the medullary sheath has in places broken down into globules or larger irregular fragments, and has become granular; in many fibres it has entirely disappeared, or has united with the axis-cylinder to form a single, homogeneous mass. The axis cylinders themselves, as is evident from the observations of Frommann, Charcot, Hayem, Joffroy and others, are frequently swollen, and often attain enormous dimensions. They present large, spindle-shaped swellings and bulging, club- shaped fragments ; they are streaky, clouded, studded with gran- ules, brittle, and apparently in a state of granular degenera- tion. The thickening of the axis-cylinder can be very readily seen in transverse sections, in which they are often found lying together in groups. Isolated swollen axis-cylinders are also found lying in the midst of unchanged nerve-fibres. The ganglion-cells are also involved in the inflammatory changes. They are swollen, often to a very considerable size, 39S ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. looking then as if they were puffed up. Their substance is clouded ; in the beginning the nucleus and nucleolus are usually intact, but in a few instances they are in process of division. Sometimes we observe glassy swelling of the cells, and a develop- ment of vacuoli in them. Their processes are also swollen, clouded, irregular in shape, and in part destroyed. At a later period the cells disappear before the advancing processes of de- struction. In the second stage we find the nervous elements fully in- volved in the process of destruction : the nerve-fibres are broken down into fragments ; the medullary sheath is in a state of fatty degeneration, and the axis-cylinder altered or destroyed. The ganglion-cells are partly melted down and destroyed, partly atrophied and reduced to small glistening scales, without demon- strable structure. The connective tissue framework is loosened and softened by the fluid exudation, the development of cells and fatty degeneration. The walls of the vessels are thickened, very rich in nuclei, filled with fat-granules and frequently sur- rounded by thick layers of granular cells. The semi-fluid pulpy mass formed by the inflamed and softened cord, contains also numerous lumps and drops of myelin, the remains of blood-cor- puscles, colorless cells, pigment-granules, fine granular detritus, and, above all, numerous fat-granule-cells. These fat-granule- cells form usually the most striking constituent of the softened myelitic mass, and attract the attention of the observer at once; they are especially distinct when the cord is examined in the fresh state. They are found deposited about the ves- sels, and in the spaces left empty by the destruction of the nerve-fibres and axis cylinders, and also in the septa of the neu- roglia. This extensive distribution of these cells indicates of itself that they are produced in different ways; it is, in fact, probable that some of them are formed from young cellular ele- ments which have taken up fat, while others can be ascribed to fatty degeneration of the glia cells, and still others to fatty de- struction of the nerve-fibres and the spindle-shaped swellings of the axis-cylinders (Hayem, Th. Simon). In the third stage we find in the affected spot, which is now engaged in an effort at cicatrization, a sclerotic connective tissue MYELITIS. 399 with numerous nuclei and neuroglia cells. At this period Deiter s cells often become very distinct and prominent; they are often large and possess numerous processes. The vessels are dilated, and their walls thickened. The ganglion-cells are mostly atro- phied. Sometimes numerous small, delicate nerve-fibres, with thin medullary sheaths, can be seen. Occasionally cysts are found, surrounded by a more or less dense layer of connective tissue, and usually also traversed by a large-meshed, connective tissue network. Their contents are partly muddy, partly serous ; microscopically, nothing can as a rule be discovered in the fluid, except detritus. In the stage of transition to sclerosis and chronic myelitis, the increase of the interstitial tissue becomes particularly dis- tinct. The threads of the reticulum become wider and thicker, the spider-cells are enlarged and increased in number, the vessels are thickened, the nerve-fibres and ganglion-cells are involved in degenerative atrophy. The tissue contains relatively few fat-granule-cells, but, on the other hand, it contains large quantities of corpora amylacea. When secondary degeneration exists, it presents the usual well-known histological characters, which will be described in detail in a subsequent chapter (No. 19). A priori, the usefulness of experimental investigations of these conditions would seem self-evident. Unfortunately, however, the attempts to clear up the subject in this way have been but few in number,-and have furnished no important, or at all events no conclusive results. Strange to say, the numberless experimental sections of the spinal cord per- formed by physiologists, although undoubtedly on every occasion followed by traumatic myelitis, have not hitherto been utilized to any extent worth mentioning, for the study of this affection. Dujardin-Beaumetz describes some experiments performed by Hayem and Liou- ville, who sought to excite myelitis by applying iodine or glycerine to the outside of the cqrd, or by injecting them into its substance; also some experiments under- taken by himself in connection with Grancher, in which mechanical injuries were employed to excite the inflammation. The results of these experiments are, how- ever, very unsatisfactory. Joffroy made some similar experiments on dogs, and obtained the same histological changes as those which have been here described as belonging to the acute myelitis of men. The investigations of Feinberg and also those of Klemm, who endeavored to produce myelitis in a reflex manner or by means of a neuritis migrans, have not 400 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. made any important addition to our knowledge of the histological genesis of the myelitic changes. A somewhat more comprehensive series of experiments was set on foot by Ley- den, but his account of the results obtained, which was published in his " Klinik der Ruckenmarkskrankheiten," is only fragmentary. He experimented on cats and do^s, and employed exclusively injections of Fowler's solution into the cord, the result being almost always a suppurative myelitis. As, however, this variety of the disease is exceedingly rare in man, the experiments are not of much value for the elucidation of the subject of acute myelitis in the human subject. Moreover, the reports that have thus far been published by Leyden, contain no conclusive in- formation concerning the manner in which the process is developed, the relation of the minute histological changes to each other in point of time, and the part taken by the different tissue-elements in the process. Still, we have learned many things from these experiments. They have proved, for instance, that an injury of the sort here mentioned can produce an intense myelitis, which may extend beyond the point of irritation; that the process presents varying degrees of intensity in one and the same experiment; that the affection diminishes in intensity as it re- cedes from the point of irritation; that this diminution in intensity is indicated on the one hand, by a tendency to localization in scattered, circumscribed spots, and on the other, by a preponderance of the connective-tissue growth over the softening, liquefaction and suppuration; that multiplication and swelling of the nuclei of the neuroglia, swelling of the nerve-fibres and axis-cylinders, disappear- ance of the medullary sheath and development of granule-cells, must be regarded as the first signs of a commencing acute myelitis, etc. In the latest experiments of Hamilton on cats, only the first days of acute trau- matic myelitis are taken into consideration. He found among other things, that rounded bodies separate from the swollen axis-cylinders and either degenerate into colloid bodies, or give rise to an endogenous brood of young round cells (pus- cells). He also observed swelling and cloudiness of the ganglion-cells, multynica- tion of the nuclei of the neuroglia, collections of cells in the walls of the ves- sels, etc. It is certainly desirable and even necessary that these experiments should be repeated with modifications, that myelitis should be produced in other ways, so as to bring the results more in accord with the lesions in man, and to furnish a more complete periscope of the process in its different modifications and its various degrees of intensity. We must here mention briefly some special forms of acute myelitis. First of all, we will speak of myelitis centralis acuta. In this form the softening and liquefaction affects pre-eminently the gray substance, which flows out when the cord is divided, leaving a cavity behind. The spinal cord is somewhat swollen throughout its entire extent, and on section the transverse mark- MYELITIS. 401 ings are seen to be greatly blurred. Hayem describes this form in the following words : diffuse inflammation of the gray sub- stance, more or less diffuse hyperaemia of the white substance; small, band-shaped foci of inflammation in the latter; more or less intense, meningitic changes. When this form possesses a hemorrhagic character, we have the myelitis centralis hemorrhagica, which Hayem designates by the term hematomyelitis. It is characterized by a more or less abundant extravasation of blood, which appears either in the form of a marked hemorrhagic softening, affecting chiefly or exclusiveby the gray substance, or in the form of hemorrhagic foci of varying sizes, which may extend into the white substance. The tissue in the neighborhood of these foci, both above and below, is in a state of myelitic softening, that may extend throughout almost the entire length of the medulla. The acute myelitis without softening, which Dujardin-Beau- metz terms myelitis hyperplastica, also deserves special mention. Its essential characteristic is an increase of the interstitial tissue, which becomes unusually dense and very rich in nuclei. The septa are wider than usual, and the vessels are thickened ; there are a few granular cells. The consistence of the cord is normal or somewhat increased. This form seems to occur principally in small spots (Westphal's myelitis disseminata), and to indicate in general a slighter degree of intensity in the inflammatory pro- cess. It is sometimes observed also in the neighborhood of spots of acute softening. It should probably be classed rather with the subacute forms, which constitute an intermediate step be- tween acute and chronic myelitis. The changes in the other organs of the body, in acute myelitis, require only a brief enumeration. In the peripheral nerves we find in many cases—especially in central myelitis—degenerative atrophy in its different stages of development. In the muscles supplied by these nerves, we find also the characteristic signs of the first stages of the same process (proliferation of the nuclei, slight atrophy of the fibres, etc.). The mucous membrane of the urinary bladder is in many cases swollen, flecked with hemorrhages and in a state of catarrh; in the severest cases it is infiltrated with diphtheritic exudation VOL. XIII.—26 402 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. and presents foul, sloughy ulcers. Sometimes similar changes are observed in the ureter extending into the pelvis of the kid- ney, and in not a few cases the kidneys have been found filled with metastatic abscesses. According to Hayem, a part of these originate from collections of vibriones. The changes characteristic of decubitus acutus in its different stages of development, are usually observed on the skin covering the sacrum and the nates, the trochanters, and other spots ex- posed to mechanical pressure. (Compare Part I., p. 121.) Other pathologico-anatomical changes, which are more or less accidental, do not require special consideration here. Pathology of Acute Myelitis. Symptoms. The general clinical history of acute myelitis is so manifold and changeable, and so different perhaps in each individual case, that we can only attempt to give here its most common features. Later on these will be filled out in many particulars while con- sidering the symptoms in detail. Even in its mode of commencement the disease is very variable. Sometimes it is preceded by general malaise and slight febrile movement, while in a few cases it commences with a chill, which is followed by the usual febrile symptoms: headache, general depression, dragging pains in the limbs, loss of appetite, etc. Frequently the scene is opened at once by spinal symptoms. In these cases the symptoms which first attract the attention of the patient are usually disturbances of sensation: paraesthesiae, formication, etc., in the extremities, a girdle-sensation or perhaps a girdle-pain at the level of the seat of disease, pain in the back and tenderness over certain spinous processes, sometimes pain- ful, dragging sensations in the bladder and rectum, gastralgic pains and the like. These are sometimes, but not always, accom- panied by motor symptoms of irritation: twitchings of certain muscles or groups of muscles, violent tremor, partial clonic spasms and in some special cases even general convulsions. MYELITIS. 403 Sometimes an isolated paralysis of the bladder is the first symptom. Very soon, however—sometimes after a few hours, or on the next day—the characteristic paralytic symptoms make their appearance. Of these, the motor paralysis is the first to appear; it is more or less complete and involves a variable number of muscles, usually taking the form of paraplegia, but not unfre- quently assuming other forms. Paralysis of the sphincters usually sets in soon after this. It often appears very early, simultaneously with the motor para- lysis, but in some cases it does not occur until long afterwards. It may, however, be entirely wanting. The same may be said of the paralysis of sensation. In all severe cases it sets in very early and is complete ; there is then usually complete anaesthesia of the lower half of the body up to a certain height, which is sometimes marked by a pretty sharply defined line. In milder cases the anaesthesia may be less com- plete and less extensive, and finally in certain forms of the dis- ease (poliomyelitis anterior), it is entirely wanting. The reflex excitability varies according to the seat of the disease. It may be rapidly and completely destroyed in the paralyzed part, or it may gradually diminish as the disease progresses, or it may remain normal, or finally it may be very considerably increased, occasionally attaining an astonishing de- gree of intensity. For most cases of acute myelitis the rapid extension of the paralysis through the cord in a horizontal direction, the com- plete paraplegia, is to some extent characteristic; not less so in many cases, is its rapid extension in a vertical direction, the rapid ascent of the paralysis towards the head, the acute ascending paralysis. These peculiarities depend on the variety and localization of the disease in the individual cases. In sharp contrast to them, there are others in which the paralysis attains its acme in the very commencement, never extending subsequently. In almost all the severe cases, vaso-motor paralyses, cystitis and pj^elonephritis, and extensive bed-sores which are often acute, set in early. All these complications may, however, be absent. 404 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. The same is true of the atrophy of the paralyzed muscles, and of the loss or modification of their electrical excitability. The subsequent course of the disease varies greatly in the dif- ferent cases and forms: 1. It may be rapidly progressive and fatal. In this case, after a few days of continuous fever with the symptoms of an ascending paralysis, death takes place from a rapidly develop- ing asphyxia. 2. Or the disease may run a slower and less violent course; the fever remains moderate or disappears entirely, but cystitis and bed-sores are developed, bringing in their train fever, emaci- ation and exhaustion, and the patients succumb after weeks or months of suffering. 3. Or the acute affection may be transformed into chronic myelitis; the paralytic symptoms persist with slight variations in intensity, until at some later period a slow exacerbation sets in, and the affection then runs the usual course of a chronic myelitis. 4. Or an improvement sets in, which, however, always re- mains incomplete. The myelitic process ceases, but not until it has irreparably destroyed a certain number of the nervous ele- ments of the cord, as a result of which a more or less extensive defect, such as paralysis, atrophy, contracture, anchylosis, or the like, is left behind. The general health, however, becomes and remains good, and the disease which he has passed through exerts no further influence on the length of the patient's life. 5. Or finally—and this is perhaps the rarest termination of all —complete recovery takes place. Several reported cases demon- strate that this favorable termination is at all events possible. A rapid improvement sets in, and, after the expiration of a longer or shorter period, all the bodily functions are completely restored. Convalescence is usually somewhat protracted. As has been stated, this clinical picture, which contains only the most general features of the disease, can be modified in many ways, the necessary result of which has been the differentiation of various forms of acute myelitis, to which we will return later. Before doing so, however, we must describe somewhat more closely the individual symptoms. MYELITIS. 405 Among the disturbances of sensation the symptoms of irri- tation, in consequence of the complaints of the patients, usually assume the greatest prominence. In a few rare cases they are entirely wanting, or are so slight that the patients do not speak of them, unless closely questioned about them. Violent shoot- ing pains are not commonly present in acute myelitis, a point of importance in the differential diagnosis from meningitis. They do occur, it is true, especially in the initial stage, but usually disappear soon, seldom persisting for any length of time. They appear sometimes in the form of neuralgic pains surrounding the trunk like a girdle at a variable height, sometimes as a circular, hoop-like, burning sensation in the skin, or they may consist of dragging, tearing, boring or burning sensations in the limbs. Pressure and movement do not usually aggravate these pains in the extremities. They are very commonly accompanied by pain in the back, extending over a more or less extensive area, and also by tenderness over several of the spinous processes. This can sometimes be recognized by passing hot and cold sponges over the spine of the back. On the other hand, various paraes- thesiae belong to the more constant symptoms of the disease. One of them is the well-known unpleasant sensation of con- striction as by a girdle, which is experienced not only on the trunk, but also in the extremities and joints. Feelings of ten- sion or swelling, and of cold or heat, pricking and sticking sen- sations, formication, etc., are experienced over more or less ex- tensive cutaneous areas, particularly in the lower extremities. Gradually the feeling of numbness and furriness and the loss of sensation become more and more prominent as the anaesthe- sia becomes more distinct. True hyperaesthesia is rarely pres- ent in acute myelitis, and when it is, is probably due usually to a complication with meningitis. It does, however, occur also in unilateral circumscribed myelitis, on the same side as the motor paralysis. Charcot describes, under the name of dysaes- thesia, a peculiar, diffuse, painful, vibrating sensation, which is produced by touching any circumscribed spot on the skin, and may extend to the entire extremity and even to both lower extremities. The symptoms of sensory paralysis are not usually slow in 406 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. making their appearance, though they too may be permanently absent. The anaesthesia may be more or less extensive and com- plete ; the paralysis of sensation is sometimes only partial, or there may be merely a slowness in the conduction of sensations. Severe pains are not unfrequently complained of in parts that are entirely deprived of sensation—anaesthesia dolorosa. Iso- lated, jerking, shooting pains, accompanied by spasmodic twitch- ings of the muscles, are very common in the paralyzed parts. The explanation of all these symptoms is undoubtedly to be sought in the development and progress of the inflammatory changes in the spinal cord. The initial symptoms of irritation are to be ascribed to the inflammatory and hyperaemic irritation of the nerve-elements in the gray and white substances, the later symptoms of paralysis to the destruction of these elements and their compression by the inflammatory exudation. The girdle- sensations depend probably on the involvement of the posterior nerve-roots in the inflamed spot; the paraesthesiae and anaesthe- siae of the posterior half of the body, on the involvement of the sensitive tracks situated in the gray substance and in the poste- rior white columns. Since these sensitive tracks lie for the most part within the gray substance, or at all events must pass through it for a certain distance, it is easy to account for the usually in- tense and complete anaesthesia in acute central myelitis. Fur- ther, the well-grounded assumption, that the sensitive tracks run principally or exclusively in the posterior half of the gray sub- stance and. the posterior and lateral white columns, explains sufficiently the fact, that in myelitis involving only the anterior portion of the gray substance (e. g., in the spinal paralysis of children), disturbances of sensation are entirely wanting. In the circumscribed, disseminated, and peripheral forms of myelitis, the degree of the disturbance of sensation will depend solely on the extent to which the sensitive tracks are involved in the pathological changes in the cord. The motor disturbances also present irritative and paralytic stages. To the former belong, in the first place, the twitchings of individual muscles or of entire extremities, which often occur in the initial period, and the spasmodic contractions of the mus- cles, which sometimes increase to a condition of tetanic rigidity ; MYELITIS. 407 also the convulsive movements of the extremities, and finally the initial general convulsions, which occur almost solely in chil- dren. Much more constant and more important, however, are the symptoms of motor paralysis, the development of which stamps the clinical picture of acute myelitis with such a charac- teristic impress. The paralysis may be developed with such enormous rapidity, that we speak of an apoplectiform myelitis. Cases have been observed, in which complete paraplegia was developed during one night, within a few hours, and even in less than an hour. It is, however, only in the hemorrhagic form of myelitis that the paralysis can develop fully within the space of a few minutes, just as it does in apoplexy of the cord. This rapid development is the rule particularly in central myelitis; in the other forms of the disease, a longer period may be neces- sary for the production of the paralysis. In such cases the mus- cles are always perfectly flaccid ; the limbs hang or lie as if they were dead, and when raised fall like the limbs of a corpse. Later in the disease, if the patient survive, the symptoms of irritation may again make their appearance in the affected limbs. Isolated spontaneous twitchings of the muscles are observed, which are often accompanied or excited by severe shooting pains. A state of muscular tension, or spasmodic tonic contractions of the muscles set in, which are excited particularly by attempts at voluntary movement or by irritation of the sensitive nerves. Finally, severe contractures are produced, which fix the legs in an extended or flexed position, and are frequently rendered more intense by attempts at active or passive movements. These symptoms, however, belong more to the later periods of the dis- ease, and hence are more constant in the subacute and chronic forms. The most common form of the paralysis is paraplegia; still hemiparaplegia, paraplegia cervicalis and isolated paralyses of particular limbs, as well as complete paralysis of all four extremi- ties along with the trunk, also occur. This depends, of course, entirely upon the seat and extent of the disease. The pathogenesis of all these motor disturbances is not by any means perfectly clear as yet. There can be no doubt, it is true, that they must be due to changes in the motor nerve-tracks 408 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. in the spinal cord, but we are unable to decide positively in every case, whether they are due to lesions of the anterior roots, or of the nerve-tracks in the gray substance or in the lateral columns, or to simple reflex processes. The arguments that are advanced in support of each of these suppositions have already been detailed while speaking of the general disturbances of mo- tility (see Part I., pp. 79 and 97), and to avoid repetition we may refer the reader to that chapter. It is consequently in regard to the localization of the morbid process, that the explanation meets with the greatest difficulties, for it is a self-evident fact that the inflammatory changes in the cord must be capable of producing irritative as well as paralytic phenomena in the motor paths. The disturbances of reflex action are especially valuable for the interpretation and localization of the lesion in many cases of acute myelitis. The state of the reflex activity, both of the skin and the muscles, may vary greatly; it may be diminished and even destroyed, or it may be considerably increased. In a portion of the cases it is abolished very soon, immediately after the development of the paralysis, and reflex actions can no longer be excited even by severe irritants ; sometimes it is not entirely abolished, but a longer time is required for the production of the movements; in other cases it undergoes a very considerable increase, so that even very slight irritations call forth the most active, reflex muscular twitchings, which may increase to a persistent, convulsive jerking of the para- lyzed part; or, in still other cases, it remains unaltered or is slightly increased for a time, and then begins to diminish and gradually becomes weaker, finally disappearing entirely. What- ever the condition may be, it furnishes a valuable indication of the state of the gray substance, for it is this portion of the cord which determines principally the state of the reflex activity. The more intact the gray substance remains, the more confi- dently can we look for a continuance of the reflex actions. When a portion of the gray substance, itself intact, is sepa- rated from its connection with the brain by a more centrally situated myelitis (e. g., the gray substance in the lumbar portion of the cord by a myelitis located in the dorsal region), the re- MYELITIS. 409 flexes are increased ; hence the exaltation of the reflex excita- bility so commonly observed in myelitis transversa dorsalis. When the gray substance is destroyed by the disease the re- flexes are abolished ; hence their disappearance in myelitis of the lumbar enlargement, and more especially in diffuse central myelitis, in which all reflex action is usually abolished from the very commencement. When this destruction of the gray sub- stance is secondary and effected at a later period of the disease by the extension of the inflammation downwards, the reflex activity may be at first normal or even increased, but will sub- sequently become weaker and gradually disappear. Hence, we shall be able in many cases to draw from the con- dition of the reflex excitability important and relatively sure conclusions, with regard to the localization of the myelitis in the gray substance. We must bear in mind, however, that the reflex actions can also be modified by changes in the anterior roots, and that, moreover, the lateral columns probably exert an important influence on them—facts which warn us not to make these con- clusions too positive. The sphincters are very frequently involved. Vesical paral- ysis is not unfrequently one of the earliest, and sometimes even one of the prodromal symptoms of acute myelitis. In severe cases there is usually complete retention of the urine, which must be evacuated by the catheter during the entire course of the disease. In other cases there is merely incontinence of urine, or this is the most constant symptom on the part of the bladder. In a word, any of those disturbances which we have described and attempted to explain in Part I., p. 132, may be observed. Sometimes the symptoms in the beginning- of the disease are more those of irritation, spasmodic closure of the sphincter with increased desire to make water. The sphincter ani behaves in a similar manner ; here, too, the most constant symptoms are those of paralysis. The explana- tion of all these symptoms on the part of the sphincters is to be found in the localization of the myelitis ; for further particulars we may refer to what has been said on this subject in the gen- eral part. Priapism is not an uncommon symptom in acute myelitis. 410 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Generally the erection of the penis is incomplete, but it often persists for days, with slight variations in degree. It must be regarded as essentially a sign of irritation, produced either by irritation of the nerve-tracks passing from the brain to the lum- bar portion of the cord (Comp. p. 313), or by reflex excitations proceeding from the bladder, skin, etc. The vaso-motor disturbances in acute myelitis have not yet been sufficiently studied. Engelken found in one case a rise in the temperature of the paralyzed part, but most authors speak of the extremities as being cold. Diffuse oedema of the paraple- gic lower limbs has sometimes been observed. The perspiration is sometimes increased, sometimes diminished in quantity. As recent physiological investigations have demonstrated that the vaso-motor innervation is of a complicated nature, we must wait for more exact observations before an explanation of these dis- turbances can be attempted. This applies with even more force to the trophic disturbances, which follow in the train of acute myelitis. They are most dis- tinct in the skin, the most striking of them being the decubitus acutus,1 which is developed regularly and early in the severer forms of myelitis, and occasions great danger to life. It appears in the well-known form of gangrenous inflammation of the skin over the sacrum, trochanters, etc., usually progresses rapidly, and proves fatal by septic fever. When the lesion in the cord is unilateral, the decubitus is situated on the opposite side of the body. It may make its appearance as early as from the sec- ond to the fifth day of the disease. For its pathogenesis we may refer to the remarks made in Part I., p. 123. There is not always time for the development of trophic disturbances in the nerves and muscles; still, even in rapidly fatal cases of central myelitis, the first traces of the degenera- tive atrophy have been discovered in the muscles and nerves. When the disease has been of somewhat longer duration, the atrophy of the muscles is not unfrequently very marked. There 1 Translator's Note.—The Germans use the term decubitus to designate bed- sores, and for the sake of convenience it has been deemed advisable to retain it in the translation. MYELITIS. 411 seems to be no question that these disturbances in the nutrition of the muscles are directly dependent on the condition of the gray substance. Every marked disturbance of nutrition in the gray substance leads to rapid atrophy of the muscles, and the study of particular forms of acute myelitis (spinal paralysis of children) has demonstrated very positively that this influence on the nutrition of the muscles is exerted especially by disease of the anterior horns. Hence, wherever a considerable and rap- idly developed atrophy of the muscles exists, we must assume an inflammation of the gray matter. The state of the electric excitability is of great value for the recognition of this degenerative atrophy. Whenever rapid mus- cular atrophy sets in, or in other words in severe affections of the gray substance, a loss of the faradic irritability of the nerves and muscles is also observed; and, unless greatly deceived, we may look for the development of the reaction of degeneration (Entartungsreaction) in all such cases. Death, it is true, often occurs so rapidly, as to leave no time for its complete develop- ment. In the more subacute cases, however, we shall frequently be able to demonstrate this reaction of degeneration, and in the forms of acute myelitis in which the changes are confined to the anterior horns of the gray matter, it is one of the most constant phenomena. On the other hand, there are cases of acute mye- litis in which there is absolutely no change in the electric irri- tability, and others in which only slight quantitative changes in the same, slight increase or diminution, can be demonstrated. The conclusion, that in such cases the corresponding portions of the gray substance have remained intact, cannot be questioned. Marked alterations in the urinary excretion occur with strik- ing rapidity in severe cases of acute myelitis. After a very few days (two to eight), the urine is alkaline and not unfrequently bloody; a muco-purulent deposit, numerous triple-phosphate crystals, etc., form very rapidly. It is not improbable, though by no means proven, that these alterations are directly dependent on the acute spinal affection, and not merely the result of the retention of urine caused by the paralysis of the bladder. Cerebral phenomena are not regularly or even frequently present in acute myelitis. Still they are not exactly rare in the 412 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. commencement of some particular forms (poliomyelitis anterior), though they usually last only a short time. In children espe- cially, we observe in such cases headache, delirium, and general convulsions. It is scarcely possible to determine, however, what part in the production of the last-named symptom is played by the great irritability of the central nervous system of the child, and what part by the disease of the spinal cord. The headache, delirium, etc., in acute myelitis may also occa- sionally be due to the fever, or to a complicating septicaemia or uraemia. Graver cerebral symptoms make their appearance, when a process analogous to that in the cord is established in the brain, where it produces its characteristic local manifestations. Oculo-pupillar symptoms are sometimes developed in cervical myelitis. Speaking and swallowing may also be interfered with, when the disease involves the medulla oblongata. The disorders of the optic nerve, of the nerves supplying the muscles of the eye and of other cerebral nerves, which play a very prominent role in the clinical histories of many cases of chronic myelitis, are unknown in acute myelitis. On the part of the digestive organs, the most constant symp- tom is great obstipation, for the relief of which the most energe- tic remedies are often required. It is probably due to paralysis of the muscular coat of the intestines. Later on this may lead to great meteorismus, which may become so excessive as to be dangerous to life. In the commencement of the disease violent paroxysms of cardialgic pain are sometimes observed; their pathogenesis is undoubtedly the same as that of the girdle- pains. Little is known concerning the behavior of the circulatory organs. The pulse is usually increased in frequency. When the myelitis extends to the cervical portion of the cord, the in- crease in the frequency of the pulse may be very great, and finally a state of pronounced cardiac weakness is produced. Many patients suffer much from palpitation or irregularity in the action of the heart, which is accompanied by unpleasant, twitch- ing sensations in the cardiac region. The disturbances of the respiration are better understood and MYELITIS. 413 more important. When the myelitis is primarily located in, or has extended to, the cervical region of the cord, they occupy the foreground in the clinical picture, and occasion immediate danger to life. In cases of ascending central myelitis, the gradual en- croachment on the respiratory movements, terminating finally in complete paralysis, can be followed with great facility. First of all, the abdominal muscles are paralyzed, and expiration and expectoration are impeded. Next in order, the intercostales and the muscles of the trunk are affected ; as a result inspira- tion is interfered with, and the patients breathe only with the diaphragm. When this last-named muscle is also involved in the paralysis, the dyspnoea becomes very intense, inspiration being carried on only by means of increased activity of the cer- vical muscles, and death by asphyxia very soon occurs in con- sequence of paralysis of the respiratory centres. In this way the fatal termination can be brought about with very great rapidity in severe cases, death often occurring in an acute attack of dys- pnoea. Other cases, however, are more protracted, and the pa- ralysis is then usually complicated by pulmonary hypostasis. The pathogenesis of the respiratory disturbances requires no special elucidation. The general health is greatly impaired in almost all cases. In exceptional instances the appetite is not affected and the pa- tients sleep well, and the nutrition of the body consequently re- mains tolerably good. Usually, however, the fever, the psychi- cal depression, the commencing cystitis and the decubitus occa- sion sleeplessness and loss of appetite which are soon followed by marked disturbance of nutrition, great emaciation and finally exhaustion. In the commencement of acute myelitis, fever is present only in a small number of cases. In these cases, however, it may at once become very high, and it may remain persistently high throughout the entire course of the disease. Sometimes it occurs in isolated, sharp attacks, and an excessive rise of temperature is not infrequently observed immediately before death. In other cases the fever is slight, never attains a high grade, and may even disappear entirely during the subsequent course of the disease. To sum up, the fever in acute myelitis is in no respect charac- 414 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. teristic. As might be expected, the cystitis, pyelonephritis, de- cubitus and septic infection very frequently give rise in the later stages of the disease to a symptomatic fever, which exhausts the strength of the patients. Course, Duration, Terminations. With regard to the course of the disease but little can be said that will be generally applicable, on account of the great diver- gences presented by the individual cases. This fact is suffi- ciently evident from what has already been said, and it will be rendered still more apparent, when we come to speak of the dif- ferent forms of the disease. The abrupt commencement of the disease in almost all of the cases, and the speedy development of the symptoms up to a cer- tain point, are to some extent characteristic of acute myelitis. It is the rapid development of the paralytic phenomena, rather than the presence and the degree of the fever, which usually leads us to characterize a myelitis as "acute." It is not exactly neces- sary for the paralysis to be developed within a few hours, in order to justify the employment of the term "acute," but it must at all events make its appearance within a few days (about one to ten). Cases which run a slower course may be classed as subacute, but no sharp line of demarcation can be drawn between the two forms. In not a few cases the commencement of the disease is exceed- ingly abrupt. The paralysis may develop in an apoplectiform manner, almost without premonitory symptoms, and it may attain considerable intensity in an hour or even less. Often, pa- tients awake in the morning with complete paraplegia, who had retired to bed on the preceding evening feeling scarcely at all unwell (myelitis apoplectica). Usually, however, there is a pro- dromal stage of variable length, and after the paralysis has com- menced, hours or days elapse before it develops into pronounced paraplegia. In some cases, which must also be classed as acute myelitis, a number of days elapse before this point is reached. Sometimes the development of the disease, instead of being con- tinuous, is interrupted by successive pauses. MYELITIS. 415 Once begun, the subsequent course of the disease is also vari- able. In the most violent and rapid cases (myelitis centralis, haematomyelitis, etc.) the paralysis rapidly ascends, symptoms of asphyxia appear, and death takes place in a few days ; or the fatal termination is brought about by the violent fever and septi- caemia caused by the acute cystitis and decubitus, and occurs after a somewhat longer period, at most after a few weeks. In the less severe cases, particularly when the entire lumbar enlargement with or without the dorsal portion of the cord, is affected, the course is somewhat slower. There is complete para- plegia with paralysis of the bladder; cystitis is gradually devel- oped, followed by decubitus, fever, cachexia and exhaustion, and the patient succumbs after several iveeks or months. In still other cases the transition to chronic myelitis is effec- tuated. There is then usually complete paralysis of motion, with incomplete paralysis of sensation and paralysis of the bladder. The symptoms remain stationary for months and years, or pre- sent slight oscillations, being at one time better and at another worse. Cystitis and decubitus may develop after the disease has persisted for a variable time, but they never become very severe, and are susceptible of being at least partly cured. Death finally results from exhaustion or from some intercurrent disease. In other cases, again, the disease ceases, leaving only a few unimportant and harmless traces of its passage. The disorders of sensation and of the bladder, and the trophic disorders of the skin are usually entirely wanting in these cases. The general health is soon completely restored. The only traces left by the disease are paralysis and atrophy of one or more muscular groups with their consequences, the patients feeling in all other respects perfectly well. The duration of life is not affected in any way by the myelitis. This is the termination in imperfect recovery. Finally, complete recovery takes place in some very rare cases. In consequence of the lack of autopsies, however, it will always be possible for sceptics to question the correctness of the diagno- sis in these cases. This complete recovery probably takes place only in the milder forms of myelitis, though these are not unfre- quently quite diffuse. This termination usually sets in early. 416 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. After the symptoms of paralysis, the fever, etc., have persisted for one or two weeks, they undergo a slow and gradual retro- gression, and after the expiration of a few weeks all the func- tions of the body are completery restored. Convalescence is, however, almost always very protracted. Medical literature con- tains a number of reported cases which demonstrate pretty posi- tively the possibility of this termination. It still remains for us to point out briefly the characteristics of the different forms of acute myelitis, as they most frequently come under observation. The traumatic myelitis, which develops after severe injuries of the cord, can be regarded as the type of acute myelitis trans- versa. It is most frequently located in the dorsal region of the cord. Its principal symptoms are: girdle-sensation and girdle- pain, complete paraplegia, anaesthesia, paralysis of the bladder, preservation and increase of the reflex excitability, absence of muscular atrophy, retention of electric irritability; in the later stages, symptoms of motor irritation, contractures, etc.; also cys- titis and decubitus. The persistence of the reflex excitability is particularly important. Acute myelitis centralis, as described especially by Dujardin- Beaumetz and Hayem, includes the cases which run the most rapid course. The commencement is usually abrupt and at- tended by disturbances of sensation; complete anaesthesia and paralysis of the lower half of the body with entire relaxation of the joints, are developed very rapidly, often in the course of a few hours or during a night; paralysis of the bladder and rec- tum. The extinction of all reflex excitability and the early com- mencement of progressive muscular atrophy, with loss of faradic irritability, are specially important. Later on, decubitus acutus, alterations in the urine, often oedema of the paraplegic limbs and neuropathic articular affections, more or less intense fever, progressive advance of the paralysis upwards, early death by as- phyxia. The hemorrhagic form of myelitis centralis, or hematomyelitis (Hayem), does not differ essentially from the simple form in the commencement. It runs the same rapid course, but the very ab- rupt appearance of the paralysis, which becomes complete in the MYELITIS. 417 course of a few minutes, or at most of an hour or a little more, marks the occurrence of hemorrhages. The more rapid the de- velopment of the paralysis, the more predominant is the hemor- rhagic element in the process. In other respects the course is the same as in the simple form.. Hemorrhagic myelitis can only be distinguished from simple, idiopathic hemorrhage into the substance of the cord, in those cases in which the hemorrhage is preceded by pronounced symp- toms of an acute myelitis ; pains, paraesthesiae, girdle-sensation, vesical weakness, muscular twitchings, commencing paresis, fever, etc. (Compare p. 291.) The so-called poliomyelitis anterior acuta (Kussmaul), the spinal paralysis of children, which occurs in isolated, circum- scribed spots in the anterior horns of the gray matter, is clini- cally a sharply characterized form of acute myelitis. Acute febrile commencement, often with headache, delirium and con- vulsions ; rapid development—in a few hours or days—of motor paralysis, which varies in area in different cases, but attains its maximum of extension in the very beginning ; no disturbances of sensation, no paralysis of the sphincters, no decubitus; on the other hand, rapidly progressive muscular atrophy, with the re- action of degeneration ; eventually, atrophy and impairment of the growth of the bones, deformities of the joints, etc. Com- plete restoration of the general health, early improvement of the paralysis up to a certain point, a number of the muscles, how- ever, almost always remaining atrophied and paralyzed, causing permanent deformities. (Compare Section No. 15.) In myelitis disseminata, as described by Westphal, the clini- cal picture is naturally not so characteristic. It ordinarily causes paraplegia, sometimes with spastic symptoms, usually with paralysis of the bladder. The state of the sensibility is variable; it is sometimes more, sometimes less impaired. The same state- ment holds true of the reflex and also of the electric excitability. Sometimes the existence of several centres of disease can be recog- nized from the grouping of the symptoms, the exacerbations, etc. The development of the symptoms after acute diseases, especially variola, or in phthisical patients, etc., might direct suspicion to this form of the affection. VOL. XIII.—27 418 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Acute myelitis is very frequently complicated with meningitis, myelomeningitis acuta. The addition of meningitic changes to the myelitic affection, although unquestionably very common, is not specially important, since the severity and dangerousness of the disease is not essentially modified thereby. The develop- ment of myelitis as a complication of acute meningitis is a more serious affair. We have already, in another place (p. 226), spoken of this condition of affairs, and endeavored to form an estimate of its influence on the symptomatology of acute spinal meningitis; this influence is, at all events, greater than has been hitherto supposed. Finally, the two inflammatory pro- cesses can set in simultaneously, so that neither one of them is dependent on or secondary to the other. Under all these condi- tions, the meningitic symptoms usually assume the most promi- nent role in the subjective complaints of the patients, while the myelitic symptoms are the most striking in the objective exami- nation. In such cases the phenomena which speak for menin- gitis are chiefly the pain and stiffness in the back, the cervical rigidity, the pronounced hyperaesthesia, the diffused pains, etc., while the contractures, the severe paralytic symptoms, the paraly- sis of \\\e sphincters, the augmented reflex activity, etc., must be placed more to the account of the myelitis. More exact obser- vations and investigations are, however, necessary for the clearer differentiation of the two processes. Diagnosis. In the matter of diagnosis, acute myelitis resembles many other affections of the spinal cord; the typical cases are easily recognized, while on the other hand, the less pronounced, the complicated and the uncommon cases are difficult to unravel. It is easy to gather from the preceding description, what the characteristic symptoms are, from which an acute myelitis can be easily diagnosticated; acute commencement with more or less marked signs of sensitive and motor irritation, very rapid develop- ment of complete paralysis, vesical paralysis, bed-sores, etc. When fever is also present, and the etiological conditions are known, the diagnosis is easy. MYELITIS. 419 There are several other diseases with which it may possibly be confounded. First of all we must mention paralysis ascen- dens acuta (see farther on, No. 17), which resembles diffuse central myelitis in particular so closely, that it is often scarcely possible to determine to which of the two diseases the case in question belongs. The results of recent investigations (West- phal) have gradually forced us to the conclusion, that paralysis ascendens acuta is a special form of disease, entirely distinct from myelitis. The diagnostic points, which speak rather for acute ascending paralysis, are the following : absence of con- vulsive movements at the outset of the affection, absence of tro- phic disturbances, a slight degree of encroachment on sensation and preservation of electric irritability. In many cases, how- ever, the positive diagnosis can only be made with the help of the autopsy. The difficulty of distinguishing acute myelitis from menin- gitis acuta is often very great, in consequence of the frequent combination of the two diseases. The following symptoms speak for meningitis: high fever, severe pain, dorsal and cervical rigid- ity, contractures, slight symptoms of paralysis, especially on the part of the sphincters, absence of severe trophic disturb- ances, pronounced hyperaesthesia, etc. (Compare also p. 245.) The differentiation of hematomyelia, or simple hemorrhage into the spinal cord, from central myelitis, and particularly from the hemorrhagic form of that affection, is often uncommonly dif- ficult. The diagnostic points are : the very abrupt development of the paralysis without fever or prodroma, the stationary char- acter of the paralysis, etc. This question has already been fully discussed in another place (p. 303). The differentiation of myelitis from hematorrhachis, or hem- orrhage into the meninges of the cord, is, as a rule, easier. The very abrupt development of the affection without premonitory symptoms or fever, the symptoms of severe meningeal irritation, the violent pains, the dorsal rigidity, the relatively moderate grade of the paralytic phenomena, and particularly the slight intensity of the anaesthesia, usually characterize haematorrhachis sufficiently. (See p. 214.) It is scarcely possible to confound acute myelitis with hyper- 420 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. emia of the cord. The absence of fever, the slight intensity of the sensory and motor disturbances, the frequent and rapid variations in the symptoms, and the absence of vesical weakness and of bed-sores, are so characteristic of the latter affection as to almost prevent the possibility of a mistake. The diagnosis from hysteria can scarcely present any diffi- culties ; at all events any doubt which may arise, will be cleared up by a few days' delay. It is unnecessary to recapitulate here the points of the differential diagnosis. On the other hand, many poisons produce symptoms, which may resemble the clin- ical picture of ascending central myelitis so closely, that the differentiation is very difficult. The seat of the disease in the cord and its extension in the transverse and vertical directions, can readily be determined from the area of the paralytic phenomena, the state of the reflex irritability, the trophic disorders, etc. As these points have already been repeatedly discussed, we may dispense with fur- ther consideration of them here. Prognosis. The prognosis varies vary greatly. In general it is unfavor- able, because the disease is almost always severe. There are, however, numerous exceptions to this rule. A perfect recovery is rare. In many cases a chronic state of disease persists, while in others the morbid process ceases, but leaves a legacy of incurable, although relatively harmless defects. The prognosis, at least as far as life is concerned, is often abso- lutely favorable (poliomyelitis anterior acuta). This much being premised, we may state that the prognosis depends chiefly on the location and extent of the inflammatory process. It is not correct to say, that it always becomes worse the higher the location of the disease in the cord. Strictly speaking, that assertion holds true only when the disease is located in the dorsal and cervical regions; in such cases the higher up it is located, the greater is the liability of the respi- ratory tracts becoming affected, hence the increasing danger to life. On the contrary, a myelitis in the dorsal region is, ceteris MYELITIS. 421 paribus, more favorable than one in the lumbar region, on ac- count of the important centres located in the latter. It is much more correct to say, that the prognosis depends on the extent of the cross section of the cord involved in the process ; the more considerable this is, the more unfavorable is the prog- nosis. It becomes worse in proportion especially to the extent of the gray substance involved. The central and posterior por- tions of the gray substance seem to be particularly dangerous in this connection, for experience teaches that acute myelitis of the anterior horns alone is not attended by any danger to life, although it certainly annihilates the function and the nutrition of the muscles. In myelitis of the central gray substance, on the other hand, the prognosis is much more unfavorable, on ac- count of the usually unavoidable development of cystitis, decu- bitus, etc. We are as yet unable to say how much the more or less extensive implication of the white columns influences the prognosis. The extent of the longitudinal section of the cord involved in the processes influences the prognosis in a similar manner; it becomes worse in a direct ratio to the longitudinal extent, or, in other words, to the length of the diseased spot. Hence a very circumscribed, transverse myelitis is not so dangerous as the same affection, when it extends over a greater length of the cord. Hence, also, the unfavorable prognosis in the progres- sive, ascending forms of the disease, and particularly in cen- tral ascending myelitis. A longitudinal extension of the disease in the white columns is, however, not by any means so porten- tous. There are various other facts which can also be made use of for the prognosis. A very rapid development and great intensity of the paralysis, complete paralysis of the sphincters, early and especially acute decubitus, progressive advance of the disease upwards, high fever, great impairment of the general health, disorders of respiration, dyspnoea, cyanosis, etc., influence the prognosis unfavorably. On the other hand, a moderate degree of para-lysis, absence of trophic and sensory disturbances, impli- cation of the bladder to only a slight extent, absence of fever and of marked impairment of the general health, commencing 422 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. improvement of some of the symptoms, etc., are signs of favor- able portent. The nature of the etiological influences and the possibility of removing them, the possible occurrence of exacerbations and relapses, the general condition of the patients, the effects pro- duced by certain therapeutic measures, etc., must also be taken into account in determining the prognosis. By close attention to all of these points, we shall in many of the cases succeed in forming a tolerably correct judgment of the course and termination of the disease. Treatment. Of a prophylactic treatment of acute myelitis, there can hardly be any question. If there be any it consists simply in the observation of those general rules, which are in any case necessary for the preservation of health. On the other hand, a causal treatment is possible in many cases. Injuries of the spinal column must be treated surgically, and simple concussions must also receive proper attention. Tumors of the spinal column should be removed if possible ; in these cases the acute meningitis also requires treatment. When the premonitory signs of myelitis make their appearance after exposure to cold, etc., the morbid process can be perhaps arrested or mitigated by an energetic diaphoretic treatment (diaphoresis, hot drinks, the warm bath, the pack, derivation to the back, etc.). Where there has been excessive bodily exertion, the same end may perhaps be attained by absolute rest in the proper position, a warm bath, etc. Suppressed secretions, profluvia and hemor- rhages should be excited afresh, if there be any reason to suspect that the suppression has had any influence in causing myelitis. The treatment of syphilis is of special importance, when an acute myelitis is developed in its course; in such cases an energetic mercurial treatment must be immediately commenced and be supplemented by large doses of iodide of potassium, " Roob Laf- fecteur," etc., when the stage of the disease indicates them. As a rule, however, the patients do not come under observa- tion until the disease is developed. The measures to be adopted MYELITIS. 423 then will of course vary both in nature and in activity, according to the form and the severity of the disease. The general features of these measures of treatment are all that we can attempt to describe here. In all cases that are at all severe and threatening, an energetic antiphlogistic treatment is indicated. This is not the place to discuss the justifiableness of the usual antiphlogistic measures. We are, moreover, still very much in want of actual observations on which to base a reliable opinion as to their efficiency in acute myelitis. Nothwithstanding this, however, in the face of so dangerous a disease, the energetic employment of all antiphlo- gistic measures is decidedly indicated. Active local bloodletting from the spine may be practised by means of leeches or wet cups, applied several times in succession ; Chapman's ice-bag, from which Tibbits saw very good results, may be employed; the trunk may be enveloped in, or the back covered with, cloths wrung out in water, which should in turn be covered with caoutchouc-paper and flannel, and should be renewed every few hours ; to these may be added the inunction of mercurial ointment into the back and other parts of the body—a measure of doubtful utility, but still one which is permissible in view of its efficiency in inflammatory affections of the eye, even when not of a specific nature. For the same reason, small doses of calomel, frequently repeated, may be tried, and eventually also iodide of potassium, in sufficient doses. Brown-Sequard recom- mends, on the ground of physiological experiment, the employ- ment of ergot and belladonna (to combat the concomitant hyper- aemia) ; these remedies deserve a trial. In the majority of the cases, however, a moderate derivation to the intestines (castor oil, "aqua laxativa," mineral waters con- taining sulphate of magnesia, senna, rhubarb, colocynth, etc.), and also to the kidneys (by the ingestion of large quantities of water, the use of Ems or Vichy water, of acetate of potash, etc.) is more important and more useful. Attention must be paid to this. One difficult question which presents itself in the treatment of acute myelitis is, whether or not the employment of energetic derivatives to the skin over the spinal column, is permissible and 424 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. serviceable. The results obtained by their employment in other affections, as well as in a few cases of myelitis, have been very encouraging, but at the same time the danger of producing ulcers, and of favoring the formation of bed-sores, and the great annoy- ance they cause the patients, are apt to deter physicians from using them. I believe that, when properly used, they can do no harm and often do good. Those which act rapidly and ener- getically should be chosen—the hot iron, or, in less serious cases, the blister. These counter-irritants should never be applied to places where the skin is already very anaesthetic ; all parts that are exposed to continuous pressure should also be avoided. In severe and threatening cases (particularly in cases of ascending central myelitis) we need not hesitate to give them a very thor- ough trial, since the great danger in which the patients are placed justifies the use of severe and even dangerous remedies. Here the greatest advantage will be derived from two bold streaks drawn with ferrum candens, or from punctiform cauterizations on both sides of the spine, repeated every day or two. The fa- vorable termination of Levy's case, in which the diagnosis of acute myelitis was in all probability correct, speaks highly in favor of this method. The antiphlogistic treatment must, of course, be modified ac- cording to the age, constitution and general condition of the patients. The more robust the individual, the more energetic should be the antiphlogosis; in plethoric patients a moderate venesection may even be advisable. The galvanic current should never be employed in the acute forms and the acute stage of myelitis. It is only in the treat- ment of the more chronic forms, and of the residua and sequelae of the affection, that is permissible and proves valuable. The cases reported by Lewin1 and Hitzig2 might possibly be adduced in oppo- sition to this statement. In Lewin's case, however, the diagnosis was not quite cer- tain. Under the galvanic treatment, which was begun on the twentieth day, the patient did remarkably well. In Hitzig's case, the chief affection was a subacute meningitis. 1 Deutsche Klinik. 1875. No. 11. 2 Virch. Arch. Band XL. p. 445. 1867. MYELITIS. 425 In addition to these therapeutic measures the most careful attention must also be paid, in the first stages, to the feeding and the nursing of the patient; his strength must be kept up, and all the evil consequences of the disease guarded against and combated. In this connection the following points must be at- tended to : absolute rest as far as possible, and of course in bed; the patient should lie often on his side or abdomen, and not ex- clusively on his back. It would hardly be possible to enforce the exclusively abdominal position, recommended by Brown- Sequard. Easily digested but nourishing food; no spirits, no tea or coffee; absolute mental quiet; avoidance of all violent movements of the body, especially of those caused by driving; careful attention to the skin, which must be washed regularly. In the milder cases a lukewarm bath may be administered. Above all things, eve^ precaution must be taken to prevent the devel- opment of cystitis and decubitus ; the directions for this will be found in the general part (Part I., p. 193). If we succeed in tiding the patient over the first few weeks, or the acute stage of the disease, the case may be safely left for a time to nature, on which our chief reliance must be placed under all circumstances. Of course, the directions given for the diet and nursing must still be strictly followed out. We can, to a certain extent, count on the development of a reparative action in the organism, which will lead to at least a partial adjustment of the derangements. In all such cases we have to deal with sub- acute and chronic forms of myelitis, and the treatment of these forms, which is given at length in the succeeding chapter, then comes into play. The time has now come for a more supporting and stimula- ting treatment (quinine, iron, good food, wine, cod-liver oil, fresh air, etc.), which will further the restoration and regeneration of the tissue ; also for the employment of baths (thermal and brine baths), or of a mild course of hydropathy; particularly, how- ever, for the employment of the galvanic current. For detailed information concerning the indications for these measures and the methods of employing them, the reader is referred to the section on the treatment of chronic myelitis. Finally, specific internal remedies, such as nitrate of silver, 426 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. chloride of gold and sodium, iodide of potassium, etc., are also indicated now. Strychnine may also be cautiously tried. If the case be progressively improving, the patient may grad- ually be allowed to move about cautiously. He should be put through a course of chamber gymnastics, etc., before he is al- lowed to go about freely. Finally, convalescence in the cases which run a favorable course, may be hastened by residence in a mountainous region, or by cold-water treatment, or by sea-baths. The patients, how- ever, must always observe great caution for a long time, and avoid every excess, every occasion of over-exertion and any ex- posure to cold. The indicatio symptomatica may be furnished by the most different symptoms. The most important, as a rule, is the care- ful treatment of the cystitis and decubitus, the rules for which have been given in the general part (Part I., p. 193). The relief of the pains and of the muscular twitchings and contractures that follow in their train, is also often very desirable. (Morphine, bromide of potassium, chloral, etc.) Sleeplessness may also require treatment. Against the asphyctic condition which sets in sub finem, and the impending cardiac paralysis, the usual irritant remedies are almost powerless. The anaesthesias, para- lyses, atrophies, etc., which persist after the cessation of the dis- ease, are most satisfactorily treated by electricity. B. Chronic Inflammation of the Spinal Cord.—Myelitis Chronica.—Sclerosis. Gray Degeneration. Definition.—We enter here on a domain, the limits of which it is exceedingly difficult to mark off. For the present we must include under the head of chronic myelitis, many affections that will doubtless be sifted out and more sharply defined in the course of time. We understand by chronic myelitis all those slowly develop- ing processes in the spinal cord which run a tedious, lingering course without fever, and which in the present state of our knowledge are ascribed to chronic inflammation. It comprises MYELITIS. 427 consequently the processes which are designated as chronic in- flammation in its narrowest sense, as induration, as sclerosis and as gray degeneration; also a portion of the slowly developing processes of softening, and perhaps some of the cases in which cavities form in the cord. We include here consequently forms of disease which vary very greatly in location and extent. In this chapter, however, we will consider only those forms which do not possess an exact localization, but are characterized rather by irregularity in seat and extent. The remaining forms, especially the funicular scle- roses, etc., will be made the subjects of special chapters. Etiology and Pathogenesis. The question whether an increased, predisposition to myelitis exists in certain persons, has not yet been sufficiently investigated, but it is at any rate exceedingly probable that it does. Here too, the hereditary neuropathic constitution presumably plays a very prominent role; numerous facts in the etiology of tabes, multiple sclerosis, etc., indicate this. Mental and corporeal over-exertion, dissipation, sexual excesses, syphilis, emotional excitement, care, grief, etc., can probably also act as predisposing causes. The disease is most common during youth and middle age, and in the male sex. Chronic myelitis can, as we have already seen, proceed from the acute form. This is not an uncommon occurrence. Hence, all the causes of the acute must also be regarded as more remote causes of the chronic affection. The latter, however, can also be primarily produced by these same causes. The differences in the degree of the external injurious influences, or of the predisposi- tion to the disease, which determine the occurrence of an acute affection in one case, and of a chronic affection in another, are still unknown. Of the exciting causes the following may be briefly mentioned: catching cold, which is one of the most im- portant, and certainly one of the most frequent causes; often- repeated exposure, long sojourn in damp, cold localities, sleeping on damp earth, etc., are especially dangerous. Bodily over- 428 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. exertion, especially when combined with exposure to cold ; hence the great frequency of chronic myelitis after military campaigns. Simple concussion of the cord without direct injury has already been mentioned (p. 346) as a possible cause of chronic myelitis; also gradual compression of the cord. Whether alterations in the circulation within the cord, such as possibly follow suppression of habitual hemorrhages (the menses, bleeding piles, etc.), can be the starting-point of chronic myelitis, is still doubtful. The question whether the myelitis, which develops in persons suffering from hemorrhoids, has a causal connection with the latter and the disorders excited by them, or whether we have to deal here with a purely accidental coincidence, which, in view of the commonness of piles, would not be at all astonishing, must still be left open. Sexual excesses are undoubtedly rather a predisposing than an exciting cause of chronic myelitis. Still, there are several cases on record, in which no other cause could be discovered to account for the disease. The same remark applies to continued, depress- ing mental emotions. Syphilis is unquestionably a very fruitful source of chronic nryelitis. Putting out of question the syphilitic affections of the vertebral column and the spinal membranes, and the specific neoplasms in the cord itself, which excite myelitis only indi- rectly by means of the compression they exert, the occurrence of subacute and chronic myelitis in syphilitic individuals or in persons who had previously suffered from the disease, is so exceedingly frequent, that the possibility of an etiological con- nection between lues and chronic myelitis cannot be denied. During the last few years I have myself met with at least a dozen such cases, some of which I dissected. It is true, that it is still impossible to decide, whether in these cases we have to deal with really specific myelitis, or with simple myelitis in persons predisposed by the syphilis to chronic inflammations. Judging, however, from the cases in which I had opportunities to hold autopsies, an account of which will be given elsewhere by Dr. F. Schultze, I must for the present regard the latter as the more probable. More attention should in future be paid to this question, which is therapeutically exceedingly important. MYELITIS. 429 Chronic myelitis is occasionally developed as a sequel of various acute and chronic diseases. Langhans found chronic myelitis with softening and the formation of cavities, in con- nection with lepra. Chronic alcoholism, chronic lead-poisoning, and perhaps also chronic poisoning with other metals, can like- wise lead to chronic myelitis. Finally, its development from irritation and diseases of per i- pheral organs must be mentioned. Most of the cases of so-called reflex paraplegia belong in the domain of subacute and chronic myelitis. It is unnecessary to add anything here, to what has been already said in different parts of this work concerning the pathogenesis of this form of disease. We will only allude to a case recently published by Laveran, which illustrates well the difficulty of explaining the etiological connection between the affection of the bladder and the disease of the cord. Pathological Anatomy. In many cases of chronic myelitis, the macroscopic examina- tion reveals no noticeable anomalies. The investigations of re- cent years have left no room to doubt, that very marked and widespread structural changes may exist in cases where the most careful macroscopic examination discloses absolutely no alterations either in the color or the markings, or even in the consistency of the cord. The changes are revealed, however, when hardened preparations of the cord are subjected to a mi- croscopical examination. It is unnecessary to dilate on the sus- picion, which this discovery throws on the statements of many excellent observers, who were content to declare a cord to be "normal" after a mere macroscopic or, at most, a hasty micro- scopic examination. There can be no reason to question the truth of the statement, that it is impossible to decide positively from macroscopic observation alone, or from a superficial micro- scopic examination of fresh specimens, that the cord is normal in structure. Not unfrequently, however, chronic myelitis causes very con- siderable macroscopic changes. These affect, on the one hand, the consistency and, on the other hand, the color of the cord, or 430 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. of circumscribed portions of it. There is almost always an in- crease in the consistency—a hardening or sclerosis of the cord ; its substance is denser and firmer, and resembles coagulated albu- men, or it may be still denser and difficult to cut, presenting a smooth section. This hardening is usually accompanied by a more or less pronounced gray, or yellowish gray discoloration of the tissue—hence the much-used name, gray degeneration. In a minority of the cases only, do we meet with more or less extensive softening. This is observed rather in the subacute cases, or in the earlier stages of a chronic myelitis, which has de- veloped from the acute form. It is sometimes met with, however, even in primarily chronic cases, e. g., in the one reported by Keen. Sometimes we meet with more or less extensive and numerous cavities, which, in a number of the cases at least, arc by several authors correctly ascribed to chronic myelitis. The spinal cord in these cases rarely presents any considerable change in volume. An increase in volume, or swelling of the whole or of circumscribed parts of the cord, is least frequent; on the other hand, a slight diminution in volume, or atrophy, is very common. What was formerly called consumption of the cord, atrophy of the cord, and tabes dorsalis, in the anatomical sense of the term, are really nothing more than different forms of chronic myelitis. In such cases the cord is atrophic and thinner than usual; sometimes it is greatly shrunken. This change may be general and equable, so that the cord still presents the appear- ance of a cylindrical structure, but it is usually limited to its lower half; or the shrinkage may be in the antero-posterior direction, so that the organ has a more flattened, band-like appearance; or, finally, the surface is somewhat depressed only in isolated, circumscribed spots, or perhaps along the entire length of certain columns. Everywhere the gray, degenerated tissue shimmers through the pia. The localization and the area of the chronic inflammation in the spinal cord may vary greatly. There may be merely isolated foci of disease, varying in number and size, and im- bedded in healthy tissue. They are dense, reddish-gray or gray, often possess a gelatinous translucency, and are either sharply defined, or gradually shade off into the healthy tissue. When MYELITIS. 431 there is only one focus, which does not take in an entire cross-section of the cord, we speak of a myelitis circumscripta. When, as not unfrequently happens, there are several of these foci scattered irregularly through the cord, we have the myelitis chronica disseminata, or sclerosis multiplex seu disseminata, which is usually combined with an analogous, disseminated scle- rosis in the brain. When the entire thickness of the cord is involved, the disease, however, being more or less limited in a vertical direction, we have before us the very common form to which the name mye- litis transversa has been applied. A portion of the cord of variable length, but usually not more than a few inches in span, appears grayish, translucent, shrunken and atrophied; the line of demarcation from the surrounding tissue is not very sharply defined, especially when, as is usually the case, secondary degeneration has set in. On section, the tissue ap- pears more or less firm, dense and dry, or occasionally more suc- culent and soft. In other cases the lesion involves only small and as a rule distinctly circumscribed portions of the cross-section of the cord, but extends farther in a vertical direction, sometimes stretching throughout almost the entire length of the organ. In this last case we have to deal with the so-called band-shaped sclerosis, or funicular degeneration. In this form of chronic myelitis, different parts of the cross-section may be involved. The affec- tion may be limited to the gray substance, and may surround the central canal in the form of a cylinder of varying thick- ness ; in this situation it not unfrequently leads to the forma- tion of cavities—this is the so-called periependymal sclerosis, which Hallopeau has described minutely. Or it may be con- fined to the anterior horns of the gray matter, one or both of which may be affected to a varying extent longitudinally: this is the poliomyelitis anterior chronica (Kussmaul). Or it may be located exclusively in the white columns, usually involv- ing a large portion of their longitudinal section, and almost always affecting both sides symmetrically. In this category belongs the much spoken of gray degeneration of the posterior columns ; the degeneration may involve the entire thickness of 432 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. these columns, or it may be limited to the funiculi graciles. The sclerosis of the lateral columns, especially of their posterior portions, and the sclerosis of the inner portion of the anterior columns, also belong here. We will speak more fully of these forms in another place. Finally, the chronic myelitis may also be confined to the periphery of the cord, forming a ring-shaped zone lying immediately beneath the pia, and corresponding to the normal cortical layer. This form is usually combined with meningitis. It constitutes the ring-shaped, peripheral sclerosis, or the sclerose corticate annulaire of Vulpian. When the chronic myelitis extends over the greater part of the cord, it is termed myelitis chronica diffusa. This extension, however, is usually not uniform, some portions being much more intensely affected than others. In many cases the myelitis is at first circumscribed, but becomes more or less diffused in course of time. A close examination reveals in very many cases the presence of the secondary degenerations, which have been often alluded to already, and which will be more fully described in another chapter. In an upward direction, it is chiefly the ascending degeneration of the posterior columns, reaching to the medulla oblongata, which attracts the attention of the observer—in a downward direction, the descending degeneration of the poste- rior portions of the lateral columns, reaching to the end of the lumbar medulla. The transition from these degenerated parts to the actual myelitic centres, is usually a very gradual one. The meninges, as a rule, take part in the chronic myelitic process. They also present the signs of chronic inflammation— cloudiness, thickening, adhesions, calcifications, etc. It is un- necessary to describe these changes here. The nerve-roots are in many cases gray, translucent, exceed- ingly atrophic, and converted into a wavy connective tissue, rich in fat, but containing few or no nerve-fibres. The peripheral nerves also are not unfrequently found in a state of degenerative atrophy. The muscles are then in the same condition; they appear very atrophic, pale, rich in connective tissue, and occasionally very abundantly supplied with adipose tissue. These points will be considered more in detail, when we MYELITIS. 433 come to speak of the forms of chronic myelitis, that are most liable to be followed by these degenerative processes. Furthermore, at the autopsy we often find changes in the joints (erosion, deformity or destruction of the cartilages, thick- ening of the capsule, serous accumulations, etc.); more or less extensive and often gangrenous bed-sores on different parts of the body; marked vesical changes (hypertrophy and ulcera- tion or diphtheritis of the mucous membrane, hypertrophy of the muscular coat, etc.) with consecutive pyelitis and nephritis, etc. We find also many other changes which are partly consecutive to the severe, chronic spinal paralysis, partly symptomatic of accidental, intercurrent diseases, but which it is unnecessary to describe here. We possess a great abundance of isolated observations bear- ing on the microscopical lesions of chronic myelitis. In general, however, there is still but little unanimity on the subject, least of all concerning the interpretation to be placed on what has been discovered. We cannot, of course, enter here into all the details, since many of the points in dispute are as yet undevel- oped, and for the practising physician of but little importance. Neither have we to speak of the methods of investigation, as that is a subject which belongs in the domain of pathological anat- omy ; essentially, all the discoveries have been made by the study of hardened preparations, colored and rendered trans- parent by various methods. It is probable that many different processes are still classed together under the head of chronic myelitis. The changes enu- merated in the following paragraphs are, however, common to all these forms, and constitute in all probability the essence of the process. Changes in the connective tissue or the neuroglia: increase in the thickness and width of the individual fibres and septa of the reticulum ; gradual transformation of the tissue into a deli- cately fibrous, fibrillated connective tissue. According to From- mann the fibril] ae are developed within the old, enlarged neuroglia fibres and cells. They form finally a dense tissue, composed of delicate, fibrillated fibres, usually arranged in long wavy bun- dles. The neuroglia-cells enlarge, and their nuclei undergo VOL. XIII.—28 434 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. proliferation; they become more numerous and more distinct. Nowhere can Deiter's cells be found more perfect and more developed than in chronic myelitis; truly gigantic specimens with numerous processes are often found. The change consists consequently in a gradual conversion of the normal neuroglia tissue into a fibrillated, delicately fibrous connective tissue, ac- companied by proliferation of the cells and their nuclei. Changes in the nervous elements : sometimes the nerve-fibres are swollen, the medullary sheath being irregularly thickened, crumbly and in a state of commencing degeneration ; in this case numerous swollen axis-cylinders, which present spindle-shaped enlargements and are fused with the medullary sheaths, are also found. More frequently, however, we find pronounced atrophy. or a starved condition of the fibres, with destruction of the medullary sheath, sometimes by fatty degeneration, sometimes without apparent change of this sort. The naked axis-cylinders then often remain in statu, quo for a considerable time; but finally, they too undergo atrophy and become shrunken and de- stroyed. Sometimes they are found stiff, brittle, very brilliant, and indurated. The ganglion-cells are sometimes clouded and swollen, and contain vacuoles. More frequently, however, they are dimin- ished in size, strongly pigmented, shrunken, atrophied and in- durated, and are finally converted into small, unrecognizable, angular structures, in which neither nucleus nor nucleolus can any longer be discovered, and which have lost their processes. Changes in the vessels.—The walls of the small arteries and veins, and of the capillaries as well, are considerably thickened, and their calibre is lessened. This of course varies very greatly in degree in different cases. The walls, especially the adventitia, are converted into a thick, homogeneous, often indurated mass, presenting proliferation of nuclei, collections of fat- and pigment- granules, and not unfrequently also granule-cells. The peri- vascular space is filled with cells and exudation ; fusion of the wall of the vessel with the surrounding, indurated connective tissue ; sometimes aneurysmal dilatations of the vessels. Appearance of heterogeneous elements: of these the fat-gran- ule-cells (Fettkornchenzellen) are the most frequently met with ; MYELITIS. 435 they are sometimes numerous, sometimes scanty, at one time de- posited around and in the walls of the vessels, at another scat- tered through the connective-tissue septa, and again arranged in rows, apparently in the spaces that, under normal circumstances, contain the nerve-fibres. This very difference in distribution indicates different modes of production. Corpora amylacea are also usually found; they are some- times present in immense numbers, scattered throughout the entire tissue, but at other times only a few can be discovered. All these things will be found in the different stages of chronic myelitis. Not unfrequently they will all be found at the same time in the same cord, provided different parts of it be the seat of different stages of the process. It is evident, that the different age of the process must occasion characteristic differences in the histological picture. All the details of these differences have not yet been thoroughly settled, but still the various stages of the disease can be charac- terized histologically about as follows : 1. The earliest stage.—Thickening and swelling of the inter- stitial tissue; greater succulence of the tissue; proliferation of the nuclei, slight swelling of Deiter's cells ; commencing thickening and alteration of the walls of the vessels; nerve-fibres rather swollen, medullary sheath in a state of incipient degeneration; axis-cylinders often no longer distinct; ganglion-cells clouded, irregularly swollen, with fewer processes, etc.; more or less abundant fat-granule cells, and a few corpora amylacea. 2. Later stage.—More marked increase of the interstitial tissue, close network of thick neuroglia-fibres, proliferation of the nuclei, increase of the neuroglia-cells, great thickening of the walls of the vessels ; distinct atrophy of the nerve-fibres, a num- ber of which have disappeared. On the other hand, the axis- cylinders sometimes survive for a very long time (particularly in the so-called multiple sclerosis, for which it seems to be to some extent characteristic.—Charcot, Leyden). Ganglion-cells atrophic, sclerosed and in part destroyed; fewer fat-granule cells, more corpora amylacea. The tissue in general, of greater density. 3. Last stage.—Almost exclusively connective tissue ; a dense 436 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. tissue, composed of delicate fibrillated fibres in a state of inex- tricable entanglement, with tolerably numerous nuclei and cells ; the latter often strikingly developed and distinct. Walls of the vessels greatly thickened, vascular lumen narrowed or in rare instances enlarged. Only a few, isolated nerve-fibres are still recognizable ; the greater part of the fibres have disappeared, and most of those which remain are atrophic ; many naked axis-cylinders. Ganglion-cells shrunken to unrecognizable ele- ments, or entirely destroyed. Very few fat-granule cells, but corpora amylacea, on the other hand, usually very numerous. The entire tissue very dense, firm, dry and shrunken. These are the appearances presented in the oldest cases, which have lasted several or many years. In many cases extensive cavities are found in the cord—this is probably the terminal stage of a very chronic myelitis charac- terized by softening. We shall return to these cavities in another chapter. These are the chief lesions found in chronic myelitis. When we attempt to interpret them, various questions force themselves on our notice, the solution of which still presents considerable difficulties. We cannot, however, well avoid de- voting a brief space to a consideration of them. In the first place, the question arises, whether in all these processes, we have really to deal with a chronic inflammation ? We cannot spare time for a close examination of this general pathological question. According to the principles that are still generally accepted, the term chronic inflammation (cirrhosis, etc.) is in accord with the anatomical lesions, which are analogous to those found in other organs when the seat of chronic inflammation. The matter, however, is still very open to dis- cussion, especially the question whether the process in many cases may not be one of simple or of degenerative atrophy. This interpretation may apply to the so- called "secondary degenerations," which some authors are disposed to class among the chronic inflammatory processes (Charcot, Hallopeau). The anatomical picture of secondary degeneration can certainly resemble very closely that of chronic inflammation. Joffroy asserts that in experimental myelitis, he found swelling and hypertrophy of the axis-cylinders in the actual focus of inflammation, but not in the parts which had undergone secondary degeneration ; this would indicate a difference in the two processes. This observation, however, requires confirmation, especially as it contradicts the statements of other observers. In secondary degen- eration we have to deal essentially with that form of degenerative atrophy which occurs in the nerve-trunks, when they are cut off from their nutritive centres. (Compare our description and explanation of this in Vol. XL, p. 412.) It is true MYELITIS. 437 that this atrophy also is not unfrequently spoken of as an actual inflammation ; it must then be regarded, however, as a specifically neurotic inflammation. Very plausible also is the theory, that in such cases there is a primary degeneration of the nerve-fibres, the products of which exert an irritant action on the interstitial tissue, and excite in it a slow, chronic inflammation (sclerosis). A process of this sort might well occur primarily in many forms of the band-shaped affection, and it would furnish a simple explanation for the fact, that interstitial, chronic inflam- matory changes exist also in the gray degeneration or degenerative atrophy of the spinal cord. This brings us to a second very important question, namely, whether the chronic inflammatory process always has the same point of departure, be this from the con- nective tissue or from the nervous elements ? Whether, in other words, we must assume an interstitial or a parenchymatous inflammation, or perhaps both together ? To thi3 question also we are as yet unable to give a decided answer. It seems both possible and probable, however, that both forms of inflammation may occur; au- thorities whose opinions carry weight, maintain this and claim that they possess observations which prove it. In general, however, we have to deal here with as- sumption against assumption. Charcot and his disciples do not hesitate to distin- guish the interstitial myelitis or sclerosis from the parenchymatous form. In the former it is claimed that the process begins in the connective tissue, the nerve-fibres not being involved until the affection has reached its later stages; hence the fibres and axis-cylinders remain unaltered for a long time (disseminated sclerosis). In the latter, on the contrary, the process begins with irritation and degenerative atrophy of the nerve-fibres and ganglion-cells, and involves secondarily the interstitial tis- sue (band-shaped sclerosis of the posterior columns, progressive muscular atrophy, probably also secondary degenerations). It is, in the present state of our knowl- edge, difficult to demonstrate the correctness of this view. An unprejudiced exami- nation of preparations from both forms of the disease shows that there are no essential differences in the histological appearances, that the same alterations may occur in both forms, and that all theories concerning the mode of their production are more or less gratuitous. Theoretically the thing is certainly possible and even probable, but it can by no means be admitted as proven. It is, in fact, very difficult to decide the question from a purely anatomical standpoint. At all events, it does not seem to us justifi- able to confine the term chronic myelitis solely to the so-called interstitial sclerosis, and to deny the character of an inflammatory process to the so-called parenchyma- tous sclerosis. To us, at least, it seems better and simpler to designate for the pres- ent all these forms together as scleroses, and to differentiate them chiefly according to their localizations. Another and a better differentiation will only be possible when a third ques- tion is decided, namely, whether the pathological process in all these forms of dis- ease, which histologically present essentially the same picture, is actually the same ? Whether, consequently, the different conditions described as induration, gray degen- eration, multiple sclerosis, secondary degeneration, etc., are to be ascribed to one 438 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. and the same distinct disease, namely, chronic myelitis, of which they constitute only different forms, or whether they represent essentially different diseases? In our opinion it is still impossible to decide this question with positive certainty. The French school in particular classes the secondary degenerations with myelitis and the band-shaped scleroses. With all reverence for the value of the evidence fur- nished by the histological appearances, we cannot repress a modest doubt of the correctness of this view, a doubt which is based chiefly on physiological and clini- cal considerations. There is another point on which, as it seems to me, most ob- servers agree, and that is that the processes in tabes and multiple sclerosis are not entirely identical, but j>resent certain differences which cannot as yet be defined with satisfactory precision. There undoubtedly remains much to be done in this department, but judging from the great strides that have of late been made in the development of the path- ological histology of the spinal cord, we may confidently expect that the concep- tion of chronic myelitis will be cleared from its obscurities in a not very distant future. Pathology of Chronic Myelitis. Symptoms. In consequence of the great diversity of the processes and forms of disease, that are included under the term chronic myeli- tis, it is difficult, if not impossible, to draw in connected strokes a general clinical picture of the affection. The following description consequently applies more to the general type of chronic myelitis, and particularly to the so un- commonly frequent myelitis transversa, where one large focus of disease exists at any height in the cord, or where there are sev- eral foci, one of which, however, determines chiefly the clinical picture. In the majority of the cases belonging in this class, there is a slow, creeping, almost unnoticed development of spinal symp- toms, which vary in nature and location. Sensory disturbances are usually the first to attract the attention of the patient, but they ordinarily discommode him but little. They consist of ab- normal sensations in the lower, more rarely in the upper extrem- ities, paraesthesiae, anaesthesiae, and the like, which, however, are subject to frequent fluctuations, and may even at times entirely disappear. They are frequently accompanied by a girdle-sensa- MYELITIS. 439 tion in the trunk at a varying height, or perhaps also in the extremities. Severe painful sensations are rare, as are also hyperaesthesiae of any degree of severity. All these symptoms are exceedingly variable and inconstant, and only very gradually attain any great degree of intensity and stability. Slight motor disturbances next present themselves and de- velop in a very analogous manner. They may, however, open the scene. A feeling of weakness and of slight fatigue, and a certain heaviness and uncertainty of gait, are the first symptoms to attract notice. The patients are incapable of making any great exertion, and very quickly become fatigued. These symp- toms also may fluctuate considerably in intensity; they are often neglected for a long time and ascribed to all possible causes but the right one, until finally, in common with the sensory disturb- ances, they assume graver significance. Sometimes the disease commences with vesical weakness, with slight incontinence or retention, more rarely with pronounced paralysis of the bladder. These symptoms may exist for weeks or months, before the other signs of the disease make their ap- pearance. Constipation is almost always present, even in the earliest stages of the disease. After a time, as the disease progresses, all the above-men- tioned symptoms are found in combination ; a slow, progressive, or sometimes an intermittent aggravation of the symptoms is noticed. Not unfrequently we observe a more rapid advance of the disease, a sudden, marked aggravation of the symptoms, under the influence of some injurious agency, such as over-exer- tion, exposure to cold, sexual excesses, the improper use of baths, and the like. Finally, after the disease has lasted a vari- able time—several months or even years—the clinical picture is thoroughly developed, usually taking the form of typical spinal paraplegia with all its consequences. There is distinct paral- ysis, varying in degree from paresis to complete paralysis; it generally takes the form of paraplegia, but may assume any other possible form. Anesthesia of greater or less intensity is rarely wanting. It varies in point of extension, but usually involves the lower extremities and the trunk up to a variable height. Partial paralysis of sensation and retardation of the sensory con- 440 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. duction occur. Paraesthesiae and dysaesthesiae in the paralyzed parts are not rare. Usually, however, the motor is more intense than the sensory paralysis. The sphincters are almost always involved ; the different varieties and degrees of vesical paralysis are met with, and similarly there may be mere weakness of the sphincter ani, or involuntary and unconscious passages from the bowels. A marked increase of the reflex activity usually occurs; a spontaneous twitching of the muscles, which is often accom- panied by severe pains, and muscular contractions and contrac- tures, etc., are also met with. The sexual power is wont to ex- pire early. In the form of chronic myelitis, to which the above descrip- tion chiefly applies, the reflex excitability may be lost after a time. Progressive atrophy of the muscles, changes in the skin, nails and joints, and chronic decubitus, with all its consequences, may also occur. When vesical derangements exist, cystitis rarely remains long absent. All these symptoms, however, are, as a rule, developed very slowly, and only very gradually attain dangerous intensity and extent. The disease may terminate in different ways. A more or less complete recovery may very slowly take place, or the affection may become stationary and remain so for many years, or a fatal termination may be gradually brought about in various ways. The clinical history is essentially the same as that of the anal- ogous form of acute myelitis, the only differences being the very slow and gradual development of the disease, the entire absence of fever, and the usually excellent state of the general health of the patient. The duration of the disease is always very pro- tracted ; it must be reckoned by years. The preceding clinical picture applies, as has been already stated, only to one of the many forms of chronic myelitis. It would require too much space, to describe in a similar manner the other forms, in which the seat of the disease is different, and we must content ourselves for the present with the brief charac- terization of them which is given below. For further particulars concerning them, we must refer to the appropriate chapters. MYELITIS. 441 When we analyze the individual symptoms of chronic myeli- tis, we meet with the same pathogenetic conditions as in the acute disease. A detailed description and minute investigation of them would consequently only lead to needless repetitions. Still, there are many points, which it is necessary for us to examine more closely before proceeding further. Among the sensory disturbances the symptoms of irritation play a comparatively unimportant role. There are cases in which pain is entirely absent throughout the entire course of the dis- ease. In other cases, however, very violent pains are expe- rienced, particularly during the stage of development, or very severe paroxysms of pain occur at intervals during the entire course of the disease. The spasmodic muscular contractions of the later stages are usually accompanied by very intense pains, and I have seen cases in which peripheral sensory irritations, such as the dressing of a bed-sore, passing the catheter, etc., ex- cited violent radiating pains in the back or the extremities. The peculiar, vibrating, painful sensation produced by touching the skin, to which Charcot has applied the term dysaesthesia, is also met with. The so-called paresthesia are more frequently observed : the girdle-sensation, formication, numbness, cutaneous burning, furry feeling, etc., are very common. Finally, anesthesia is almost regularly developed in the later stages of the disease; there are cases, however, in which it is entirely or almost en- tirely absent. The anaesthesia may vary greatly in degree. All possible forms of sensory paralysis, from mere slowness of con- duction to the most complete anaesthesia, may occur. It is not necessary to describe these things in detail; for an explanation of them we may refer to the general part (p. 6Q et seq.). Among the motor disturbances also, the symptoms of irrita- tion are of subordinate importance, particularly in the first stages. Usually there is only an occasional, slight, muscular twitch, or a sudden twitching movement of the legs, or the like ; there may also be slight muscular contractions and trembling of the legs after fatiguing exertion, or when the weight is laid on the toes. The signs of paralysis, however, are usually much more im- 442 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. portant and more prominent. Ordinarily, the first symptoms are marked weakness, loss of tone, and a sense of fatigue. In the early part of the disease these symptoms are not unfrequently relieved by moderate movement, such as walking; the patients feel stiffer and more fatigued at starting out than after they have walked for a time. As the disease progresses the stiffness and helplessness become more marked and are objectively evident. The movements are slow and stiff ; the fingers and toes, for in- stance, can no longer be moved about quickly, or this is only possible with the help of many associated movements. The legs feel heavy, "as if they were filled with lead," and the feet are dragged along the ground, the toes readily catching in every slight inequality. The walk has a pronounced paralytic character. Gradually both walking and standing become impossible. When the patients attempt to stand they collapse; their legs can no longer sustain them. Even while lying down the move- ments become progressively weaker and less frequent, until finally, the case terminates in complete paralysis. This may vary greatly in form. In the great majority of the cases it takes the form of paraplegia, but it may occasionally appear as hemi- paraplegia or spinal hemiplegia, or even cervical paraplegia, etc. The spastic symptoms may return again in a later stage. First of all, a gradually increasing contraction of the muscles sets in; this is manifest at first only during passive motion, but it soon becomes evident also during the voluntary movements, which are impeded and retarded by it. The characteristic " spas- tic" walk, which we have described elsewhere (Part I., p. 97), is now developed. The muscles become more and more tense and rigid, until finally a state of permanent and more or less marked contracture is produced. This may affect either the extensors or the flexors, the latter being, as a rule, attacked only in the later stages of the disease. The adductors are likewise almost always involved. The stiff and paralyze'd limbs are not unfrequently shaken by twitches and spasmodic movements, which either arise spontaneously or are excited by sensory irritations. These twitches and movements are often exceedingly active and may resemble voluntary movements; they are of ten accompanied by MYELITIS. 443 severe pains. They are most readily excited by sensory irrita- tions : cutaneous irritation, catheterization, micturition or defe- cation, traction on the tendons, etc. They may develop into long- continued, convulsive tremor of the lower extremities. Sometimes all voluntary movements are accompanied and followed by this spasmodic muscular action. The various, special disturbances of motion, such as the ataxia, the tremor accompanying voluntary movements, etc., which occur in other distinctly localized forms of chronic myelitis, will be described more minutely in the appropriate chapters. All the motor disturbances are very readily explained by the chronic inflammatory processes going on in the motor conduct- ing tracks and central apparatus, although it is not always pos- sible to determine the exact point in the central nervous system, at which these processes are located. Of late it has become cus- tomary to ascribe the spastic symptoms, which develop during the later stages of the affection, to secondary degeneration of the lateral columns. It cannot be denied, that there are good grounds for this assumption. The vaso-motor disturbances in chronic myelitis are, as a rule, not of a very striking nature. The coldness of the feet, which is very frequently complained of and proves very annoying to the patients, probably belongs here, as does also the often observed, cyanotic, bluish-red color of the lower limbs. In consequence probably of the very slow development of the obstruction to con- duction, the vascular innervation is able to adapt itself to the loss of a part of its spinal centres, so that the resulting derangements are not very marked. The state of the reflex irritability varies. In the majority of the cases it is increased and is very active. Very curious things are often observed in this connection; reflex movements of the strangest kinds are produced by irritation of all imaginable sensi- tive regions. Tickling the soles of the feet causes active jerking and kicking movements in the paralyzed legs; colic pains, the introduction of a catheter, the act of dressing a bed-sore, etc., may excite movements in the legs. I have seen evacuation of the urine produced by irritating the skin of the feet, or by introduc- 444 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. ing the finger into the rectum ; erections produced by rubbing gray ointment into the thighs ; a discharge of faeces occur during the dressing of a bed-sore, etc. The tendon-reflexes are also, as a rule, abnormally active, often excessively so. The slightest irri- tation of the tendon of the quadriceps extensor femoris causes a reflex movement, which can readily be made to develop into clonic spasm. The most marked clonic spasm of the muscles of the calf can be excited by passive flexion of the foot; reflex movements can also be produced by irritation of the tendons of the adductors and of numerous other muscles. Both of the conditions which are known to lead to increase of the reflex activity—destruction of the connection between the reflex apparatus and the brain, and abnormal irritability of the gray substance—may be present in chronic transverse myelitis. It is probable that in most of the cases the increase is due to a combination of these two conditions. On the other hand, there are cases in which the reflex irrita- bility is diminished, or even entirely abolished. In such cases we must, in accordance with the views at present held, assume either that the gray substance is very extensively involved, or that the conducting power of the nerve-roots which come into play, is destroyed by the myelitis. There is an unmistakable parallelism between the state of the reflex excitability and the state of the electric irritability of the nerves and muscles. When the reflexes persist, the electric excitability is also, as a rule, preserved. In the majority of the cases, I have found the latter to be both qualitatively and quan- titatively normal. In a few isolated cases there was a distinct increase in the faradic and galvanic excitability (without quali- tative anomalies) of the nerves of the paralyzed limbs ; in other cases there was an unimportant quantitative diminution of this excitability. I am as yet, however, unable to say, whether or not this pathological state will afford us any assistance in determin- ing the seat, stage, or course of the disease. In those cases, however, in which the reflexes are abolished in consequence of extensive implication of the gray substance, atrophy of the muscles usually sets in, accompanied by loss of their faradic excitability (probably with the reaction of degener- MYELITIS. 445 ation in the majority of the cases). In certain forms of chronic myelitis, which we can with great probability locate in the an- terior horns of the gray matter, this state of affairs constitutes the rule, the loss of electric irritability occurring remarkably early and rapidly. Further and more accurate investigations of these phenomena in chronic myelitis are greatly to be desired. There is a very close connection between the electric irrita- bility and the state of the nutrition of the muscles. Usually the latter is intact and good, and it can remain so during the entire course of the disease. In other cases a slow, progressive atro- phy of the muscles sets in in the later stages—a sign that the gray substance has become more extensively involved. In still other cases a rapidly progressive atrophy of the muscles is ob- served, which sets in early, and is accompanied by the reaction of degeneration. The territorial extent of the atrophy varies greatly ; it depends on the extent of the central disease. Some- times the upper extremities are chiefly or alone affected by the atrophy, the lower limbs presenting simple paralysis without atrophy. This is easily accounted for by differences in the condition of the gray substance of the cervical and the lumbar enlargements. In regard also to other trophic derangements, the individual cases vary greatly. They are entirely wanting in some forms of chronic myelitis, of which we will presently give brief de- scriptions ; as a rule, disorders of sensation and of the bladder are also wanting in such cases. Frequently, however, and more especially in cases of myelitis transversa, decubitus is devel- oped sooner or later, generally in the chronic form already de- scribed (Part I., p. 122); sloughs form in the usual places of predilection, their formation being not unfrequently hastened by more or less accidental agencies (sitting or lying in the same position for a long time, unusually severe pressure or other me- chanical injury, a long railroad journey, febrile diseases, etc.). Sometimes, when the patient has not been nursed with proper care, the attendants will be astonished by the unexpected dis- covery of a bed-sore, which has already attained large dimen- sions, on the nates or over the sacrum. The sore may develop 446 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. and spread with more or less rapidity, but it usually runs a chronic course. When great attention is paid to cleanliness, etc., the parts first affected may, after separation of the sloughs, heal up in the course of a few weeks or months ; fresh bed-sores, however, constantly form in other situations, often in considera- ble numbers, or the already cicatrized spots break out afresh on the slightest provocation. The patients, even when they are covered with large ulcers, may, if carefully nursed, drag out a miserable existence for a long time, until finally death ensues from exhaustion. Under all circumstances the formation of ex- tensive sloughs is an unfavorable sign ; it marks the beginning of the end. In some rare cases large decubitus ulcers may be- come permanently cicatrized, even though there be no noticeable improvement in the primary disease. I have at present one such case under observation. With respect to the pathogenesis of the bed-sores in chronic myelitis, we have nothing to add to the re- marks made in the place mentioned above. In the forms of chronic myelitis which more especially engage our attention here, the sphincters are almost always involved in the paralysis to a greater or less extent. The vesical functions in particular are almost regularly impaired at an early period; there are some exceptional cases, however, in which the bladder remains unaffected throughout the entire course of the disease. In many cases the vesical paralysis is the first symptom, and pre- cedes the other manifestations of the disease often by a consider- able period (Laveran' s case). It may present any of the different forms and degrees which have been enumerated elsewhere (Part I., p. 132); it may vary from slight retention of urine to complete incontinence, or constant dribbling of urine. The variations in the localization and extent of the myelitis explain sufficiently these differences in the vesical symptoms. Naturally, cystitis with all its evil consequences, which render the nursing and treat- ment of the patient so much more difficult, does not remain long absent under such circumstances. Pyelitis and nephritis may set in later, and hasten the fatal termination. The functions of the rectum usually suffer in an analogous manner to those of the bladder. Sexual power is usually impaired early. As a rule, it dimin- MYELITIS. 447 ishes with more or less rapidity, and finally disappears entirely. Notable exceptions to this rule are met with, however, particu- larly in cases of incomplete paraplegia, and in those forms of chronic myelitis which affect chiefly or exclusively the voluntary motor apparatus. The general nutrition often remains perfect for a very long time. It is not at all rare to meet with patients, whose blooming and well-nourished appearance presents a most striking contrast to the state of perfect helplessness, to which they are reduced by a complete paraplegia or some other form of paralysis. This is to some extent characteristic of certain special forms of chronic myelitis, which will presently be described. In all the more severe and progressive cases, however, a constantly increasing disturbance of the general nutrition is observed, though usually not until after the development of cystitis and bed-sores. Loss of appetite, fever, repeated chills, digestive derangements, pro- gressive emaciation and finally complete exhaustion generally constitute the final symptoms in such cases, provided some inter- current disease does not terminate life sooner. With regard to the disorders of the cerebral nerves and of the brain itself, we have but little to say. There are cases of chronic myelitis, e. g., of tabes and multiple sclerosis, in the clinical picture of which disorders of certain cerebral nerves, such as the optici, the nerves of the muscles of the eye, the faciales and the hypoglossi, occupy an important position ; there are other cases, in which psychical disturbances and disorders of speech and of the voice are equally prominent. We will return to these symp- toms in the appropriate chapters. In the cases of myelitis trans- versa, however, which interest us more especially at present, cerebral symptoms and disorders of the cerebral nerves are usu- ally entirely wanting throughout the whole course of the disease, or, at most, they occur during the agony. Finally, there are cases in which the process slowly ascends until it at last reaches the medulla oblongata ; disorders of deglutition, speech, respira- tion, circulation, etc., are then produced, and bring about the fatal termination. The sequence and grouping of these symp- toms follow naturally from the functions of the cervical marrow and the oblongata, and it is unnecessary to describe them in 448 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. detail, especially as they present very great differences in the individual cases. Course—Duration— Terminations When the chronic form of myelitis is developed from the acute form, it is preceded by the symptoms of the latter; some of these symptoms undergo a gradual retrogression and the gen- eral health improves, but the paralyses, pains, contractures, etc., persist and subsequently become slowly and gradually more developed. In the other cases, we observe the slow, lingering development, which has been briefly described above. Of course the individ- ual cases do not resemble each other exactly in every particular, but the fundamental characteristic of the disease always remains the same; it is the successive, gradual appearance of the various spinal symptoms, their development from insignificant begin- nings which often attract little or no attention. Sometimes the development of the affection, instead of being continuous, is in- terrupted by intervals of more or less marked improvement; these alternate with exacerbations and slight relapses, each of which leaves its mark in an increase of the disturbances. When the disease has attained a certain height it may remain stationary for many months or even years, or it may slowly pro- gress and terminate in different ways. The great multiplicity of the morbid conditions included under the term chronic mye- litis, makes it impossible to give even an approximate estimate of the duration of the disease. All we can say is that it is an affection whose duration can only be measured by years. In not a few cases, many years elapse before the final termination is reached, while in others the disease may persist during the life- time of the patients, without directly threatening existence. It very rarely terminates in recovery, and when it does the cure is usually exceedingly incomplete. Moreover, relapses are very liable to occur, and they furnish good reason to doubt the reality of the cure. Various residua, such as paralyses, atrophies, par- tial anaesthesias, deformities, vesical disorders, etc., often remain behind permanently, even when the actual morbid process has MYELITIS. 449 undoubtedly ceased ; hence the recovery must be regarded as in- complete. In one relatively mild case that came under my own observa- tion, an intercurrent ileo-typhus exerted a very favorable influ- ence on the course of the disease. In another case, an inter- current scarlatina seemed to exert a similarly favorable influence. A slow progressive course, leading gradually and in different ways to a fatal termination, is, however, so much more common as to be almost the rule. The process may slowly creep upwards, until, at last, disturbances of deglutition and respiration set in, and death is caused by asphyxia. Or the secondary affections caused by the myelitis, the decubitus, cystitis, p}raemic and septi- caemic infection, etc., destroy the vital powers of the patient and lead to death by exhaustion. In such cases we sometimes ob- serve a peculiar final stage, or stage of agony, in which death is preceded for da}^s by high fever, chills, somnolence, delirium, signs of collapse, etc., for which the autopsy reveals no cause. Finally, death may be due to the development in the medulla oblongata or in the brain of a process analogous to the myelitis, or it may be caused by accidental, intercurrent diseases (pneu- monia, typhus, choleraic diarrhoea, etc.). Different Forms of Chronic Myelitis. In what precedes we have sought to delineate the clinical his- tory of myelitis transversa; if we exclude from consideration those well-marked forms, which are sharply localized in particular parts of the cord, and to which special chapters will be devoted, it is the most common and typical form of the affection known as chronic myelitis in its narrower sense. To briefly recapitulate, the typical picture of myelitis transversa is about as follows : Slow development and persistence of spinal symptoms, which vary according to the height at which the disease in the cord is located; symptoms of irritation not very prominent; girdle- pains, pains in the back and paraesthesiae, indicating the seat of the disease ; signs of sensory and motor paralyses occurring to- gether or in succession; early development of a more or less complete paraplegia, the upper limit of which can* usually be VOL. XIII.—29 450 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. readily determined by the disturbances of sensation and motion ; weakness of the bladder and rectum ; reflex irritability usually increased ; general health good until the later stages, when it is impaired by the cystitis and bed-sores. The symptoms vary somewhat, according to the location of the morbid process in the cord. When the lumbar enlargement is affected, we find complete paraplegia extending up to the hypogastric region, anaesthesia of equal extent, paralysis of the bladder and rectum, loss of reflex excitability, and usually mus- cular atrophy. Bed-sores develop early. When the process is located in the dorsal region of the cord, paraplegia also exists, but the sensory and motor paralysis ex- tends higher up—to the level of the nipples or even further ; the muscles of the abdomen and back are involved. Expiration is impeded. Paralysis of the sphincters, bed-sores, etc., as in the preceding form ; characteristic of the dorsal affection, however, are the often very marked increase of the reflex actions, the ab- sence of muscular atrophy, and the appearance in the later stages of signs of irritation, contractures etc., in the muscles. When the cervical enlargement is the seat of the disease, the usual initial symptoms are observed, but they affect principally the upper extremities, and the paralysis which follows frequently takes the form of paraplegia brachialis—the hands and arms are affected first and chiefly, the paralysis of the legs not appearing until later. When the affection is at its height, all the four ex- tremities are more or less completely paralyzed. Paralysis of the sphincters, decubitus, and increase of the reflexes in the lower extremities, are present here as well as in m}relitis of the dorsal region; the impeded inspiration, the oculo-pupillar symptoms, and the atrophy of the upper extremities with extinction of their reflex activity, are, however, characteristic of the cervical affec- tion. In consequence of the loss of their reflex activity, the upper present a striking contrast to the lower limbs. The electric irritability is diminished or destroyed in the atrophied muscles. When only the upper part of the cervical marrow is attacked, the clinical picture varies somewhat from the above. There is paralysis of all four extremities, it is true, but the nutrition of the upper limbs remains intact, and their reflex activity is rather MYELITIS. 451 increased than diminished. Moreover, severe disturbances of respiration (paralysis of the diaphragm), difficulty of swallowing, impairments of speech, vomiting, singultus, etc., occur which im- part an exceedingly threatening character to the clinical picture. A particularly common form of chronic myelitis is the so-called compression-myelitis, which occurs in connection with any dis- ease, that occasions a slow compression of the cord. We have given a detailed account of this form of the affection in another place (p. 320), to which the inquirer is referred. We shall con- tent ourselves here with the statements, that the clinical pic- ture corresponds perfectly with that of spontaneous transverse myelitis, and that the only thing, which is at all distinctive and characteristic of a compression-myelitis, is the existence for a variable period preceding its development, of initial symptoms referable to some particular portion of the cord (severe pains and cramps, local paralysis, atrophy, or anaesthesia, dorsal pain and stiffness, local hyperaesthesia, etc.). The form of chronic myelitis which is confined to the anterior horns of the gray matter, poliomyelitis anterior chronica (see Section No. 16) is, as a rule, readily recognized. It is character- ized by a slowly increasing weakness and paratysis of the limbs, which advances progressively from below upwards ; by distinct and sometimes rapid atrophy of the muscles, with loss of the faradic irritability (and probably with development of the reac- tion of degeneration); by the absence, or the very slight develop- ment of the sensory disturbances, which frequently exist only in the initial stage, in the form of dragging and tearing pains; also by the extinction of the reflexes, and the complete absence of decubitus and of vesical weakness. This is the affection which Duchenne has described under the name " Paralysie generate spinale anterieure subaigue," the localization of which in the anterior gray substance is at all events exceedingly probable. It is as yet impossible to give an accurate clinical description of that form of chronic myelitis, which is limited to the central gray substance, and to which the name myelitis centralis has been given. This form is the myelite periependymaire of the French, and it probably includes also a portion of the cases of hydromyelie and syringomyelic. Many cases present absolutely 452 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. no symptoms, while others, as it appears, present the clinical pic- ture of progressive muscular atrophy, but with more prominent paralytic symptoms. Hallopeau ascribes to this form of the dis- ease, circumscribed paralyses of different parts with atrophy and loss of electric irritability, vague pains, very little or absolutely no anaesthesia, sometimes tremor, and the like. The clinical pic- ture is consequently so exceedingly vague and uncertain, that a positive diagnosis cannot be made from it. In some cases the chronic myelitis gradually extends until it involves the entire cord ; it may then be termed myelitis univer- salis progressiva. This form is characterized by progressive weakness and paralysis of the muscles, extending slowly from below upward, rarely in the reversed direction, while the muscu- lar contractions and contractures, and also the atrophy of the muscles, are less pronounced ; the electric irritability disappears slowly. The reflexes are usually diminished. There are more or less violent pains in the back, trunk and extremities, dys- aesthesiae and paraesthesiae and later on marked anaesthesia, paralysis of the sphincters, and bed-sores. The clinical picture is consequently essentially that of Duchenne's "paralysie gene- rale spinale diffuse subaigue," the individual cases, of course, presenting countless modifications, according to the stage and the extent of the process. The clinical history of myelitis chronica disseminata, or multiple sclerosis, which will be described in detail in another place (No. 11), is in some cases very characteristic, and in others just the contrary. The reason of this is that the grouping and character of the symptoms depend entirely on the accidental locations of the different centres of disease. The numerous, concomitant cerebral symptoms, the psychical disturbances, the peculiar impairments of speech, and the affections of different cerebral nerves, are particularly important; so are also the very irregular distribution of the parabyses, the peculiar and varying range of the anaesthesia, the trembling of the limbs during volun- tary movement, etc. That form of chronic myelitis which is confined to the poste- rior white columns, and is usually designated as tabes dorsalis (gray degeneration or sclerosis of the posterior columns), will MYELITIS. 453 be described in detail in a subsequent chapter (No. 12). It is characterized, in the early stages, by severe lancinating pains, slight disturbances of sensation, a girdle-sensation, and not un- frequently by implication of the optici and the nerves supplying the ocular muscles ; in the later stages, by impairment of co-or- dination (ataxia), weakness of the bladder and of the sexual functions, loss of the tendon-reflexes, etc. An essentially different clinical history is, on the other hand, presented by that form of chronic myelitis called lateral sclero- sis, in which the morbid process can with great probability be located in the lateral columns. Here we have a motor weakness, which gradually increases in intensity and range, and is accom- panied by striking muscular contractions and contractures, and by great increase of the tendon-reflexes. There is no ataxia, but instead of it a markedly spastic gait; no disorder of sensation, no atrophy of the muscles, no diminution of their electric irrita- bility, no paralysis of the bladder, no decubitus. This form, too, must be made the subject of special consideration (see No. 13). Finally, it is very difficult to recognize during life that form of myelitis which is localized in the peripheral layers of the white substance, and which is perhaps most correctly designated as myelomeningitis chronica (the sclerose corticale of the French). It may be recognized in a few cases by the fact that the symp- toms of chronic meningitis (see p. 255) are accompanied by some- what more pronounced manifestations of both sensory and mo- tor paralysis. It is said that muscular atrophy, as a rule, does not occur. These points are not very safe or reliable from a diagnostic point of view. Diagnosis. The diagnosis of the different forms of chronic myelitis is to a great extent evident from the preceding descriptions, and for further details we may refer to the special chapters which follow. We must make place here, however, for a few wrords concerning the simple, chronic myelitis transversa. It is characterized by slow development of paraplegia with relatively slight irritative symptoms, but with more or less marked disturbances of sensa- 454 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. tion and of the bladder ; usually also with muscular contrac- tions, increased reflexes, and decubitus. Hence, all, or at least most of the paths in the cross-section of the cord are included in the lesion, though with varying degrees of intensity. The pro- cess, however, is limited to a relatively small area in a vertical direction, a fact which can be most readily recognized from the state of the reflex irritability. The affection is but slightly pro- gressive in character, and runs a tedious course. The diagnosis of transverse myelitis can readily be made from these points, all the more certainly if the existence of such etiological influences as slow compression, syphilis, and the like, can be demonstrated. The height at which the lesion is located in the cord can usually be easily determined from the range of the paralysis, the state of the reflex and electric irritability and of the nutrition, etc. The differentiation of transverse myelitis from the other forms of the affection, from the later stages of tabes, from lateral scle- rosis, from multiple sclerosis, and also from progressive muscular atrophy and from paralyses of the cauda equina, is in most cases easy. Still there are many cases of peripheral paralysis due to affections of the plexus or of the cauda equina, to com- pression of a number of the nerve-roots, etc., in which the differ- entiation from chronic myelitis is very difficult. In the diagnosis of such cases, the co-equal extension of the motor and sensory disturbances, the absence of all reflexes, the loss of electric irri- tability, the limitation of the disturbances to certain isolated nerve-territories, etc., may be turned to good account. There still remain, however, numerous complicated and per- haps irregular cases, in which an exact diagnosis of the special form of the disease is downright impossible. This leads us to say a few words concerning a point to which, despite its great impor- tance, too little attention has been paid in practice, and to the disregard of which a great part of the obscurity and confusion in the accepted clinical conceptions of the disease is due. It is the simple fact, that the myelitic processes, described in the preceding pages as strictly localized in particular parts of the cross-section of the cord, do not by any means always remain limited to these particular parts, but often extend beyond them and involve neighboring parts; that, in other words, in addi- MYELITIS. 455 tion to the special forms of chronic myelitis, transition-forms exist and combinations occur which are of course characterized by combinations of the clinical histories. While, in the very great majority of the cases, sclerosis of the posterior columns gives rise to the typical clinical picture of tabes, while the regu- lar form of sclerosis of the lateral columns, as a rule, remains limited to the lateral columns and produces its own special symptoms, while poliomyelitis anterior chronica has its own dis- tinct clinical history, we meet in practice with not a few cases in which the typical symptoms of tabes are combined with those of sclerosis of the lateral columns, as well as cases in which the symp- toms of a poliomyelitis anterior are added to those of a lateral sclerosis or of a tabes. Pathological anatomy has already fur- nished a sufficient explanation of this fact. A number of reliable observations have been recorded, in which the anatomical exami- nation demonstrated the co-existence of gray degeneration of the posterior and of the lateral columns, or the combination of an extensive lesion of the anterior gray substance with sclerosis of the posterior or lateral columns. Careless investigations and an insufficient acquaintance with these facts have naturally led to the incorrect conclusion, that lesions of special parts of the cross- section of the cord do not give rise to special groups of symp- toms, but that on the contrary these lesions can cause sometimes one and sometimes another set of symptoms. The knowledge which is now possessed of the pathology of the cord, teaches us, however, that each typical clinical picture must correspond to some distinct anatomical lesion, and that where Ave meet with a combination of different clinical pictures, we must also assume a combination of different anatomical lesions. Valuable confirma- tion of this statement is furnished by the striking conformity of the typical cases of each particular form of the disease. These combined forms are not at all rare, although they certainly con- stitute but a small minority in comparison with the pure, typical cases of each form. It is true, that we cannot hope to be able to recognize these typical clinical pictures whenever met with, even when more or less confused by combination with one an- other, without a careful observation and study of an abundant material. Without this preparation, the differential diagnosis of 456 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. such cases will prove very troublesome, and we shall have reason to complain of the obscurity and ambiguity of the clinical his- tories, while with it we shall be able to take a more decided stand, and to resolve the combination pictures more readily into their various component parts. That every case of this sort requires a special diagnosis, and that countless modifications are possible, are self-evident facts. We will return to these points again when speaking of the individual forms of the disease. Prognosis. The prognosis varies very greatly in the different forms of chronic myelitis; for details, we may refer to the appropriate chapters. In simple chronic myelitis transversa the prognosis is in general unfavorable. The affection is always a severe and a dangerous one, and the best that can be hoped for is recovery with a heritage of considerable residua. A real and complete recovery can only be looked for in exceptional cases, where the disease is very mild and has developed in otherwise healthy per- sons, and where, moreover, treatment has been begun in the earli- est stages. Only rarely, also, will it be possible to predict a partial recov- ery, followed by a persistence of the status quo for many years or until the natural end of life. In such cases a complete recovery of power over the limbs can never be expected. In the majority of the cases a slow, progressive course must be looked for, and usually only a few years of life can be promised to the patients. The prognosis will be partly determined or influenced by the more or less progressive and ascending character of the disease, by the tendency to aggravations and relapses which sometimes exists, by the effect produced by certain therapeutic measures, and finally, by the more secondary symptoms, particularly the cystitis and decubitus which most frequently place life in dan- ger. None of these points require a more extended considera- tion. MYELITIS. 457 Treatment. Is there any prophylaxis for chronic myelitis ? Unquestion- ably, though only to a certain, very limited degree. The pre- cautionary measures, which in general prove useful in preventing the development of diseases of the cord, are serviceable here also. Their employment is advisable particularly in the case of the numerous individuals, who belong to neuropathic families, and more especially when affections of the spinal cord have occurred in the generations immediately preceding. In such individuals, more even than in others, the most beneficial effects will be de- rived from a rational hardening of the body (by means of cold sponging, baths, gymnastics, exercise in the open air, pedestrian excursions, nourishing diet, proper but not too warm clothing, etc.), and from appropriate hygiene of the nervous system (proper alternation of rest and work, avoidance of mental overexertion and of violent emotional excitement, sufficient sleep, etc.). The avoidance of sexual excesses, of spirituous drinks and other irritating articles, of bodily overexertion, of the causes of catch- ing cold, etc., will also assist to a certain extent in keeping the spinal cord in a state of health. Unquestionably, much would be gained in many of these cases, if the physician could induce the individuals in question to follow out strictly the above pre- cautionary measures. Unfortunately, however, we can rarely succeed in this. In respect to the causal indication in chronic myelitis, it is only in isolated cases that anything can be done. In this con- nection, the importance of a careful treatment of acute myelitis, continued until recovery is complete, must be alluded to. In other cases there may be some compressing agent (caries of the verte- brae, new growths, etc.), which we must endeavor to remove ; or a s}'philis, which forms the basis of the spinal affection, must be energetically attacked; or diseases of peripheral organs, of the intestines, or of the urinarj7- or sexual organs, must be subjected to proper treatment. When, in addition to hemorrhoids, a ten- dency to constipation, dyspepsia, etc., exist, the appropriate treatment for them should be employed ; the favorable results 458 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. obtained in many cases of chronic myelitis (so-called hemor- rhoidal tabes), by a course of treatment at saline springs, may perhaps be accounted for by its influence on these derangements. Usually, however, in consequence of the slow and lingering man- ner in which the disease is developed, it is impossible to discover any causal indication, or, if discovered, to carry it out. For the treatment of the disease when it has developed to a certain degree, we possess, it is true, numerous remedies, but we must not deceive ourselves with regard to their efficiency. Chronic myelitis, in all its different forms, is a disease from which recovery is rare, and in the best cases slow. The earlier the treatment is begun, the better are the prospects of a favora- ble termination. Hence, it is particularly important, that notice should be taken of the earliest and even the most trifling of the initial symptoms, and an energetic and appropriate treatment at once commenced. It is better to be too careful and anxious, and to ascribe excessive importance to trifling and perhaps harmless symptoms, than to suffer the patient and ourselves to be de- ceived concerning the gravity of the initial symptoms, and thus give the creeping evil time to develop into a dangerous and un- conquerable foe. We shall rarely have an opportunity to employ antiphlogistic measures. The development of the disease is much too linger- ing to permit their employment; the symptoms of hyperaemia and irritation remain more in the background. Hence, blood- letting, ice, confinement to bed, drastic cathartics, depressing diet, and the like, should be avoided. These measures will only be indicated, when subacute or acute exacerbations occur. Under such circumstances, the treatment laid down for acute myelitis should be employed. The much used and often misused derivative measures will naturally be the next to be thought of. Unfortunately, ex- perience teaches that they prove, as a rule, of very little use. In former times they were invariably employed, and in a very energetic manner ; the red-hot iron was an especial favorite, and all sufferers from spinal disease bore the marks of it in numerous cicatrices on the back. The results produced by these measures were entirely disproportionate to the frequency and energy with MYELITIS. 459 which they were employed. The persistent employment of milder derivatives (repeated flying or suppurating blisters, pus- tulating salves, painting with iodine, etc.) has also proved, as a rule, of little use. Personally I do not remember to have ever obtained any distinct advantage from the employment of these remedies, though, it is true, my experience with them has not been particularly extensive. Our attention is, however, directed to them over and over again by the favorable results they pro- duce in other diseases, and perhaps fresh trials of them are now more admissible, in view of the facts that we can diagnose the different forms of the disease more positively, and can also pick out more readily the cases which present any chance of success. Such trials, however, should be carried out in a systematic manner, and with exclusion of other remedies. We recommend as a relatively harmless, and still in many cases decidedly efficient derivative measure, the application of dry cups along the spine, repeated every few days. Brown- Sequard praises highly the daily employment of a hot (37-40° C, 98.5°-104° F.) douche to the back, for two or three minutes at a time; the stream should be nearly an inch in diameter. In the treatment of chronic myelitis at the present day (we are speaking now of all the forms together, referring to the special accounts of the different forms for further details), the chief reliance is placed on three curative agencies. These are baths (particularly the thermae, hot and cold brine baths, and to a less degree steel-baths), hydropathy, and galvanism. We have already (in the General Part, p. 164 et seq.) spoken at length of these things, and endeavored to determine with some degree of accuracy the general indications for their employment, and we have only to add here a few points bearing directly on their use in chronic myelitis. In order to attain an approximately correct idea of the action of these agents, I have made out a table from the cases of chronic myelitis (in all its forms, inclusive of multiple sclerosis, lateral sclerosis and sclerosis of the posterior columns), that have come under my own observation, of which I have notes of the treatment and its effects. This table includes 175 different observations that were made on 107 different cases. It is true 460 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. that this material is not homogeneous. It contains a large number of hospital cases, and many old and severe cases that defied all treatment ; most of them were treated solely by elec- tricity ; many of them have undergone several courses of treat- ment, and have thus afforded opportunity for repeated observa- tion. With all this, however, some important points, which I would gladly see made the subject of further investigations, can be gathered from this table. In the first place, the result of my collation of facts is decid- edly unfavorable for the indifferent therme (Wildbad, Teplitz, etc.). Out of twenty-two cases in which these thermae were em- ployed, there were no less than twelve which were decidedly in- jured by them ; in these cases an aggravation of the disease set in during or immediately after the course of treatment by baths. Of the remaining ten cases, seven experienced no change at all, and only in three was there any improvement; one of these was cured. In two of the three cases which were improved, the baths were, however, cooler, of shorter duration, and less numerous. These observations coincide with the experience of most spe- cialists. The results are at all events not encouraging ; they take away all desire to send such patients to the thermal springs, which was formerly the universal custom, and is even yet fre- quently done. If the physicians located at watering-places could be induced to publish unprejudiced and careful observations, based on correct diagnoses, a great desideratum would be ful- filled. At all events, I no longer risk a trial of the thermae in these cases, except when I have guarantees for the most cautious employment of a modified course of baths. The temperature of the bath should never be above 33°-34° C. (91f-93£° F.), and prolonged immersion should be avoided. If I were to attempt to pick out the actual cases for which the thermae are suitable, I should find myself in a difficult position. It is usually stated that the cases with prominent irritative symptoms, with hyper- aesthesia, with meningitic symptoms, etc., are especially benefited by them. I must confess, however, that without further critical observations, I cannot regard these indications as reliable. At present I would only recommend a trial of hot baths after other remedies have failed, and even then only with every precaution. MYELITIS. 461 My experience has been much more favorable with the thermal brine baths (Rehme, Nauheim). I possess notes of twenty-one cases ; of these twelve were improved by the course of treatment, nine received no benefit from it, but none were rendered worse. Here, too, I am convinced that much depends on the manner in which the treatment is carried out, on the temperature and duration of the baths. It is advisable that they should be of a moderate temperature (30-26° C.—86-7S|° F.) and not too prolonged, and that the water should not contain an excessive quantity of carbonic acid. Any increase in the activity of the treatment must be made with great caution. These baths are suitable for most of the cases. At the most, I would hesitate to recommend them for cases attended by great irritability, violent pains and other symptoms of irritation. I have had no experience at all with the ordinary brine-baths, and very little with chalybeate and turf baths. The latter proved useful in two cases, and detrimental in one. They are highly extolled by many authors. In Franzensbad particularly, various good results have been obtained by their use. This, too, is a subject worthy of further investigation. Concerning animal-baths, hot sand baths, pine-needle baths, steam-baths, hot-air baths, etc., I know very little from personal experience. In most of the cases they are superfluous, and, when used at very high temperatures, they are actually injuri- ous and dangerous. On the other hand, the results of a rationally conducted cold- water cure are exceedingly favorable. Out of twenty-nine cases of which I have notes, the results of the treatment were favorable in twenty-one, negative in five, and unfavorable in three. Here too, of course, everything depends on the manner in which the cold water is used. I cannot insist too much on the danger of forced cures, of all severe and strongly exciting procedures, such as the employment of water at very low temperatures, douches, sharp slappings, etc. These measures are, as a rule, absolutely injurious in cases of myelitis ; even wet packs of the entire body have, to my surprise, generally proved injurious. Simple rub- bing with wet cloths, foot-baths and sponging the back, hip- baths, half-baths with affusions to the back, local compresses to 462 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. the back left on till they become warm, etc., seem to be the measures which are chiefly applicable. The treatment should always be begun with moderate temperatures (20-25° C.—68-77° F.), and we should never go below 16-12° C. (60f-53|° F.). I believe also that excessive prolongation of the treatment is inju- rious. Many over-zealous hydropathists are only too often led, by their great confidence in the water-cure, to prolong the treat- ment to an extent that proves detrimental to the patients. The water-cure is, all things considered, one of the most important and most promising means of treating chronic myeli- tis. The mistrust with which it is regarded by some authors is, as far as my own experience goes, entirely unjustifiable. It is suitable for almost all cases, though of course the method of application must vary according to the peculiarities of the indi- vidual cases. Some patients, however, cannot bear the treatment at all; it is followed by insufficient reaction, causes chilliness, discomfort, etc. In such cases the treatment should not be per- sisted in. The choice of the establishment is of course a matter of great importance. I prefer one situated in a healthy moun- tainous locality and in a wooded region. The chief requisite, however, is always the presence of an intelligent and competent physician. In recent times the galvanic current has acquired a promi- nent position in the therapy of chronic myelitis. Out of one hundred cases treated by it, I obtained a more or less favorable result in fifty-two. Complete recovery ensued, it is true, only in a few of these cases, but a very considerable and striking im- provement was observed in quite a number of them ; in most of them, however, the improvement was only moderate. In forty- seven of the cases the results were negative, although in some of them the treatment was persisted in for a very long time. In only one case was the effect of galvanization decidedly bad. The chief part of this treatment is, of course, the direct gal- vanization of the cord, which must be conducted precisely ac- cording to the principles which have been exhaustively consid- ered in another chapter (see page 178). The electrodes must be applied differently, in accordance with the differences in the position and extent of the focus of disease. It is best to let MYELITIS. 463 both poles act successively, either with a stabile or with a slowly labile current. When we have to deal with band-shaped sclerosis, it is advisable to include the cervical sympathetic also within the sphere of the electricity. The current used should not be very strong, and the seances should be short. I cannot insist suffi- ciently on the point, that the treatment, to be successful, must be conducted with great care and skill. Great patience on both sides is, as a rule, necessary. The treatment must be continued for months, being occasionally interrupted only to be recom- menced after a brief pause. It is expedient to alternate or com- bine galvanization with other methods of treatment. It is as 3~et impossible to indicate the cases for which the galvanic treatment is especially suitable. It may, indeed, be tried in most or all cases, as we know of no positive counter- indication. Every now and then, however, we shall meet with patients who cannot bear, or who think they cannot bear, even the most cautious application of the galvanic current. In such cases the treatment must be at once discontinued. Little can be expected from internal medicines in the treat- ment of chronic myelitis. Nitrate of silver, which was first recommended by Wunderlich, is the most reliable of all of them. In a few cases it has undeniably proved beneficial. It is impos- sible to give the exact indications for its employment, but, as it is in general a harmless medicine, it may be tried in most of the cases. Brown-Sequard very urgently recommends ergot and belladonna, both of which are said to lessen the congestion of the spinal cord and to diminish its reflex irritability. He gives the ergot in doses of 0.30-0.50 (gr. v.-viiss.) twice a day, and in connection with it applies a large belladonna plaster to the back, or gives extract of belladonna internally in doses of 0.015 to 0.02 (gr. |-i) twice a day. The effect is said to be very decided in many paraplegias. Iodide of potassium has rather unexpectedly proved almost invariably useless. I at least, often as I have prescribed it, have never seen any decided improve- ment follow its use. Even in the paraplegias of syphilitic patients, its curative action is often very limited. Arsenic, too, has in my experience, as a rule, proved useless. Phos- phorus I have seldom prescribed; its curative action seems to 464 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. me dubious, and its administration not entirely without danger. Strychnine is in my opinion almost always decidedly objection- able in chronic myelitis. In the earlier stages it is more liable to do harm than good, and for the later stages, when the residua of the myelitis (paralyses, etc.) are to be treated, we possess in electricity a much more reliable as well as safer remedy. In consequence of the long duration of the disease, the phy- sician will often find himself tempted to employ in a tentative manner, not only the above, but also numerous other remedies. It will be fortunate both for physician and patient, when the right remedy is discovered at once. The general management, the diet and the mode of life of the patients are in our opinion of very essential importance. These points are still very often sinned against, partly through igno- rance, partly through carelessness. Above all, rest and a regular mode of life are essential; overexertion of every kind, mental as well as bodily, must be avoided; sexual intercourse should be confined within the strictest possible limits or completely stopped; all excitement, violent emotions, etc., must be prevented as much as possible. The diet must be simple and easy of digestion, but at the same time nutritious. Many patients are, however, benefited by a very abundant supply of nourishment, and by cod-liver oil. Spirituous drinks should only be allowed in small quantities. Strong coffee and tea and strong cigars must be avoided. It is very important that the bowels should be kept regular ; for this purpose we must usually employ both aperients and clysters. The patients should be strongly urged to keep as much as possible in the open air. When practicable, a prolonged sojourn in a mountainous region at a moderate elevation, or at the sea-side, will be useful; it is also advisable that the winters should be passed in the South, in the Riviera, the southern Alpine valleys, etc. The regulation of the bodily exercise is usually a very important question. Much harm can easily be done by ex- ceeding the permitted amount of exercise. I have repeatedly known patients, who had begun to improve, to be thrown back for a long time by an unduly prolonged walk. The idea which is entertained by many patients, that a commencing muscular weakness and stiffness can be removed by forced exertion of the MYELITIS. 465 muscles, must be energetically combated. I believe that patients who are still capable of moving about, should be allowed to take only so much exercise as they can indulge in without fatigue; as soon as they begin to grow tired, they must rest for a time, and may then resume the walk or other movement. In many cases, it is true, exercise is out of the question—the patients are bed-ridden, paralyzed. Such patients must make it a point not to lie always and exclusively on the back. Brown- Sequard wants to discard the dorsal position entirely, and to replace it by the lateral or abdominal position, but it is more than doubtful whether it will be possible to do so. For these paraplegic patients a wheel-chair may be used, though it is but an unsatisfactory substitute for walking exercise. It will at least enable them to enjoy the fresh air regularly and freely. In most of the cases of chronic myelitis, there are also a number of symptomatic indications that require attention. The most important of these is unquestionably the prevention of cystitis and decubitus; the closest attention must be paid to this point under all circumstances. We have already dis- cussed it at length on page 193 et seq., to which the reader is referred. Another frequent and important indication is the relief of the pains—of the lancinating pains of tabes, the spontaneous and radiating pains of myelitis transversalis, etc. These will very frequently resist all imaginable remedies, and prove a source of great annoyance to the physician, as well as of torment to the patient. The most rapid relief will always be obtained from hypodermic injections of morphine, but the dangerous conse- quences of the constant use of this drug must deter us from too frequent employment of the injections. After morphine the most serviceable drugs are bromide of potassium, quinine, bro- mide of quinine, zinc, and valerian. Cutaneous irritation, elec- tricity (the faradic brush or galvanic current), Preissnitz's com- presses, applications of chloroform, and frictions with veratrine, oil of hyoscyamus, and the like, often do good service. Similar remedies are employed with more or less success to relieve the manifestations of motor irritation, the painful spasms, reflex twitching, etc. For the paralyses, atrophies, anaesthesiae, etc., VOL. XIII.-30 466 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. which persist after the disease has run its course, electricity is the sovereign remedy. The general plan of treatment must of course, apart from the stage of the disease, be regulated chiefly according to the indivi- duality of the case, or the internal and external conditions of the patient. Any causative influences that may be discovered must be first of all removed, and the surroundings of the patient and his mode of life regulated. In the relatively recent cases, which are still in the early stages, the following course of treatment may be recommended after the above points have been attended to: mild, but nevertheless efficient hydropathic treatment, in conjunction with the employment of the galvanic current; in appropriate cases these may be combined with mild derivatives (blisters, dry cups, Preissnitz's compresses, etc.), change of air, and a sojourn in the mountains or at the sea-side. As the dis- ease progresses a course of treatment at the hot brine-springs, or in a hydropathic establishment may be tried, alternating with the treatment by galvanism; internally the persistent use of nitrate of silver. In the older cases, where the prospects of recovery are much less, a cautious alternation of the different methods of treatment is requisite. During the winter such patients should be treated by galvanism, and should also be made to employ cautiously cold applications combined with frictions. In the summer the thermal brines, cold-water treatment in the mountains, and per- haps also the thermae, may be tried. In addition to these meas- ures, various internal remedies may be tried, the symptomatic indications must be carefully fulfilled, and decubitus and cystitis must be guarded against. Under all circumstances, the employment of psychical influ- ences constitutes an important part of the treatment of chronic myelitis. The courage of the patient must be maintained, his confidence in the various methods of treatment strengthened, and his hopes constantly aroused and reawakened. Unfortu- nately the physician must in only too many cases rest contented when he can succeed in this task, which is itself by no means a light one, and brighten the miserable existence of the patients by an occasional glimmer of fresh hope. MYELOMALACIA. 467 10. Simple Softening of the Spinal Cord.—Myelomalacia. Brown-Sequard, Lectures, etc., on Paralysis of the Lower Extremities, p. 34. 1861. —Hennig, Fall von Erweichung des Riickenmarks. Arch. d. Heilk. I. S. 188. 1860.—Leyden, L. c. IL S. 38, 51 ff.—Panum, Experim. Beitr. z. Lehre von d. Embolic Virch. Arch. Bd. 25. S. 308. 1862—Hasse, L. c. 2 Aufl. S. 706.— Hammond, L. c. 3. edit. 1873. p. 463.— Willigk, Ueber d. Verhalten d. Nerven- zellen bei embol. Processen im R.-M. Prager Vierteljahrschr. 1875. in. S. 41. —D. J. Hamilton, On Reflex Paralysis and Urinary Paraplegia. Brit, and For. Medico-chir. Rev. Tome I. VII. p. 440. 1876.— Em. Bertin, Ramolliss. d. 1. moelle. Diet. Encyclop. des. Sc. meU II. Ser. T. VIII. p. 751. 1854. It may perhaps seem venturesome in the present state of our knowledge, to devote a special chapter to simple, non-inflam- matory softening of the spinal cord. We are still deplorably ignorant with regard to this affection, and hence the chapter will necessarily be a short one. That there really is, however, a non-inflammatory as well as an inflammatory softening of the spinal cord, must unquestionably be admitted ; it is demon- strated both by convincing analogies with similar processes in the brain, and by a certain number of anatomical and clinical facts. It is in order now to describe as accurately as possible, the anatomical changes and clinical history of this simple soften- ing, in order to differentiate it more positively from the inflam- matory affection. It seems to us particularly desirable to protest against the misuse of the word "softening," which is at present very com- monly applied to simple and even to acute inflammation. The terms softening and inflammation are by no means synonymous; not every softening is the result of inflammation, and not every inflammation leads to softening. The latter certainly occurs as a concomitant and a consecutive lesion in many forms of spinal inflammation, but it is by no means an essential part of them. We might, with just as much and perhaps even more reason, employ the term "hyperaemia," or "exudation," or "fatty de- generation," to designate inflammation. It is unquestionably better to discard entirely the use of the term "softening" for inflammatory conditions; this would be the best way to avoid misunderstandings. If used at all, it 468 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. should be reserved for the simple, non-inflammatory processes of softening, which are undoubtedly met with in the cord ; for these, it seems to us perfectly appropriate. It is true that the existence of these non-inflammatory changes has not yet been demonstrated with that degree of positiveness, which is desirable, and that we do not, as in the case of the brain, possess experimental proofs or clinical observations equiva- lent to them (cerebral emboli) for the most important forms of the softening. With respect, moreover, to the histological pro- cesses, and more particularly the points which distinguish the simple from inflammatory softening, we are as yet to a great ex- tent in outer darkness. Still, it seems to us that there has been too great a tendency in recent times to class under myelitis all lesions of the spinal cord characterized by softening, even though the characteristic histological evidences of inflammation be by no means always present. A few brief remarks concerning simple softening may be made now, principally with a view to incite others to further studies and investigations. The pathogenesis of the affection is enveloped in numerous obscurities. The softening which is due to thrombosis and em- bolism is probably the easiest to explain, in consequence of its analogy with the corresponding cerebral process. The effects of embolism of the abdominal aorta, from which we might expect the most valuable information in this connection, have not yet been sufficiently studied. It has been stated, that white softening of the cord has been found as one of these effects. Embolism of the small arteries of the cord is very rare, and would at all events produce only very circumscribed centres of softening. Panum, Vulpian and others have studied it experi- mentally, and have demonstrated the development of small cen- tres of red softening as the result of such emboli. Leyden found small, inflammatory foci produced by emboli, which were derived from ulcerative endocarditis. Willigk, in his recent investiga- tions, discovered no centres of true softening in the neighborhood of the obstructed vessels, but found instead of softening, in some cases a hyperplasia of the connective tissue with atrophy and destruction of the ganglion-cells, and in others a peculiar "col- MYELOMALACIA. 469 loid" degeneration of the ganglion-cells without increase of the connective tissue. All this requires further study and investiga- tion. The case of multiple thrombosis of the small vessels of the cord, reported by Hamilton, is a remarkable one. . There is little reason to doubt that a severe affection of the walls of the vessels, such as atheroma, calcification, or sclerosis, diminution of the vascular lumen, etc., can also cause similar retrogressive metamorphoses in the tissue of the cord, which finally terminate in softening. Second in order of importance comes the softening produced by slow compression of the cord. We have already (p. 323) stated, that a true myelitis (compression-myelitis, inflammatory softening) of the affected portion of the cord is almost without exception excited by such compression. Nevertheless, excep- tions do apparently occur. The fact that in not a few cases of compression of the cord, the microscope reveals in the softened mass no granule-cells, no hyperplasia of the connective tissue, no proliferation of the nuclei, but only swollen and disinte- grated nerve-elements, speaks unmistakably in favor of the view that the process is sometimes, at least for a time, one of simple softening. There is nothing forced in the theory, that the is- chaemia of the cord caused by the compression results in simple softening, and that this condition may persist as long as the compressing mass does not develop strongly irritating qualities, and implicates the cord only very gradually and slowly. This, too, requires verification. It is still very doubtful whether a spontaneous simple soften- ing ever occurs. At all events, the older observations which are adduced in favor of it, are by no means conclusive, since they lack the microscopical examination which alone can determine positively the absence of inflammatory changes. A senile softening of the cord is spoken of, but we must con- fess that the supposed examples of it contained in medical liter- ature do not by any means convince us of its actual existence. Still, it is certainly possible that the vascular affections, which are so common in old age, may occasionally give rise to small spots of softening in the spinal cord. At all events, however, the fact requires more accurate authentication. 470 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. We may mention, finally, that Hammond assumes sexual ex- cesses to be the cause of simple softening in a few cases. Under these circumstances there is but little that can be said concerning the special pathological anatomy of myelomalacia; there is always danger of confounding the inflammatory with the non-inflammatory foci of softening. In fact, macroscopically they resemble each other very closely. The spinal cord is soft and pulpy, and swells up above the level of the cut; in pure cases it is white, and in the later stages becomes creamy, milky, and fluid. Pronounced red softening can, however, also occur in consequence of the blood being dammed back in the ischaemic vascular territories. When the fatty degeneration assumes spe- cial prominence, the softened spot may acquire a more yellowish color, and present the appearances of yellow softening. At its boundaries, the softened spot usually merges imperceptibly into the normal tissue. It is difficult to decide whether the case of Hennig should really be classed as simple softening; if it must be, it would present a sort of gelatinous or colloid degeneration, with fatty degeneration of the vessels. The microscopical examination can alone furnish conclusive evidence of the inflammatory or non-inflammatory nature of the softened spot. Unfortunately, however, we do not as yet possess a sufficient number of accurate reports bearing on this point. Wherever we find a large number of cells containing fat granules, tensely distended blood-vessels, numerous young cells, increase of the interstitial tissue, swollen axis-cylinders, etc., we are justified in assuming positively the inflammatory character of the process. On the other hand, when these characteristics are wanting, and we only find simply swollen and disintegrated nerve-fibres, gan- glion-cells in a state of glassy swelling, a few cellular elements and fat-granule-cells, and a small quantity of fatty detritus, we must diagnose a simple softening. Further and searching in- vestigations of this point are, however, very much to be desired. The symptomatology of simple softening is also exceedingly obscure. In the clinical histories we meet with the picture of a more or less acute or subacute myelitis unattended by fever, and presenting only a few non-essential modifications, that are of MYELOMALACIA. 471 little help in the diagnosis. According to Hammond, tne absence of motor symptoms of irritation is particularly distinctive of simple softening. That this, however, does not hold true of all cases without exception, is demonstrated by the histories of many cases of acute myelitis. In the commencement of the disease a sensation of numbness and a feeling of weakness are experienced, which gradually be- come more intense, but are not accompanied by pains, muscular twitchings, etc. Progressive weakness of the bladder is added to the paralysis ; the anal sphincter is also affected, and the reflex excitability seems diminished. In the later stages of the affection we have the complete pic- ture, modified only in accordance with the localization of the softened spot, of a severe sensory and motor paraplegia, with paralysis of the sphincters, bed-sores, and the well-known termi- nation. According to Brown-Sequard and Hammond, the absence of motor and sensory signs of irritation is conclusive for the diag- nosis from inflammatory softening. According to them, there are no pains, no spasms, no hyperaesthesia, and no increase of the reflex activity. Personally, however, we cannot suppress a slight doubt as to the pathognomonic importance of the absence of these symptoms, and feel ourselves forced to look to the future for the possibility of a more exact diagnosis of simple myelo- malacia. The prognosis of the affection must be decidedly unfavorable, when the centres of softening are at all extensive. The very small foci, which give rise only to a very limited array of symp- toms, or perhaps to none at all, do not, as a rule, call for a prog- nosis. The treatment of simple softening can also be disposed of in a few words. It must be carried on essentially according to the rules laid down for the non-febrile forms of myelitis without prominent inflammatory symptoms. Brown-Sequard recommends, besides iron and quinine, chiefly iodide of potassium, which is best administered in a bitter decoc- tion (cinchona, Colombo, rhubarb); strychnine only with the greatest caution; no ergot! no belladonna ! He believes, further, 472 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. that the cold douche or shower-bath to the back is indicated, as is also confinement to the dorsal position. In general, abundant and nourishing food, when possible moderate exercise, and the employment of the galvanic current, will be found advantageous. 11. Multiple Sclerosis of the Spinal Cord (and Brain).—Mtd- tiple, nodular Sclerosis; disseminated, multilocular, insu- lated Sclerosis of the Central Nervous System.—Sclerose en plaques disseminees.—Insular Sclerosis. Cruveilhier, Anat. pathol. Livr. 32, 38. 1835-42.— Charcot, Klin. Vortr. fiber die Krankh. des Nervensyst. Deutsch von Fetzer. 1874.—Hasse, 1. c. 2. Aufl. S. 708.—Rosenthal, 1. c. 2. Aufl. S. 147.—Hammond, 1. c. 3. Edit. p. 637.—Ley- den, 1. c. II. S. 375.—Bernheim, Diet, encyclop. des Sc. med. II. Se*r. T. VHI. p. 707. Frerichs, Ueber Hirnsklerose. Haeser's Arch. X. S. 334. 1849.—Valentiner, Ueber Sklerose des Gehirns u. R.-M. Deutsche Klin. 1856. No. 14 bis 16.—Leyden, Ueber graue Degen. des R.-M. ibid. 1863. No. 13. — Rindjleisch, Histol. Detail zur grauen Degen. Virch. Arch. Bd. 26. S. 474. 1863.— W. Zenker, Sklerose des Gehirns u. R.-M. Zeitschr. f. ration. Medic. 3. Reihe 24. Band. 1865. —• Vulpian, Notes sur la sclerose en plaques, etc. L'Union me"d. 1866. Nr. 67-72.—Charcot, Gaz. des hop. 1868. Nr. 102, 103.—Ordenstein, Sur la paralys. agit. et la scl6r. en plaques generalisee. These. Paris, 1867.— Bourneville, Mouvem. m6d. 1868. Nr. 13-25, u. 1869, Nr. 27 bis 38.—Bourne- ville et Guerard, De la sclerose en plaques diss6m. Paris, 1869.—Guerard, Essai sur la sci. en plaques. These. Paris, 1869.—Liouville, Gaz. m6d. 1870. Nr. 19 u. 20.—Joffroy, ibid. Nr. 23, 2L—Magnan, ibid. Nr. 14. p. 183.—Leo, Beitr. zur Erk. der Sklerose des Gehirns u. R.-M. Deutsch. Arch, fiir klin. Medic. IV. 1868.—H. Schuele, ibid. VII. S. 159. 1870, u. VIII. S. 223. 1871. W. Leube, ibid. VIII. S. 1. 1870.—u. Klin. Ber. aus dem Krankenhaus zu Jena. 1875. S. 111.—Zenker, Deutsch. Arch. f. klin. Medic. VIII. S. 126. 1870. —Ebstein, Spinale Form der multipl. Sklerose. ibid. IX. S. 528, u. X. 595. 1872.—Kelp, Ueber Hirnsklerose. ibid. X. S. 224. 1872.—Buchwald, ibid. X. S. 478. 1872.—Otto, ibid. X. S. 531. 1872.—Berlin, ibid. XIV. S. 103. 1874. —Engesser, ibid. XVII. S. 556. 1876.—Baerwinkel, Arch. d. Heilk. X. S. 590. 1869.—C. Hirsch, Deutsch. Klin. 1870. Nr. 33-38.—Radlick, Fall von Sclerose en plaques. Diss. Berlin, 1874.—Pohl, Sklerose des Gehirns u. R.-M. Diss. Berlin, 1874.— Westphal, Ueber eine Affection des Nervensyst. nach Pocken u. Typhus. Arch. f. Psych, u. Nerv. III. S. 376.1872.— The same, Neue Charitg- Annalen. I. Jahrg. 1874. S. 427.— Otto, Casuist. Beitr. zu den nervos. Nach- MULTIPLE SCLEROSIS. 473 krankh. der Pocken. Virchow-Hirsch, Jahresbericht pro 1872. II. S. 23.— Jolly, Ueber multiple Hirnsklerose. Arch. f. Psych, u. Nerv. III. S. 711. 1872. —Chvostek, Wien. med. Pr. 1873 u. 1874.—Allgem. Wien. med. Zeit. 1875. Nr. 11-20.— W. Moxon, Eight Cases of Insular Sclerosis. Guy's Hosp. Rep. XX. p. 437. 1875.—Holliere, Sur quelques points du diagnost. d. 1. sclfir. des centr. nerv. Lyon m6d. 1875. Nr. 28.—F. Schultze, Ueber das Verhaltniss d. Paralys. agit. zur multiplen Sklerose des R.-M. Virch. Arch. Bd. 68. 1876.—Christidis, Ueber multiple Sklerose, etc. Diss. Wurzburg, 1875.—E. Killian, Ueber einen Fall von diffuser Myelitis chronica. Arch. f. Psych, u. Nervenkrankh. VII. S. 28. 1876.—Putzar, Fall von multipl. Sklerose des Gehirns u. R.-M. Deutsch. Arch, fur klin. Med. XIX. S. 217. 1877. History. The disease now generally known under this name has only figured in the annals of science for a few decades, and only be- came thoroughly understood during the last decennium. The first minute account of the affection appeared, accompanied by excellent illustrations, in the large atlas of Cruveilhier (1835 to 1842). A similar case, observed by Tuerck in the year 1855, was entirely lost in a clinical point of view. The clinical history of circumscribed sclerosis begins with the work of Frerichs (1849), which was very greatly enlarged and perfected by Valentiner (1856). A few years later, the pathologi- cal anatomy of the disease was greatly cleared up by the labors of Rindfleisch (1863), Leyden (1863), and Zenker (1865). The French works, which followed those of the above-named investi- gators, have, however, undoubtedly contributed most to our knowledge of the disease. They defined more sharply the morbid picture presented by the affection, gave due prominence to its essential points, and secured for it a place in pathology as a legitimate and recognizable disease. After the appearance of the first works of Vulpian and Charcot (1866-1868), the latter in par- ticular contributed very greatly to the enlargement of our knowl- edge of multiple sclerosis; with the help of his pupils (Orden- stein, 1867, Bourneville and Guerard, 1869) he has studied it in an exhaustive manner, from almost every point of view. About the same time there appeared in Germany an excellent account of a case observed by Leo, which was the first of a long 474 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. list of careful and full reports (by Schuele, Leube, Ebstein, Kelp, Buchwald, Otto, Berlin, Engesser, Baerwinkel, Hirsch, West- phal, Jolly, Chvostek, and others). These reports have contrib- uted not a little to the enlargement of our knowledge and to the elucidation of different important questions. In France, also, numerous isolated observations have been recorded since the above date (by Liouville, Joffroy, Magnan, and others). In Eng- land, however, until the appearance of the recent work of Mox- on (1875), the disease was overlooked and almost entirely unknown. Through the labors of the above-named writers, we have ac- quired a pretty accurate knowledge of the affection, especially in its practical relations, although numerous questions of detail, some of them not unimportant, are still in an unsettled state, while in the domain of therapeutics in particular almost every- thing still remains to be done. Definition.—Multiple sclerosis is a form of chronic myelitis and encephalitis. It is characterized, anatomically, by the development of numer- ous, insulated sclerotic nodules, varying in size, and of a chronic inflammatory nature, which are scattered irregularly throughout the entire cord, and usually also throughout the entire brain, but which seem to possess, nevertheless, certain spots of predilection. Sometimes a less intense, but more diffuse sclerosis unites the different nodules with one another. Clinically the manifestations of the disease are very variable and manifold, assuming almost protean shapes. This is the nat- ural result of the development of the nodules in so many differ- ent localities, which are seemingly determined by accident. Motor pareses and paralyses are never wanting, while disturb- ances of sensibility belong to the less constant symptoms. Dis- turbances of co-ordination (ataxia) are very frequently observed, and a peculiar, exceedingly characteristic tremor, which accom- panies voluntary movements and progressively increases, is almost regularly present. These symptoms are accompanied by a more or less extensive list of bulbar and cerebral symptoms, the most prominent of which are a peculiar disturbance of speech (scanning, monotony of voice), noisy inspiration, impairments of MULTIPLE SCLEROSIS. 475 sight, nystagmus, pronounced psychical disturbances of varying degrees, and apoplectiform attacks. We have to deal here with an affection that runs an exceed- ingly chronic course—a course moreover which always goes on progressively from bad to worse. Very considerable fluctuations in the severity of the symptoms do occur, it is true, but a per- manent improvement is rarely observed. For practical reasons we shall discuss together the multiple scleroses of the cord and of the brain. The exclusively spinal form of the affection is rare, and the characteristic morbid pic- ture belongs essentially only to the cerebro-spinal form. Etiology and Pathogenesis. Hereditary influences may in many cases be regarded as pre- disposing to multiple sclerosis. Duchenne observed hereditary transmission of the disease in one case, and I have myself observed the same thing. Frerichs saw a brother and sister who wrere suffering from the disease, and a similar case has come under my own observation. The general neuropathic tendency may per- haps play its well-known role here also, as hysteria and other nervous disturbances sometimes, though relatively seldom, pre- cede the affection. In other respects but little is known concern- ing the influence of this diathesis. According to Charcot's statements, the female sex presents a considerably greater predisposition to the disease than the male sex. The fact that his observations were partly conducted at the Salpetriere (Women's Hospital), will explain the discrepancy between his statements and those of other observers. Chvostek observed sixteen cases, of which ten were men and six women. Of the nine cases observed by myself, four were men and five women. Hence there is no marked difference between the two sexes in this respect. It is certain, however, that the affection is pre-eminently a dis- ease of youth and middle age. It most frequently makes its appearance during the second and third decades of life ; it rarely or never appears after the forty-fifth year, and relatively few 476 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. cases have been known to occur in children under ten years of age. Among the direct causes, we must mention first, " catching cold,^ the influence of which has been repeatedly demonstrated. The disease has been known to develop after sudden and severe exposure ( KaSZ ; contraction slow, tonic, prolonged). In the course of two or three months the galvanic irritability sinks again, often far below the normal standard, but retains the characteristic qualitative alterations, and these constitute the main point in the examination. In the course of one or two years and more after the beginning of the disease there is gener- ally nothing but a trace of galvanic irritability in the muscles ; but not unfrequently the characteristic sluggish jerking can still be shown here too, and, indeed, it is often possible to prove, by means of the galvanic current, that muscular substance is still present where this was thought to have entirely disappeared. In still older cases there is generally nothing definite to be estab- lished. In those muscles that do not atrophy, a greater or less simple diminution in the faradic and galvanic irritability is gener- ally found ; the same thing is true in all those muscles and nerves which have regained their mobility up to a certain point; in these the reaction of degeneration can, of course, no longer be demonstrated. It is desirable that these relations should be more systematically tested than has yet been done. To be sure the material is not easily obtained, and is only to be had by a fortunate chance, and the examination of the unruly and screaming little patients is attended with great difficulties. It is also often out of the question exactly to localize the current in single muscles, for the abundant layer of fat, in children, the well-preserved sensibility, the resistance of the patient, etc., make it much more difficult to determine the contractions. The cases which occur in adults are too rare to furnish sufficient material for observation, which can best be obtained in large children's hospitals. I regard the reaction of degeneration as quite a constant manifestation in the spinal paralysis of children, one which can generally be dis- tinctly shown only in the first years of the disease, often not being recognizable with certainty at a later period. I have, at least, never yet, amongst a large num- ber of cases, failed to find the reaction of degeneration on careful search. The above statement is based upon the examination of cases after the lapse of four, eight, and fourteen weeks, after six, twelve, twenty-two, and twenty-four months, POLIOMYELITIS ANTERIOR ACUTA. 693 and from that up to several, or even many years. Furthermore, it also entirely corresponds with the known results of electrical examination in the same affection in adults. The changes in the bones and joints which arise in the course of the disease are almost equally important with the changes just described in the muscles. The bones of the paralyzed limbs are materially retarded in their longitudinal growth, so that, in the legs for instance, differences of from 3 to 20 cm. (1.1 to 7.8 inches) may occur, as compared with the healthy side. The same tiling is true in the upper extremities. The long bones, furthermore, remain much thinner than normal; they not rarely become po- rous and inclined to bend, yielding, and friable. Their epiphy- ses and processes grow smaller and less distinct; the shoul- der-blade and the patella often remain far below their natural size, the paralyzed hand or foot is shorter, narrower, and thinner than the sound one; even the pelvis may remain considerably behind-hand in its development, being below the normal measure- ments of circumference and height. It is a remarkable fact that the interference with the growth of the bones is by no means always in direct proportion to the atrophy of the muscles of the same extremity ; sometimes the one and sometimes the other is in the ascendancy, and the inter- ference with the growth of bone may persist in spite of the dis- appearance of the paralysis (Volkmann). I have myself had occasion to observe this fact. Volkmann also, not without reason, counts a case of " unilateral paralysis of the face," observed by him, as belonging to the spinal paralysis of childhood. Other cases should be tested with reference to similar connection. The joints become deformed, abnormally movable, partly through disappearance of the articular extremities of bone and of cartilages, partly through relaxation and stretching of their ligamentous apparatus. The movableness of the limbs is thus often rendered very great, so that patients can frequently execute all kinds of unusual movements and wonderful dislocations of the limbs. The changes in the skin must also be noticed. The skin 694 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. becomes flaccid, withered, doughy, sometimes dry, scaly, brittle. The most striking characteristic, however, is the coldness and cyanosis which is uniformly observed in the paralyzed limbs. Heine carefully measured the lowering of temperature in many cases, and was able to prove very marked differences as com- pared with the healthy extremity. There can hardly be a doubt that this lowering of temperature and cyanosis are due less to diminished nutrition in the paralyzed limbs than to vaso-motor paralysis, and it would be interesting to note whether, in the first stages of the disease, there is not a temporary elevation of tem- perature. I demonstrated this to be the case in one adult pa- tient. By means of the conditions above described—the paralysis and atrophy of muscles, the interference with the growth of bones, the changes in joints—all severer cases lead to paralytic contractures and secondary deformities, which may cause the most revolting distortions of the limbs, of the spinal column, etc., and are most graphically set forth by Heine in numerous illustrations. The atrophy and secondary contraction of the muscles, the laxness and malformation of the joints, the curva- tures of the spine, all combine to produce the most deplorable and extraordinary cripples, such as, in countless numbers, excite the sympathy of the passers-by upon the highways and in the market-places. What are called paralytic contractures are especially effect- ive in the development of these deformities. According to Heine, these do not begin to develop until the children com- mence to use their limbs and drag themselves about with them, whether well or ill. This statement, however, may not be so rigidly correct. The most varied forms of club-foot occur (talipes varus, val- gus, equinus, and calcaneus), and various combinations of the same (most frequently of the equinus and varus). Retrocurva- ture of the knee, inversion and eversion of the same, are also met with, as well as contractures in the knee- and hip-joints, kypho- sis, lordosis, and extreme instances of scoliosis. In the upper extremities the deformities are liable to be much less serious; the hands and fingers are generally found flexed, the shoulder- POLIOMYELITIS ANTERIOR ACUTA. 695 joint gradually becomes immovable, the pectoralis and the latis- simus dorsi are more or less contracted. The occurrence of contractures is chiefly the result of a high degree of paralysis and degenerative atrophy of the muscles. Considered in detail, the more precise method of development may be threefold. 1. By far the most frequent cause of paralytic contracture, in these cases, is the continued approximation of the points of at- tachment of the muscles, induced partly by the weight of the parts, partly by external pressure in walking, standing, sliding, etc. This point has been thoroughly discussed by Volkmann, on the basis of Hueter's investigations, and the former seeks to ex- plain almost all paralytic contractures on mechanical grounds. According to him the deformities are developed partly by reason of the weight of the limbs concerned and the position which they assume when at rest, partly through the fact that limbs, articu- lar extremities, and articular surfaces are subjected to an abnor- mal burden, when called into use, and are thus gradually pressed into abnormal positions. In both instances the points of attach- ment of certain muscles would be more or less permanently ap- proximated to each other, and thus a gradually increasing nutri- tive shortening of the same occurs, a permanent contracture and deformity. This must certainly be the explanation of all those contrac- tures and deformities which arise when all the muscles surround- ing a joint are completely paralyzed, or when the deformity and contracture take place in the line of traction of those very mus- cles which are especially paralyzed. Talipes equino-varus is the form most easily explained; the foot, being left to its own weight, assumes this position, which becomes more and more fixed the longer the patient remains in bed, or the longer step- ping upon the foot, which would counteract this deformity, is avoided, or the patient merely steps upon his toes. Paralytic talipes valgus occurs when the patient begins to walk again very soon after his attack, and steps on the foot while there is more or less complete paralysis of the mus- cles of the leg ; he then steps on his entire sole, and the foot, which is loose in its joints, gives way, toward the outer side 696 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. (knickt soweit nach aussen urn), until prevented, by physiologi- cal restraints, from bending any further. Even talipes cal- caneus is said to be due principally to mechanical causes, inasmuch as when the muscles of the calf are entirely para- lyzed, the individual steps upon the os calcis, and this is then gradually and mechanically pushed forward; by this means the distance between the points of attachment of the muscles of the sole is also diminished, and for this reason the plantar curva- ture of the sole reaches a peculiarly high degree of development in this variety of club-foot. It appears to us, however, that here the co-operation of the antagonistic muscles of the front of the leg, which are less paralyzed, is of material significance. Retro- curvature of the knee is brought about by the fact that the joint, deprived of its power of fixation by the muscles, is extended backwards as far as its physiological restraints will admit, in order to transform the leg into a firm support for the body. In the upper extremities, too, the majority of contractures and de- formities are developed in the same simply mechanical manner. 2. But contractures may also furthermore be brought about by the fact that the antagonists of the paralyzed muscles remain effective. In every voluntary action of the same their points of attachment are approximated to each other, and there is no mus- cular power present to draw them apart again; in many cases, indeed, this is accomplished through the weight of the parts or other mechanical means ; but where this is not the case these muscles fall into permanent nutritive shortening, and thus in- crease the deformity. A certain degree of participation in the production of paratytic contractures and deformities, even though it be but subordinate, must certainly be attributed to this active mobility of antagonistic muscles ; thus in talipes calcaneus, thus in contractile bending of the knee-joint with complete paralysis of the quadriceps extensor muscle. 3. Finally, a certain part in the production and fixation of paralytic contractures may be attributed to the proliferation of interstitial connective tissue and its subsequent retraction, which takes place with the degenerative atrophy of the muscles. This, however, would seem to be of subordinate significance. Mechanical causes certainly play the principal role, in this POLIOMYELITIS ANTERIOR ACUTA. 697 matter, and the manifold and adventurous methods of locomo- tion to which many of these patients accustom themselves, as well as the extremely varied localization and extent of the paralysis, account for the fact that the most wonderful and striking mal- formations and crippled conditions occur in these very patients. So far as concerns the pathogenetic explanation of the prin- cipal symptoms of the disease, as described thus far, these may doubtless all be explained in one way. The acute, inflammatory, and destructive lesion of the gray anterior horns is undoubtedly to be held accountable for all these disturbances. And indeed the lesion of the large ganglion-cells—and, we may add, the de- struction of all nervous channels of communication—seems to be of very special importance in this respect. It is difficult to make any more definite statement on this subject; still the application of what we now know about it seems pretty easily made; inasmuch as the spinal paralysis of children is one of the very conditions, among others, which has contributed to clear up our knowledge of the physiological functions of the gray anterior horns. According to all we know, the gray anterior horns are points of passage for direct motor conduction from the lateral columns to the anterior roots. Whether this conduction, in all cases, passes through large ganglion-cells, and whether these, there- fore, constitute a species of ganglionic centres (Knotenpunkte), is not yet certainly determined, but seems very probable. It seems, furthermore, tolerably certain that the large ganglion-cells exercise distinct trophic functions with reference to the nerves and muscles (and probably also to the bones, joints, etc.). It is still undecided whether all these ganglion-cells have at the same time motor and trophic functions, or whether, as Duchenne and Joffroy conjecture, and as Hammond also believes, there are two kinds, purely motor and purely trophic; nor is this point capa- ble of easy demonstration. At the same time the latter suppo- sition is not exactly improbable, and is certainly more convenient as applied to the theory of this and kindred diseases. The more or less complete destruction of the anterior gray horns, arising acutely, explains all the manifestations encoun- tered in quite a plausible manner: the paralysis by the destruc- tion of motor tracts, the atrophy of muscles and the hindrance 698 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. of the growth of bones, with their results, by the destruction of the trophic apparatus. The fact of the disease occurring in cer- tain circumscribed areas, and the immunity of certain groups of ganglia, explains the localization and extent of the paralysis, and the immunity of certain single muscles and groups of muscles. The acute inflammatory nature of the process accounts for the sudden appearance of the paralysis; the wide extension of the process over the spinal cord accounts for the initial fever and the wide extent of the paralysis at the beginning. The possibility of the partial resolution of the acute inflammation explains the rapid disappearance of the first stormy manifestations, and the later partial restitution of the muscles. Upon the supposition, therefore, that our views concerning the functions of the anterior gray horns are correct, the clinical manifestations of the spinal paralysis of childhood are in suffi- ciently satisfactory correspondence with the anatomical lesion. The remaining functions of the spinal cord, with few excep- tions, suffer no disturbances whatever, or but very slight ones. The sensibility of the skin is almost always intact. At the beginning of the affection there may be complaints of pain, par- sesthesia, and the like, here or there, but they are quite transi- tory manifestations which may easily be explained by the inflam- matory swelling and hyperemia in the initial stage. At a later period sensibility is generally intact everywhere. Only occasion- ally is there a slight, generally very insignificant dulness of sen- sibility complained of, especially a slight diminution of sensibil- ity to pain and lessened intensity of the sensation of tickling. This may be explained partly by an unusual extension of the diseased process to the central and posterior gray substance, partly, however, also by the great coldness and poor nutrition of the extremities. Reflex activity, on the other hand, always suffers very severe disturbances. It is a matter of course—on account of the degen- erative atrophy of the muscles and nerves, if for no other rea- son—that in all muscles which are severely attacked reflex action is completely extinguished; in these muscles no sign of reflex twitching can be aroused, either through the skin or through the tendons. But even in those muscles which are but slightly POLIOMYELITIS ANTERIOR ACUTA. 699 attacked, reflex activity is liable to be, at least temporarily, very much lowered or entirely extinguished. As the reflex circuits are generally considered as being located in the anterior gray substance, and reflex activity is thought to be connected with the large ganglion-cells, this condition of things is readily to be understood. Disturbances of the function of the bladder are not exactly rare during the first days ; there may be complete paralysis of the bladder, with retention of urine, but more frequently there are involuntary evacuations through incontinence of the bladder (and the same thing also holds true with regard to evacuation of the bowels). But these manifestations always disappear com- pletely again within three to eight days. Not seldom, however, especially in little children, a slight weakness of the bladder, with occasional incontinence, remains for a time. But this dis- turbance, too, is likely to disappear within a couple of weeks or months, leaving no trace behind, and in the later stages of the disease bladder disturbances certainly belong to the rarest ex- ceptions. The occurrence of bladder troubles is sufficiently accounted for by the occasional somewhat greater extension of the anatom- ical lesion within the gray substance. The sexual functions probably never suffer any disturbance, or at least only quite exceptionally and rather indirectly (through muscular paralysis, deformities, etc.). They generally remain quite intact, both in men and women. The same thing is true with regard to the functions of the special senses, the psychical and other cerebral functions. The vegetative functions are also usually carried on quite undisturbed. The appetite and digestion are good, bowels some- times rather sluggish. The general nutrition of the body is usu- ally admirable, if some other circumstance does not incidentally disturb it. b. Poliomyelitis Anterior Acuta in the Adult. When this malady attacks adults, we have essentially the same picture of disease presented to us as in children. It is 700 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. merely modified, in a non-essential manner, by the fact that the brain of the adult offers somewhat more resistance to the initial disturbances, that the general organism is not so highly disposed to fever, and that the growth of the bones is already completed, and the firmness of the joints is greater. Here, too, the disease begins with a general ill-feeling, with fever which is generally introduced with lively pain in the back and the extremities, and not rarely with paresthesia (formica- tion, a feeling of numbness, etc.). Severe cerebral symptoms are generally wanting ; general convulsions have never yet been ob- served, but severe headache, dulness, somnolency, and even slight delirium occur. Well-marked gastric symptoms, vomiting, etc., have been repeatedly met with. In some cases the fever reaches great intensity. Then the paralysis is developed, more or less rapidly, gene- rally in the course of a few hours, perhaps over night, more rarely not until after a few days. Just as in the case of children, it is more or less widely spread, complete, and with entire fiac- cidity of the paralyzed muscles. Now and then temporary weakness of the bladder is also de- veloped. Reflex action in the paralyzed muscles is either low- ered or extinguished ; though in some cases (thus with Frey) it may be retained, at least in those muscles which are not perma- nently and not completely paralyzed. These statements, how- ever, need further confirmation, through accurate examinations. An improvement of the general condition very soon sets in— after one or two days, rarely not till the eighth or tenth day— and then an improvement in the paralytic symptoms soon fol- lows. This, then, either gradually advances—usually not until after many weeks and months—to complete restitution of the paralyzed parts (temporary paralysis, case of Frey), or there is merely a partial restitution of the muscles, and the rest of them remain for a long time or permanently paralyzed. In these, as in the case of children, rapidly progressive atrophy then follows, with evidences of the reaction of degeneration, etc. The skin becomes lax and withered, the extremities cool and cyanotic. But there exists no trace of disturbances of sensation ; the patient never takes to his bed; the bladder troubles that may POLIOMYELITIS ANTERIOR ACUTA. 701 have existed soon subside ; the sexual function remains entirely normal; the general nutrition becomes quite good again. In the further course of the disease the evil consequences of the paralysis and atrophy of muscles inevitably show themselves in the shape of paralytic and myopathic contractures and the deformities resulting therefrom. These, however, never reach the same degree as in children, partly because in adults there is no interference with the growth of bones, and therefore no short- ening of limbs, because the greater firmness of the joints and their ligaments in adults prevents more serious deformities of the same, and because adults notice the deformities at their very be- ginning, and seek, by means of early treatment or careful man- agement, to remove them, or to hinder their further development, which is, of course, not nearly as much the case with children. The differences between acute spinal paralysis in children and that in adults actually reduce themselves down to this more slight development of the secondary and consecutive alterations in the latter. In all other respects, in the extension of the paral- ysis and atrophy to single or to many muscles, to one or to all extremities, or to the trunk, in the further course of the disease, in the insignificant influence of the same on the general well- being, etc., there is the most complete correspondence between the two, and it is therefore not necessary to add anything fur- ther with regard to the affection in adults. Course—Duration—Terminations. There is not much to be added to what has already been said on this subject. The typical and ordinary course of the disease —with its extremely acute beginning and very quick transition to a chronic stage, and with its gradual development of second- ary changes—is, in the majority of cases, pretty much the same, and has been described with sufficient minuteness in the preced- ing pages. With reference to the course of the affection, we will only add a few words on the subject of so-called temporary spinal paral- ysis. The term "temporary paralysis" seems to have been first used by Kennedy ; at least he is everywhere cited as authority 702 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. for the occurrence of temporary paralysis in children, and I think unjustly so, for scarcely any of his cases belong under this general head, and those which do belong under it were not "temporary." At the same time, such temporary forms -of acute spinal paralysis do seem to occur, as has been claimed by Duchenne, Volkmann, and others, and established by Frey with several undoubted cases. Neither can we see any reason why the restoration of motility, which in ordinary cases is regularly ob- served in a part of the muscles, should not in the lighter cases extend to all the paralyzed muscles. These temporary forms are distinguished from the permanent ones only in this, that in the course of some weeks, or a few months, complete restoration of all movements takes place, although, at the beginning, these cases were by no means to be distinguished from the severer forms ; they may even have been characterized by atrophy with loss of faradic irritability. These temporary forms occur in adults as well as in children. Nothing further need be added with regard to the duration of the disease. The termination of the disease seems always to be favorable, so far as its relation to life is concerned. There is no evidence that this disease, of itself, has ever directly induced death. In persons who have been affected with spinal paratysis death re- sults from accidental occurrences, the weakness of age, or any disease imaginable. Cases of this affection divide themselves, quite simply, into two classes: those in which complete recovery takes place—the temporary paralyses just mentioned, and those in which the recovery remains incomplete, that is, there is recovery with some remaining defect. This defect is due to permanently paralyzed and atrophied muscles, to the shortening and bending of limbs, etc. Daily experience teaches that this defect, even when it is very great, need not materially interfere v/ith the general well- being, nor the following of an occupation, nor the enjoyment of life. To be sure, there are also miserable cripples enough who have been placed in the saddest predicament for their entire lives by means of acute spinal paralysis, even though they may still enjoy a good appetite and a clear head. POLIOMYELITIS ANTERIOR ACUTA. 703 We would here again briefly call attention to one point. It would be well worthy of further attention to investigate whether persons who have once gone through with an attack of acute spinal paralysis do not show a greater disposition to diseases of the spinal cord, so that in later life they are attacked with other spinal affections. I have stated above that this has occurred but seldom in my own experience and that of others—so seldom, in comparison with the absolute frequency of the spinal paralysis of children in general, that I am rather inclined not to believe in any such causal relation. Still, this experience may prove to be deceptive, and, on closer investigation, the facts may turn out differently. Diagnosis. With the degree of knowledge at our disposal to-day, and in view of the great uniformity of the picture of the disease and its course, it is certainly quite easy to recognize acute poliomyelitis anterior. There will be no difficulty in making the diagnosis where the characteristic grouping of symptoms is present; where a sudden febrile affection, not unfrequently accompanied by severe cerebral manifestations, is quickly followed by a wide- spread paralysis of a high grade, with complete relaxation of the limbs; where early improvement of the general condition, and not long after partial recovery from the paralysis follows, while the more severely paralyzed muscles lose their faradic irritabili- ty and fall victims to rapid atrophy ; where reflex action is com- pletely extinguished, but cutaneous sensibility and the functions of the bladder and rectum are entirely preserved. Under these circumstances it will not be necessary to wait for secondary con- tractures and deformities, for the arrest of the growth of limbs, etc., to confirm the diagnosis. But, even in the lightest, and what might be called fragmen- tary cases, it will, as a rule, be possible to make a diagnosis with greater or less certainty by means of a thorough examination of the nerves and muscles, careful regard to the development of the disease, and all other circumstances relating thereto. During its latest stages, likewise, the disease may still be recognized by 704 ERB —DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. its sequels, and, unless all points in the history of the case going to show the method of its development are wanting, may be pro- nounced upon with certainty. Here, however, it is easier to imagine the possibility of confounding it with the sequels of other kindred forms of disease. We must, however, as a matter of course, be careful not to place in this category every instance of spinal paralysis arising in childhood, even if accompanied with atrophy. This is, alas, still too often done. But such a stretching of the idea of what is included under " spinal paralysis of childhood " is not justifi- able at the present day, and it must be positively required that in the diagnosis the characteristic signs of the disease be ad- hered to. Acute poliomyelitis anterior must be distinguished from the following forms of disease : From acute, central, or transverse myelitis. Here the dis- tinction will not generally be difficult, on account of the disturb- ances of sensibility and of the bladder and rectum which are almost invariably present in these diseases; on account of the occurrence of bed-sores; on account of the fact that there is usually increased reflex action and usually no atrophy. The principal marks of distinction are the disturbances of sensibility and of the bladder, also the course of the affection. Haematomyelia, or hemorrhage into the gray substance, may present great similarity to acute spinal paralysis, on account of the rapid development of the paralysis, the subsequent atrophy and reaction of degeneration, the absence of reflex action, etc. But the non-febrile beginning of the former, the entirely sudden, apoplectiform appearance of the paralysis, the almost invariable disturbances of sensibility, the paralysis of the sphincters, the bed-sores, etc., insure the diagnosis of hemorrhage. Myelitis from compression—such, for instance, as not rarely leads to rapidly developed paraplegia in Pott's disease—can only be confounded with poliomyelitis anterior by reason of great inattention, or in quite exceptional cases. The disturbances of sensibility, the heightening of reflex excitability, the paralysis of the bladder, the spasmodic manifestations in the lower ex- tremities, the absence of atrophy and the reaction of degenera- POLIOMYELITIS ANTERIOR ACUTA. 705 tion, the presence of affections of the vertebral column, of lively pain, of disturbances of the general health, etc., are enough to determine the presence of this form of disease. The cerebral hemiplegia, which is not rare in children and quite frequent in adults (especially what is called "hemiplegia spastica infantilis"), is to be distinguished from our disease by the more or less complete demonstration of the following symp- toms: headache, dizziness, affection of the cerebral and spinal nerves, strabismus, a stupid expression of countenance, paralysis with tension of the muscles and spasmodic contractures, increased reflex excitability of the tendons, no atrophy or but a very slight degree of the same, the preservation of electrical irrita- bility, involuntary additional movements on voluntary motion of the sound side of the body, stiffness and extension of the joints, the bones not at all or but little shortened, more or less consid- erable disturbances of sensibility, no scoliosis, etc. These signs are also sufficient for a differential diagnosis, even when such a cerebral affection is bilateral. Progressive muscular atrophy is to be distinguished from acute spinal paralysis simply by its chronic development, the progressive course of the disease, and the lesser prominence of the paralysis ; furthermore, by the retention of electrical irrita- bility, the hereditary relations of the disease, etc. Pseudo-hypertrophy of the muscles is likewise to be recognized by the slow development of the disease, the absence of severe paralysis, the increase in the volume of the muscles, and the absence of any atrophy. The spasmodic spinal paralysis of children, two cases of which I have reported,1 is very easily to be distinguished by the slow, insidious and unnoticed development of paresis (which seldom goes on to complete paralysis), by the muscular tension and contractions, the increased irritability of the tendons, and the absence of atrophy and the reaction of degeneration. The distinction between our disease and the paralysis of chil- dren following delivery,'1 which, at a certain stage, may have 1 Virchow's Archiv. Bd. 70. Heft 3. 1877. 2 See this Cyclopaedia. Vol. XL {Erb, Diseases of the Peripheral Nerves), p. 561. VOL. XIII.—45 706 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. some resemblance to the spinal paralysis of children, of limited localization, is generally determined by the history of the case ; and when this is not true, by the characteristic localization, as well as by the disturbances of sensibility that are present; fur- thermore, by the absence of a febrile initial stage, the occurrence of the trouble at an early age, etc. The peripheral paralyses of single groups of muscles and nerves through pressure, faulty position, tight bandaging, etc., such as not rarely occur in children, will be correctly pronounced on by demonstration of the cause, by the absence of the charac- teristic initial stage, by the strict localization of the trouble in a definite peripheral nerve-domain, by the presence of disturbances of sensibility, by the rapid, favorable result, etc. For the distinction between this and subacute and chronic poliomyelitis, see the following section. Prognosis. Acute atrophic spinal paralysis does not appear ever directly to threaten life; its prognosis is therefore absolutely favorable, so far as life is concerned. The first onset, it is true, often looks dangerous, and it does not appear exactly impossible that death may occasionally follow during the initial stage. It is a ques- tion which as yet remains undecided, whether some cases of death from "convulsions" do not belong in this category. This can only be decided by a very careful and intelligent examina- tion of the spinal cord in such cases. I was forcibly struck by the fact that in von Heine's histories of his patients it repeatedly appears that one or another child in the same family had died of convulsions. The prognosis with reference to complete recovery is quite different. Here it may be pronounced as almost absolutely un- favorable. The "temporary" forms of the disease are so rare that they can hardly be taken into consideration; in fact, the best we can do, almost always, is to make a prognosis of recov- ery with greater or lesser remaining defects. The parts that do not regain their mobility in the first two or three months, or within the first six months, seldom do so at a later period. POLIOMYELITIS ANTERIOR ACUTA. 707 There is then little to be expected in the way of direct attempts at recovery, although slight and partial improvements, even at later periods, are not exactly rare. At the same time the usefulness of the extremities may still be materially improved through appropriate orthopaedic opera- tions, gymnastics, electrical treatment, etc., and thus the magni- tude of the defect be rendered less noticeable by the patient. The prognosis in this respect depends upon the grade and extent of the paralysis, upon the preservation and the functional capacity of certain muscles and groups of muscles, upon the extent of the atrophy and the amount of deformity already present, upon the age of the patient and of the disease at the beginning of treatment, upon the intelligence and perseverance of the patient, and more of the same kind. A rich experience will of course sharpen one's judgment with regard to the value of these several conditions. Therapeutics. The treatment of acute spinal paralysis naturally falls into two divisions: the treatment of the acute inflammatory attack, and that of its sequels and results (the paralysis, atrophy, con- tractures, and deformities). The fulfilment of the first task is rendered difficult by the fact that the endeavors of the physician often come too late, or that his diagnosis remains in doubt until the paralysis is fully developed. In all cases, however, which come under treatment in good time, the measures which would be applicable in acute myelitis are to be adopted with all energy—of course, in a manner fitting the circumstances, and especially with due reference to the tender age of many of the patients. Local abstraction of blood, there- fore (leeches, cups, etc.), is to be employed, first of all, at the parts especially affected (the lumbar and cervical enlargements); cathartics (calomel, infusion of senna, etc.) ; inunction of mer- curial ointment to the back; the use of ergotine, belladonna, or iodide of potassium in appropriate doses; derivatives (strips of blister plaster the length of the spine, painting with tincture of 708 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. iodine, etc.); and, in appropriate cases, the application of ice, or the employment of Priessnitz's cold wraps about the trunk. In cases of severe brain-symptoms, Kussmaul recommends a tepid bath, with cold affusion to the head. Still, we need not be immediately driven to more active interference by apparently threatening manifestations, as experience teaches that there is hardly ever any real danger during the initial stage. But if we should succeed, by energetic treatment, in suppressing the mye- litis at its outset and thus preserving a portion of the nervous elements from positive destruction, it would be a great point gained. In the second stage of the disease it must likewise be our main endeavor to induce a favorable change in the diseased focus itself within the spinal cord, to favor the resolution of the inflam- matory and degenerative changes, so that whatever of nerve-ele- ments, fibres and cells, may still be capable of being saved, shall be saved and again put in condition to perform their functions. Those ganglion-cells which have once been totally destroyed can- not be reproduced, but probably cells and fibres which are in the act of degeneration may be preserved from further destruction, and gradually brought back again to the performance of their functions. It is only on this supposition that there can be any sense in the further symptomatic treatment of peripheral nerves and muscles. It is hard, indeed, to determine how far the power of our curative measures reaches towards the fulfilment of this indication ; up to the present time not much can be said in praise thereof. The galvanic current may undoubtedly be regarded as one of the principal means of influencing the diseased area within the spinal cord ; and it is the catalytic action of the current that is to be tried. What we want, therefore, is a stabile action of the current upon those portions of the spinal cord which are chiefly diseased. Our best plan will be to place a large electrode, which will cover the entire diseased area, over the corresponding por- tion of the back (over the lumbar or cervical enlargement), and to apply the other to the anterior surface of the trunk, and first to let the anode, then the cathode act for from one to two min- utes at a time, with a moderately strong current. The earlier POLIOMYELITIS ANTERIOR ACUTA. 709 this treatment is begun, the better ; during the later stages little is to be expected from it, although, according to the well-estab- lished experience of some, a favorable effect is by no means im- possible. The treatment must be continued for a long time, or must be repeated, at intervals, for several years. It must be admitted that, as yet, this treatment has been fol- lowed by no specially brilliant results ; this is perhaps partly due to the fact that these cases almost always come under treatment far too late, and that physicians have often contented themselves with the peripheral application of the current to the paralyzed muscles, instead of making the diseased area within the cord itself the main object of galvanic treatment, as should always be done. It is also quite evident that the faradic current is not the one to be used in these cases. According to my own experience, which relates almost exclusively to old cases and later stages, I can report no brilliant results ; still, I have often seen improve- ment set in, which I was obliged unquestionably to ascribe to the treatment, so that I cannot concur in the unfavorable verdict of Volkmann on electrical treatment. This verdict has also already been corrected by Hitzig and Juergensen. To be sure, we may not expect much from inappropriate, inadequate, or purely per- ipheral electrical treatment, and under all circumstances the at- tainment of any considerable result requires unusual patience and perseverance on the part of the physician as well as the patient. The same end—healing and resolution of the changes within the spinal cord—may be sought to be reached through the gen- eral stimulation of tissue-changes and of nutrition. On this ground something is to be expected from the use of baths (ther- mal springs, saline springs, thermal saline springs rich in gas, animal baths, pine-needle baths, cold-water cures, sea-baths, etc.). No more precise indications for the selection of the kind of baths can yet be given. For children, I should first use saline springs and saline thermal springs, afterwards light cold-water treatment; and for somewhat larger children, also sea-baths (and sea-air). For adults, I would recommend gaseous saline thermal springs, and then the energetic cold-water cure. On the same principle, a strong and abundant diet will be of benefit, with prolonged sojourn in the open air—the air of moun- 710 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. tains and woods—and the use of cod-liver oil. It is a question whether rubbing the skin with spirituous or other applications may have a similar though feebler effect, by exciting the activity of the skin and aiding the circulation; at all events, it may be tried. As a matter of course, all sorts of internal remedies have been tried—iodide of potassium, iodide of iron, nitrate of silver, etc.— all, at best, with doubtful results. Strychnine has been warmly recommended by many for the second stage ; Heine and Sinkler have found it alike inefficacious when used internally or exter- nally. In view of the much surer and safer action of electricity, its use may well be ignored. Hammond recommends ergot to be given as early as possible, and in full doses. Finally, symptomatic treatment is of the highest importance. This is to be directed, first, against the paralysis and atrophy of the muscles. The principal means to be used is electricity. In addition to the direct galvanic treatment of the spinal cord itself, the systematic peripheral treatment of the nerves and muscles is also to be carried on. Naturally, the galvanic current is the one to be used first, on account of the reaction of degeneration of most of the muscles. Still, Duchenne has arrived at quite noteworthy results even with the faradic current; this is especially applica- ble to those nerves and muscles which have but slightly lost or entirely retained their faradic irritability. But these muscles, naturally, also offer the best chances for galvanic treatment. The method of treatment is simple: the labile application of the ca- thode over all the paralyzed muscles and nerves, while the anode is best placed upon the vertebral column at the height of the main lesion. For very much atrophied and but slightly irritable muscles, changes in the current are to be recommended in which both electrodes are to be applied to the muscle (one upon the nerve-trunk belonging to it). The strength of the current should be such as to produce distinct twitchings and lively redness of the skin. The faradic application is to be made with moist elec- trodes, and with a pretty strong current. Treatment must al- ways be continued for a very long time—months and years—with longer or shorter intervals. By this means some slight progress is generally attained. POLIOMYELITIS ANTERIOR ACUTA. 711 In support of the electrical treatment, massage and kneading of the muscles, together with appropriate gymnastic exercises, may be undertaken. The application of warmth (warm-water compresses, sand-bags, etc.) has also been recommended to fur- ther the blood-supply and nutrition ; and for this purpose, too, some have advocated friction of the limbs with irritating sub- stances (oil of mustard, tincture of cantharides, strong liquor ammoniaB, extract of nux vomica, etc.). But the main portion of the treatment generally, and in old cases always, falls within the domain of orthopaedic surgery. It is not our province here to enter into details on the difficult and manifold indications which arise in this connection ; we refer our readers, for that, to treatises on surgery and orthope- dics. We will only allow ourselves a few brief observations on the main principles of the orthopaedic treatment. The main point, and the most important task, which devolves precisely upon the practitioner who has these cases under treat- ment at the beginning, is the prevention of contractures and deformities ; when these are once developed and have grown old, they are a more appropriate object for the specialist in ortho- paedics and for orthopaedic institutions. The physician may render considerable service in this respect, if he keeps in mind the purely mechanical methods of origin of the majority of con- tractures and deformities, and early enough counteracts these mechanical causes. This is the main point, and in its accom- plishment electricity, gymnastics, light frictions, and baths can serve merely as mild adjuvants. The essential point consists in watching the position of the limb when at rest, and in guarding the movements and the gait so as to avoid the undue burdening of one side of the body and continuous false positions. In guarding against the oc- currence of talipes equinus it is sufficient, according to Volk- mann, if, during the earliest stage, while the patient is lying \ down, the foot be fastened to a light foot-board by means of a flannel bandage, and this be drawn up somewhat towards the leg by a strip of adhesive plaster. On their attempting to walk, children should be put into stout-laced boots, with a steel shank on the outer or inner side of the boot-leg, or with the sole slightly 712 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. thicker on the one side or the other; in this way the develop- ment of talipes varus or valgus may be counteracted. The for- mation of talipes calcaneus may be combated by supplying the defective action of the posterior muscles of the leg by a strong bridle of rubber (the best is a rubber ring), which passes from the heel to a trough-like fixture that is applied to the leg just below the knee, and that is held firmly in place by a side-bar fastened to the shoe. Indeed, the lost muscular power, wherever it occurs, may be replaced in various ways by means of elastic tugs and the like. According to the seat and extent of the paralysis, according to the kind and magnitude of the deformity, the most varied machines and supporting apparatuses are to be applied, in the construction of which orthopaedic surgery has accomplished a great deal, and which often secure to the patient a very consider- able use of his limbs. In the more severe deformities tenotomy and forcible means of correction may come into play. According to Volkmann, patients should, as far as possible, avoid the use of crutches and similar supports, especially at the beginning of their ailment. 16. Subacute and Chronic Inflammation of the Gray Anterior Horns.—Poliomyelitis anterior, subacuta et chronica.— Chronic atrophic spinal paralysis.—Paralysie generate spi- nale anterieure subaigue (Duchenne). Duchenne (de Boulogne), Recherches electrophysiol., patholog. et therap. Compt. rend, de l'Acad. d. Sc. 1849—De l'eleetrisat. localised. 1855. 3. edit. 1872. p. 459.—Nesemann, Heilung eines bis zur vollstand. Lahmung aller Extremitaten vorgeschritt. Falles von progress. Muskelatrophie u. s. w. Berl. klin. Woch. 1868. Nr. 37.—Poche, Quelques consider, sur les amyotroph. d'origine spinale. These. Paris, 1874.—Frey, Fall von subacut. Lahmung Erwachsener. Berl. klin. Woch. 1874. Nr. 44, 45.— Erb, Ueb. acut. Spinallahm. bei Erwachs. und iiber verwandte spinale Erkrankung. Arch. f. Psych, u. Nervenkrankh. V. Beob. 7. 1875.—Cornil et Lepine, Cas de paralys. g€ner. spin, anter. subai^ug suivi d'autopsie. Gaz. m6d. de Par. 1875. Nr. 11.—Lemoine, Paralys. de l'adulte. Guerison. Lyon mgdic. 1875. Nr. 15.—Lincoln, Case of Spinal Paralysis in an Adult. Bost. Med. Surg. Journ. 1875. March 25.—& G. Webber, Contrib. to the Study of Myelitis. Transact. Americ. Neurol. Assoc, for 1875. Vol. I. p. POLIOMYELITIS ANTERIOR CHRONICA. 713 55.—Golldammer, Ueb. einige Fiille von subacuter Spinalparalyse. Berl. klin. Woch. 1876. Nr. 26.—Hammond, Diseases of the Nerv. Syst. 6. edit. 1876.— Klose, Zur Lehre von der Paralys. spinal, anter. subacut. Diss. Breslau, 1876. —Bernhardt, Beitr. zur Lehre von der acut. atroph. Lahmung Erwachsener. Arch. f. Psych, u. Nervenkrankh. VII. S. 313. 1877. History. It was Duchenne who, first in the year 1849, and then again in 1853, described a peculiar form of spinal disease, character- ized by motor paralysis, progressing more rapidly or more slowly, accompanied with atrophy in bulk of the muscles, and loss of their faradic excitability, without any other manifestations. This statement attracted but little attention until Duchenne, in the third edition of his "Electrization localisee" (1872), again and more emphatically pointed out the existence of this form of disease, and gave a detailed description of the same. Influenced in part by a hypothetical belief with regard to the anatomical basis of the disease—which he believed to consist in chronic de- generation of the gray anterior horns—he designated it "Para- lysie generale spinale anterieure subaigue." Since that time the existence of the disease has been univer- sally recognized as a clinical fact, and single instances of it have been described by various authorities (Poche, Frey, Erb, Web- ber, Cornil et Lepine, Klose, Goltdammer, Bernhardt, and others). The only point on which there is still any doubt is with reference to the anatomical basis of the disease, although the single reports of post-mortems thus far made by Cornil et Lepine and by Webber, would seem strongly to confirm the hypothesis first set up by Duchenne. Further observations on this subject are desirable. Definition. Clinically considered, the disease presents itself as a motor paralysis, usually developed without fever, with but slight gen- eral disturbance and insignificant disturbances of sensibility. 714 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. The paralysis more or less rapidly seizes the entire lower extrem- ities__generally in the course of a few days, or at the most a few weeks_ana soon extends to the upper extremities also (much more rarely showing the opposite order of development and be- ginning in the upper extremities) ; it is associated with complete flaccidity of the muscles and loss of their reflex excitability, and is followed by rapidly progressive atrophy in the bulk of the paralyzed muscles, with the well-marked reaction of degen- eration. The disease has certainly, as a rule, an ascending course, though it is by no means always progressive ; its development generally comes to a stand-still sooner or later, this arrest intro- ducing a gradual retrogression of the disturbances, which may lead to more or less complete recovery. The anatomical limits of the disease cannot, as yet, be de- clared with absolute certainty ; but, according to all that we know, there is every probability of its being located in the gray ante- rior horns. The two post-mortem examinations thus far made virtually confirm this, and thus, for the present, we may desig- nate the disease as a subacute or chronic inflammation or degen- eration of the gray anterior horns, with extensive disappear- ance and atrophy of the large multipolar ganglion-cells. Etiology. The causes of the disease under consideration are as yet ex- ceedingly obscure. Nothing is known of any definite predispo- sition thereto, and no hereditary influences have as yet been demonstrated. All the cases observed thus far have been in adults, and, indeed, between the ages of thirty and fifty, as is also the case with the majority of other chronic spinal diseases. Under the head of exciting causes, traumatic injuries have been cited—a fall upon the hip or back ; furthermore, gross exposure to taking cold, damp dwellings, and, in the case of Klose, free indul- gence in beer and excesses in venery. All these are mentioned as possible etiological conditions. In the majority of cases, however, no definite cause for the disease can be demonstrated. POLIOMYELITIS ANTERIOR CHRONICA. 715 We must, however, here briefly call attention to one etiologi- cal factor which is, as yet, of hypothetical, though perhaps of very great significance: that is, chronic lead-poisoning. In speaking of the pathogenesis of lead paralysis,1 which is such a peculiarly characteristic affection, I have sought to show that its origin is probably spinal instead of peripheral, and E. Remak' has established this more accurately and in a more detailed man- ner by the sifting and critical examination of a larger amount of material. He comes to the conclusion that quite circumscribed alterations in the gray anterior horns probably lie at the founda- tion of lead paralysis. These alterations might well be of a degenerative or chronic inflammatory nature, but are, as a rule, capable of resolution. Bernhardt has also recently given in his adherence to this view. In fact, the whole state of things in lead paralysis, with reference to mobility, atrophy, electrical relations, the absence of disturbances of sensibility, etc., is so entirely analogous to that in poliomyelitis anterior chronica, that we are almost forced to the theory of changes in the anterior gray horns in lead paralysis. On the other hand, again, I recently saw two cases of paralysis of the upper extremities, which, in all their details, were so completely analogous to lead paralysis that only the entire lack of any sort of evidence of lead-poison- ing was sufficient to determine me to give up this diagnosis, and accept that of a chronic circumscribed poliomyelitis anterior. Thus, everything crowds us at least into regarding the localiza- tion of lead paralysis and of chronic anterior poliomyelitis as the same. It is left to further investigations to determine whether the saturnine alterations in the gray anterior horns are the same in kind as the others—whether, therefore, the lead-poisoning calls forth an inflammatory affection. It would be well, at all events, to keep this question in view in the future. 1 Erb, Diseases of the Peripheral Nerves. This Cyclopaedia. Vol. XI. 2 Zur Pathogenese der Bleilahmungen. Arch. f. Psych, und Nervenkrankh. Vol. VI. p. 1. 1875. 716 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Pathological Anatomy. Up to the present time there are but two reports of post-mor- tems before us, which certainly do not fulfil all the requirements of a vigorous critique. We here communicate them in brief. In one case, which terminated in death at the end of four years, Cornil and Lepine found softening of the lowest division of the spinal cord. The principal change was in the gray ante- rior horns, consisting of chronic inflammation, thickening of the vessels, an abundance of fatty, granular cells, the perivascular spaces filled with blood, disappearance of a great part of the gan- lion-cells, increase of the cells of the neuroglia. In the cervical portion there was a sclerosis of the antero-lateral column en- tirely surrounding the anterior gray horn, and being limited farther down to the posterior divisions of the lateral column (secondary degeneration ?). The anterior roots were atrophied ; in the muscles the usual fatty atrophic changes were found. In Webber's case, which had lasted eleven months, he found degenerative atrophy of the muscles, the anterior roots in a high state of degeneration, the posterior roots but very slightly degen- erated. In the gray substance there wras here and there an exu- dation and an increase of nuclei around the vessels ; disappear- ance, atrophy, and degeneration of the large ganglion-cells in the anterior horns ; but slight changes in the ganglia of Clarke's columns and of the posterior horns; in the white columns a part of the nerve-fibres were degenerated, the neuroglia hardly changed. The same alterations which Webber ascribes to a pre- eminently parenchymatous inflammation were found to extend as far up as into the medulla oblongata. From these two not altogether coinciding reports, this much, at least, would appear evident: that even if the lesion is not entirely confined to the gray anterior horns, it is at least most pronounced in these; and that what here especially attracts atten- tion, in addition to the chronic inflammatory changes, is the degen- erative atrophy of the large, multipolar ganglion-cells. In the anterior roots and in the muscles those changes are to be found which have already repeatedly been described as being charac- teristic of degenerative atrophy of these structures. POLIOMYELITIS ANTERIOR CHRONICA. 717 Pathology of Poliomyelitis anterior chronica. Symptoms. It will suffice for all practical purposes to give a somewhat minute general picture of this, on the whole, rare affection. A more detailed pathogenetic discussion of its symptoms would bring to light the same occurrences as constitute the principal manifestations of the acute form. The disease may be developed with very varying degrees of rapidity; sometimes in a more subacute manner, developing a widespread paralysis within a few days or weeks, but generally pursuing a more chronic, insidious course, so that its develop- ment may extend over years. Accordingly, light indications of fever, gastric disturbances and dyspeptic manifestations, headache, and the like, may be present or may be wanting at the beginning of the disease. On the other hand, we shall rarely fail to encounter all kinds of paresthesia and light manifestations of sensory irritation (drawing and shooting pains in the back and limbs, backache, etc.) among the precursors of the disease. It is also common to find that for a long time such persons have suffered from great weariness and diminished endurance in the limbs. The actual beginning of the disease is generally marked by a distinct motor weakness in the lower extremities, or in but one of these, or at least more prominently in the one. This weak- ness more or less rapidly grows distinct; it increases in the course of days or weeks to pronounced paresis, so that the pa- tient breaks down on going upstairs, and soon finds his walks reduced to a minimum, or is confined to his bed. During this entire development there is never any tremor, never any ataxy in the limbs. On examining such patients, their movements are found to be sluggish,awkward,weak,and paretic; the movements of the knee and ankle-joint are usually more severely interfered with than those of the hip-joint. Sooner or later this paresis increases to complete paralysis of single muscles and groups of muscles, or 718 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. of the entire extremity. The rapidity with which this takes place varies exceedingly in different cases; sometimes it occurs within a few days, sometimes not till after the lapse of many months, or even after years. Then the muscles are comjjletely flaccid and soft, the limbs easily movable in all directions ; at first there is no sign of any contracture. Very soon a progressive atrophy in bulk takes place in the paralyzed muscles ; the calves of the legs turn into lax, flabby sacks, the muscles of the thigh and gluteal region grow thin and flaccid, and the tape-measure shows a diminution in the vol- ume of the muscles from week to week. This atrophy may advance till it causes a skeleton-like emaciation of the limbs, amounting to almost entire disappearance of the muscles. In its earlier stages it is generally accompanied with more or less fre- quent and active fibrillar twitchings of the muscles. The feet are cold and easily grow cyanotic. Sensibility of the skin is usually completely intact in all directions; it is but rarely that this is slightly dulled and that patients complain somewhat of insensibility and numbness. Reflex action in the paralyzed muscles is completely extin- guished; neither through the skin nor through the tendons can the slightest reflex twitching be produced. It is usually not long before the affection also extends to the upper extremities ; these grow awkward, feeble, heavy, grad- ually paretic, and at last completely paralyzed. Here, too, the trouble extends more prominently or earlier to individual groups of muscles; sometimes the extensor group of the forearm is earlier and more severely paralyzed than the rest, sometimes the flexors and the little muscles of the hand are more prominently affected. In general the fingers and hands are more severely paralyzed than the forearm and shoulder. The hands assume a correspondingly characteristic position, the arms lie lax and im- movable as they are placed, no trace of any contracture being demonstrable. Reflex action is completely extinguished in the paralyzed muscles. Sensibility in the upper extremities, too, so far as ob- jective examination can prove, seems to be entirely normal, or diminished to an entirely insignificant degree. Subjectively, pa- POLIOMYELITIS ANTERIOR CHRONICA. 719 tients sometimes complain of numbness in the fingers, of pares- thesia in the domain of the ulnar nerve, etc. Here, too, rapidly progressive atrophy ensues, uniformly dis- tributed over the paralyzed muscles, which may lead to the highest degrees of emaciation, especially in the hands and fore- arms. In some instances the muscles of the back and abdomen also share in the paralysis : the patients can no longer sit up ; expira- tion, coughing, sneezing, defecation, etc., are rendered difficult. There is generally an entire absence of any disturbances of the bladder, the rectum, or the genital organs; the functions in question are carried on undisturbed and in quite a normal man- ner ; the exceptions to this are rare. The nutrition of the skin does not suffer in the least; no bed- sores occur. The vegetative functions are also all of them normally per- formed. The appetite and digestion, which may, at the worst, have been slightly and temporarily impaired at first, are good; sleep is natural; the general nutrition and well-being are usually quite undisturbed. No symptoms at all on the part of the brain or the cerebral nerves appear, at least during the earlier stages of the disease. The initial headache ordinarily soon disappears. Examination of the paralyzed and atrophied muscles by elec- tricity gives quite the same results as in acute anterior poliomy- elitis, only modified to a slight degree to correspond with the much slower development of the malad}r. Here, too, Duchenne showed a diminution of faradic excita- bility occurring from the beginning, and advancing more or less rapidly to complete loss of the same. Here, too, according to my own experience and that of others (Bernhardt), this is nothing more than one of the manifestations of the reaction of degeneration. I have been able to prove this electrical disturbance in all the more recent cases that have come under my notice (five in all), and indeed in its most pronounced form. The motor nerves were entirely unexcitable to both the faradic and the galvanic current; the muscles did not respond to faradization, their galvanic excitability being retained, and 720 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. during the first weeks and months of the disease being slightly heightened (see the case reported below), afterwards more or less diminished, but always changed in quality (AnSZ> KaSZ ; twitch- ing sluggish, tonic); their mechanical irritability was at first heightened. At the stage in which we generally first see these cases, gal- vanic excitability is generally already much lowered, but usually still permits of the very distinct recognition of the qualitative anomaly. With the cure of the disease the electrical excitability returns but very slowly and gradually to its normal standard. We have now become familiar with the occurrence of the "reaction of degen- eration " in various diseases of the spinal cord, and it would seem to be time that we should enter briefly upon the relations of the same, in order to throw some light upon its diagnostic significance and to indicate the important points in gen- eral j)athology which result from the connection of this with other already recog- nized facts. We have found that the reaction of degeneration appears in its full develop- ment in acute anterior poliomyelitis in the form of complete loss of faradic and galvanic excitability of the motor nerves, loss of faradic excitability of the mus- cles, but heightening and qualitative changes in the galvanic excitability of the muscles. We have, therefore, in this form of disease, complete paralysis, a high grade of atrophy, the motor nerves and muscles involved in degenerative atrophy. Quite the same thing is found—only somewhat milder in degree, corresponding to its more chronic course—in chronic anterior poliomyelitis: the complete reaction of degeneration, the electrical excitability of the nerves entirely abolished, etc.; here, therefore, likewise entirely the same condition, viz., paralysis, atrophy, the motor nerves and muscles degenerated. Quite a different state of things exists in amyotrophic lateral sclerosis. A case which I accurately examined of late showed, in the upper extremities, the faradic and galvanic excitability of the motor nerves entirely preserved (at all events not materially diminished); in the muscles an elevation and qualitative change of gal- vanic excitability (reaction of degeneration) on direct irritation, while on indirect irritation the muscles reacted normally (twitching like lightning, KaSZ>AnSZ); the muscles also responded to the faradic current.1 At the same time there was a high degree of atrophy and complete paralysis of the muscles. Here we therefore found paralysis, atrophy, the motor nerves not degenerated, the muscles degenerated. In progressive muscular atrophy (typical form) it is somewhat different again. 1 The same condition, therefore, exists which is characteristic of the so-called middle form of facial paralysis and some other peripheral forms of paralysis. Compare this Cyclopaedia, Vol. XI. POLIOMYELITIS ANTERIOR CHRONICA. 721 In a part of the muscles attacked, the excitability, through the nerve, is preserved or appears to be simply lowered; in the muscles themselves faradic excitability is preserved, but galvanic excitability is preserved with the characteristics of the reaction of inflammation (though generally with already very much lowered excita- bility). In another portion of the muscles—in those that are very highly atrophied— faradic excitability is abolished, the nerve is entirely unexcitable, and the muscle reacts only on a very heavy galvanic current with sluggish twitching, AnSZ>KaSZ. In those muscles, however, which are but slightly affected and which were attacked at the beginning, electrical excitability appears still to be quite normal on direct and indirect irritation. At least so I have found it, since paying attention thereto, in all the cases carefully examined by me. If Bernhardt (1. c.) recently doubts the occurrence of the reaction of degeneration, this is to be excused on the ground that, in progressive muscular atrophy, at all events, the reaction of degeneration is very hard to demonstrate, and may easily be overlooked in a not very careful search. There are various reasons for this. One is the very slow development of the disease, so that the characteristic increase of excitability subsides and the qualitative changes alone remain ; another is the preservation of the excitability of the nerves, so that the normal neuro-muscular twitchings mark the qualitative alterations. A still stronger reason, however, is the fact that the degeneration of the fibres within a muscle takes place in a scattered manner; among the degenerated fibres there still always remain a certain number of healthy and still excitable fibres, which respond to irritation, and thus mark the existence of the reaction of degeneration. The more slowly the process advances, the lower sinks the excitability of the degenerat- ing fibres, and the increasing strength of the current required to produce an effect may for a long time compensate for the numerical diminution of healthy fibres; so that the relation of things long remains obscure. It will, therefore, only be possible to demonstrate the reaction of degeneration in its earlier stages in those muscles which degenerate pretty rapidly, and in which larger numbers of degenerated fibres are to be found; the later stages of this reaction (with great diminution of galvanic excitability) can only be shown in those muscles which have already attained a high grade of degeneration. This naturally varies in each individual case. Con- sequently, the reaction of degeneration can always only be demonstrated in single muscles, sometimes more and sometimes less distinctly. I have thus far always found it in this way. In progressive muscular atrophy, therefore, the reaction of degeneration exists with retained excitability of the motor tracts (at least for a long time) ; but, in contrast to amyotrophic lateral sclerosis, no paralysis here exists until the muscles are almost entirely degenerated. Here, therefore, the manifestations are grouped as follows: no paralysis, but atrophy; the motor fibres not degenerated, the mus- cles degenerated. I recently found quite an analogous state of things in a well-pronounced case of bulbar paralysis. In the muscles of the chin and lips, and even of the tongue, the excitability of the nerves was found retained and almost normal; in the muscles themselves, however, the well-marked reaction of degeneration on direct irritation. VOL. XIII.-46 722 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. I had expected this condition on account of the analogy of the disease with pro- gressive muscular atrophy. Quite similar variations are also to be met with in other forms of paralysis. Among these may be mentioned the occurrence of the well-marked reaction of degeneration in severe peripheral traumatic and rheumatic paralysis ; the occurrence of the "middle form" in slight rheumatic and traumatic paralysis (of the facial, radial, etc.'); finally, the extraordinary fact, in a case of lead-poisoning made known by me,* where the reaction of degeneration was present in a muscle that was not paralyzed, whereas ordinarily in lead-poisoning the muscles act just as in chro- nic anterior poliomyelitis. It is difficult to form a plausible conception of the course and connection of the various trophic and motor tracts which might, even to some degree, enable us to comprehend these various facts. Some of the conclusions to be drawn from the facts briefly collected in what has been said above may even now be indicated. If it had needed any confirmation, all the facts would have unanimously con- firmed the doctrine that the occurrence of the reaction of degeneration is always and everywhere associated with the existence of certain histological alterations in nerves and muscles which we comprehend under the name of degenerative atrophy.3 But it would furthermore also appear that the motor tracts, within the central or- gan, to some degree run their course separately from the trophic apparatuses and tracts, as there are central paralyses with atrophy (poliomyelitis anterior) and without atro- phy (spastic spinal paralysis), and likewise central atrophies which exist for a long time without actual paralysis (bulbar paralysis, progressive muscular atrophy). We can, furthermore, hardly escape the conclusion that the trophic influences for motor nerves are somehow separated in space from those for the muscles ; that, accordingly, different trophic central apparatuses and tracts may perhaps exist for the nerves and the muscles. This appears from the fact that the muscles may degenerate alone, without the nerves taking part in the degeneration. (So in amyotrophic lateral sclerosis, in bulbar paralysis, in progressive muscular atrophy, in the middle form of paralysis of the facial and radial nerves, in the case of lead-poisoning described by me.) At all events, therefore, these tracts cannot be completely identical; they must present some differences in their localization, or perhaps only in their resistance to influences that cause disease. We can, even though it may be with some difficulty, form a hypothetical idea of the existence and position of the various apparatuses and tracts belonging here, within the central organ as well as in the peripheral nerves, whereby we might explain the above-mentioned differences in the different forms of disease. All the facts go to show that these apparatuses lie principally in the gray substance of the anterior horns. But our anatomy will not so soon show us how these are arranged 1 Compare the appropriate sections in Vol. XL of this Cyclopaedia. 4 Erb, Ein Fall von Bleilahmung. Arch. f. Psych, u. Nervenkrankh Bd. V p 445 1875. 5 This Cyclopaedia, Vol. XI. POLIOMYELITIS ANTERIOR CHRONICA. 723 and distributed there. We may, therefore, be permitted, with all due reservations, to draw a hypothetical diagram of this arrangement, according to the postulate which virtually results from the facts above communicated. In the accompanying Fig. 17, let a be the motor conduction from the brain, which undoubtedly lies in the lateral column; let this continue through the gangli- Fia. 17. Diagram of the arrangement and connection of motor and trophic centres and tracts in the spinal cord and in the peripheral motor nerves. onic point d (multipolar ganglion-cell?), into which the reflex tract, s, coming from the sensitive sphere, opens through the anterior roots and the peripheral nerves (a—d—a') to the muscle m. Let b be the trophic central apparatus for the mus- cles ; the tract b—b' represents the trophic conduction tract emanating from this apparatus and somewhere (probably at d) uniting with the motor tract. Let c be 724 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. the trophic central apparatus for the motor nerves (which possibly coincides with d) and c—c' the tract which conducts its trophic influences to the motor fibres. With this diagram, the special arrangement of which within the spinal cord is of pourse unknown—and indeed, for the present, a matter of entire indifference—one can form quite a clear idea of the origin of the different forms of disease, provided, at the same time, he has due reference to the phenomena of reflex action. If the tract a alone is interrupted by disease, we have simple paralysis without any degenerative atrophy, and without the reaction of degeneration—simple lateral sclerosis. If a and the centre b are simultaneously diseased, then there is paralysis with atrophy of the muscles, and the reaction of degeneration in the muscles, but no change of the motor nerves, whose electrical excitability is retained—amyotrophic lateral sclerosis. If the centre b alone is diseased, there is atrophy of the muscles, at first without paralysis and without degenerative atrophy of the motor nerves, reflex action being retained—bulbar paralysis and progressive muscular atrophy. If b, c, and d are simultaneously diseased (or, if we suppose that all the tracts pass through d, then on disease of d alone), there is paralysis "with degenerative atrophy, and the reaction of degeneration in nerves and muscles and loss of reflex action—acute and chronic poliomyelitis anterior. If we imagine b, c, and d to represent the different ganglion-cells of the gray anterior horns, and the diagrammatic conduction tracts to represent the different connections of the same among one another, with the lateral columns and the anterior roots, then we shall readily see that this diagram to a great degree harmo- nizes with the recently accepted views concerning the forms of disease which here occupy us. Even the view adopted by Duchenne and Joffroy, by Hammond and others, that there are separate motor and trophic cells, has found representation in the diagram. But this diagram also furnishes points towards the elucidation of the different forms of peripheral paralysis. If the conduction d, a' alone is disturbed, simple paralysis, without degeneration and the reaction of degeneration, will exist (the light form of rheumatic paralysis of the facial); if d, a' and b, V are simultaneously disturbed, then paralysis with the reaction of degeneration in the muscles, but not in the motor-nerves (the middle form of rheumatic paralysis of the facial); finally, if in addition to d, a' and b, V, c, c' is also paralyzed, then there is paralysis with the reaction of degeneration in the nerves and muscles (severe form of facial paralysis'). But, aside from these more theoretical, and, as yet, entirely hypothetical sides of the question, accurate electrical examination also has its diagnostic importance in such forms of disease. So far as one can judge, up to the present time, with the very scanty material thus far on hand, some not unimportant diagnostic facts would seem to come to light. 1 Compare my Essay, cited above—A Case of Lead-Poisoning. L. c. p. 455. POLIOMYELITIS ANTERIOR CHRONICA. 725 Well-marked, complete reaction of degeneration, with loss of the excitability of the motor-nerves and with elevation, or, at least, without any great degree of diminution of the galvanic excitability of the muscles, is evidence in favor of poliomyelitis anterior, both of the acute and chronic form. It is always accom- panied with paralysis, disappearance of reflex action, and a high degree of atrophy. The middle form of the reaction of degeneration, without any material disturb^ ance of the excitability of the motor-nerves, and with well-marked elevation, or, at least, without any material diminution of the galvanic excitability of the muscles, speaks in favor of amyotrophic lateral sclerosis; this is always accompanied with paralysis and atrophy, but reflex action may be preserved. The middle form of the reaction of degeneration, but with a greater or less degree of diminution of galvanic excitability of the muscles, which is hard to demonstrate and can only be shown in single muscles and groups of muscles, speaks in favor of progressive muscular atrophy (and bulbar paralysis). There is then no complete paralysis, non-uniform atrophy, while reflex action may be retained. It is true that the later stages of the disease, such as are so often found in the little mus- cles of the hand, cannot easily be distinguished by electrical examination alone from similar changes caused by poliomyelitis anterior or amyotrophic lateral sclerosis (nor from peripheral paralysis, lead paralysis, etc.), but then the diagnosis can usually be made from the other manifestations, and from the development and course of the disease. At all events, it seems worth the while to pay further attention to these relations, as they are not only of diagnostic importance, but promise to throw light upon cer- tain difficult problems in the physiology of the spinal cord which cannot easily be approached in other ways. To be sure, these examinations demand great practice, patience and technical knowledge, and I cannet too urgently recommend the greatest care in conducting test examinations. I can guarantee the facts discovered and communicated by me, but they urgently require to be extended and confirmed in numerous new observations. The further course of chronic poliomyelitis anterior, after it has been developed to the point above described, may shape itself in various ways. In the majority of instances the disease now remains station-. aryfor some time. The paralysis increases no more, the weak- ness or impossibility of movement remains about the same ; but: the muscular atrophy does still advance. Now, too, moderate: paralytic contractures may be developed, chiefly caused by the; mechanical approximation of the points of attachment of the muscles. No other new disturbances arise. After a while—a couple of weeks or months—very gradual improvement sets in, generally first in the upper extremities ;> 726 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. single movements first return, others again grow more distinct and stronger, and thus the improvement gradually advances, while the galvanic excitability of the muscles sinks more and more, and slowly gives place to the normal conditions of excita- bility, the contractures disappearing again little by little. But the improvement is slow; it is only after the lapse of months that the patients can again eat, write, and use their hands for all kinds of manipulations. Then the lower extremities have their turn; first the move- ments of the hip-joint become freer and more powerful, then those of the knee, and not till quite late those of the foot and toes. The course of things with reference to electrical excitability and the contractures is precisely the same as in the upper extremities. The question of how far this improvement goes varies some- what in individual cases. Not infrequently it advances to com- plete recovery, so that mobility is quite restored, the nutrition of the muscles again becomes normal, and patients regain all their former capabilities. This may, however, require many months and even years. Incomplete recovery, however, is far more frequent. A part of the muscles (especially those in the domain of the peroneal nerve) remain paralyzed and atrophic, and patients retain the defect thus induced for life. In a minority of instances the malady advances further and further upwards ; finally, disturbances of respiration set in, signs of asphyxia, various bulbar symptoms, paralysis in the domain of the facial nerve, of the tongue, of swallowing, etc., and these manifestations gradually lead to death. Sometimes this like- wise follows, without any further complications, through simple exhaustion. The duration of the disease is, accordingly, in most cases, comparatively long ; at best it is a question of months, generally of years. The progressive cases terminate fatally in from one to four years. In view of the small number of observations thus far at our command, I may be permitted to communicate a brief outline of the following case, of a rather subacute form, recently observed by me. POLIOMYELITIS ANTERIOR CHRONICA. 727 Mr. A. G., forty-two years of age, was always of robust constitution and health, and has exposed himself with impunity to many injurious influences (heat, draughts, travels, the free use of alcoholic drink). For a year past he has often complained of unusual weariness. His illness began at the end of July, 1876, with general weakness, headache, slight dyspeptic symptoms, etc. The patient still went about, notwithstanding increasing weakness of the legs, until the 22d of August, when, his legs giving way, he fell down-stairs. From this time on he was bed-fast. The only subjective trou- bles complained of were some shooting and piercing pains in the legs, with transitory formication. At the end of September similar weakness in the hands set in, so that the patient could neither write, feed himself, nor do anything else with his hands. He never had the sensation of a tight band about his body. The functions of the bladdei- and rectumioere entirely undisturbed. His general condition of late had been quite good. Condition on examination, the 6th of October.—There was a high degree of pare- sis and partial paralysis of the lower extremities. Movements of the ankle-joint and toes were quite impossible, of the knee- and hip-joint quite difficult. Sitting up in bed was very difficult. The upper extremities were also to a high degree paretic, especially the hand and forearm. The grasp of his hand could scarcely be felt; the extensors were completely paralyzed. The power of the mus- cles of the upper arm was materially lowered, that of the muscles of the shoulder least so. The mobility of the muscles of the neck and face, of mastication, deglutition, and of the eyes was completely intact. The sensibility of the skin in the feet and legs was somewhat, although but very slightly, dulled; from the thigh upward, as well as in the upper extremities, it was entirely normal, excepting a subjective sensation of numbness in the tips of the fingers. Reflex action—of skin and tendons—in the lower extremities was completely abolished. The muscles, which were very lax and flabby, were already considerably atrophied in all four extremities. The bladder and rectum acted normally. No bed-sores. Appetite and digestion regular. Sleep good. Head free. Faradic excitability in the paralyzed muscles and the nerves belonging to them was greatly lowered, in part entirely abolished. The galvanic excitability of the nerves of the lower extremities was completely extinguished ; in the muscles, on the contrary, it was raised and changed in quality (twitching, sluggish, AnSZ>KaSZ); so at least in the domain of the peroneal and tibial nerves. In the domain of the crural nerve, diminution of the galvanic excita- bility could already be demonstrated with a continuation of the qualitative change. In the upper extremities the well-marked reaction of degeneration existed only in the extensors of the forearm and in the interossei muscles. The mechanical excitability of a portion of the atrophied muscles was distinctly heightened. 728 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. The treatment consisted of the use of dry cups along the spine every couple of days, Priessnitz's cold-water compresses to the back, and iodide of potassium. His condition very soon began to improve. At the beginning of November this was distinctly perceptible in all the extremities, even though but to a very slight degree. At the beginning of December the patient was able to sit in a chair, and to move his arms and legs much more freely. In the upper extremities the domain of the radial nerve was still completely paralyzed; a slight contracture of the flexors of the hand and of the fingers had set in. Movements of the elbow- and shoulder- joint were now perfectly free and strong. In the lower extremities there was still entire paralysis of the foot and the toes. Extension of the knee-joint feeble; lifting of the leg possible ; a slight contracture of the flexors of the leg. Sensibility and the state of the bladder were normal. The paralyzed muscles still showed the reaction of degeneration. He was now ordered galvanic treatment to the back and extremities. His condition now steadily improved. At the beginning of February, 1877, the mobility in the extensor region of the forearm was pretty well restored; the con- tracture of the flexors had almost entirely disappeared; the hands had greatly gained in strength, the patient could again feed himself. The mobility of the muscles of the thigh was materially improved; the muscles of the legs were still completely paralyzed. The atrophy was somewhat less. Electrical examination still showed the full reaction of degeneration, although now with distinctly diminished galvanic excitability. Middle of March, 1877.—The mobility of the upper extremities was now almost entirely normal; the first signs of movement in the joints of the feet now began to appear; the general condition very good. Middle of April, 1877.—Continued improvement. Movement of the feet and toes is becoming more distinct and extensive, although but very gradually. The patient is now able to stand somewhat, and, if well supported, to move a few steps. The upper extremities are now almost entirely normal. Diagnosis. The picture of the disease in subacute and chronic poliomye- litis anterior has so much that is characteristic about it, that in cases which are at all well-marked it can very easily be recog- nized. Especial significance is to be attached to the tout ensemble of the disease and the successive development and consecution of the symptoms. This disease can generally be easily distinguished from all similar and kindred affections, notwithstanding the great similarity that frequently exists between them, by the lassitude POLIOMYELITIS ANTERIOR CHRONICA. 729 weakness, paresis, and finally paralysis, occurring at first in the lower and then in the upper extremities, the muscles being lax, without tension or contracture ; by the progressive atrophy with the reaction of degeneration ; by the failure of reflex action ; by the absence of any disturbances of sensibility and of the bladder, as well as of any tendency to the formation of bed-sores ; by its slowly progressive course and its usually favorable termination. The differential diagnosis between this and acute anterior poliomyelitis can only come in question when it refers to the sequels of the latter affection. The existence of the latter is de- termined, however, by the fact of its extremely acute beginning, which at once causes the highest degree of paralysis. The subacute form has a decidedly progressive course: it extends more or less rapidly upward, the paralysis increases for a time, the disease may at last terminate fatally, or it may run a similar progressive course towards recovery. In both respects there seems to me to be such an essential difference between the acute and chronic forms that it appears to me doubtful whether the two actually represent the same process of disease developed with different degrees of acuteness. Progressive muscular atrophy has very often been confound- ed with chronic anterior poliomyelitis. Notwithstanding all the resemblance which the two forms of disease may bear to one another in certain stages, they may easily be distinguished by the following characteristics : in chronic poliomyelitis there is first paralysis and afterwards atrophy ; in progressive muscular atrophy the paralysis becomes associated with atrophy which has already long existed ; in the former there is atrophy in the bulk of the muscles, in the latter only partial atrophy of the same; in the former the well-marked reaction of degeneration can be demonstrated as well as the failure of reflex action; in the latter, if there is any reaction of degeneration it is only the middle form, and reflex action is retained ; the former runs its course comparatively fast and generally favorably, the latter very slowly and always unfavorably. The distinction between this disease and amyotrophic lateral sclerosis is still more easy. The latter, it is true, resembles chronic poliomyelitis in the paralysis and atrophy in bulk of the 730 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. upper extremities, but in the lower extremities it shows paralysis without atrophy, with tension of the muscles and contractures, with increase of the reflex action of tendons, etc. Perhaps ex- amination by electricity may also contribute something towards the determination of this question, if the fact should be further confirmed that in amyotrophic lateral sclerosis only the middle form of the reaction of degeneration occurs. With regard to the distinction between this and the slower forms of Paralysis ascendens acuta, see the following section. Chronic anterior poliomyelitis will be capable of being easily distinguished from all other forms of chronic spinal disease, from transverse chronic myelitis, multiple sclerosis, tabes dor- salis, spastic spinal paralysis, etc., if proper regard is paid to the condition of sensibility, of the bladder, of the nutrition of the skin, of reflex action, of electrical excitability, etc., quite irre- spective of the other peculiarities of these various forms of disease. In the well-marked and more diffuse forms, therefore, the disease is easy to recognize. But it is a question which can only be determined by further successful investigations, whether an- other series of more partial forms of paralysis and atrophy of the extremities do not belong in the same category. It already seems probable that this is, to a certain degree, the case in so- called lead-paralysis. But I would also raise the question with regard to quite simi- lar conditions of disease which have arisen spontaneously, viz., with regard to partial paralysis with atrophy and the reaction of degeneration without disturbances of sensibility in the extremi- ties ; with regard to a good many cases which are cited in papers on progressive muscular atrophy, but which absolutely have not been progressive ; whether all these do not owe their origin to a quite circumscribed chronic anterior poliomyelitis. Of course this question can only be solved by accurate clinical observa- tions, made with this object in view, and finally settled only by pathologico-anatomical investigation. I therefore recommend it as worthy of further attention. POLIOMYELITIS ANTERIOR CHRONICA. 731 Prognosis. The prognosis of this disease is never to be treated lightly; life may very easily be endangered, which never seems to be the case in the acute form. At the same time the prognosis is comparatively favorable, as in the majority of cases recovery follows, and at all events the improvement, as a rule, goes much farther than in the acute form. At the same time patients must make up their minds to a comparatively long duration of the disease, extending perhaps over several years. The prognosis is bad only in that form of the disease which advances upward with comparative rapidity. Whenever diffi- culty of breathing and of swallowing, labored action of the tongue, etc., set in, a fatal termination is at least very probable. The more partial forms are never dangerous to life, but may lead to permanent disappearance of the muscles and correspond- ing defects of motion. Therapeutics, In view of the small number of observations as yet made, there is, of course, no question of any established, independent treatment of the disease. In general, those principles are applicable which we have laid down elsewhere for the treatment of subacute and chronic myeli- tis generally. Therefore, at the beginning of the disease, we may employ abstractions of blood, derivatives of all sorts, hydro- pathic applications to the back, iodide of potassium, ergot, etc. Undoubtedly at a later period the most that can be expected is from the galvanic current. It must be left to the future to determine whether mineral baths, cold-water treatment, or other similar means are of any special avail, and what internal reme- dies promise the best results. The best we can do at present is to continue our trial of the curative measures appropriate in chronic myelitis. 732 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 17. Paralysis Ascendens Acuta.—Acute Ascending Paralysis. —Landry*s Paralysis. 0. Landry, Note sur la paralysie ascendante aigue\ Gaz. hebdom. 1859. Nr. 30, 31.—Kussmaul, Zwei Falle von todtl. Paraplegie ohne nachweisb. Ursache. Erlangen, 1859. — T. L. Walford, Softening of the Spinal Cord. Assoc. Med. Journ. 1854. Nov. 11. (Canstatt's Jahresb. III. S. 33.)—Gomes de Voile, Obs. d. paral. asc. aig. Union mGd. 1861. Nr. 13.—Leudet, Paral. asc. aig., rapid. mortelle, surven. dans 1. conval. d. 1. fievre typholde. Gaz. des h6p. 1861. Nr. 58.—Pellegrino-Levi, De 1. paral. asc. aigue. Arch, gengr. 1865. I. p. 129.— Bablou, Obs. d. paral. asc. aig. Gaz. hebdom. 1864. Nr. 49.—Gru, Union m6d. 1866. Nr. 152.—Caussin, Gaz. des hop. 1866. Nr. 23.—H. Jones, Brit. Med. Journ. 1866. Oct. 27.—Hayem, Paralys. asc. aigue. Gaz. des hop. 1867. Nr. 102.—Harley and Lockhart Clarke, Fatal Case of Acute Progress. Paralysis. Lancet. 1868. Oct. 3.—C. Lange, Om obstigende spinal paralyse. Hosp. Tid. 12. Aarg. Nr. 6-10. (Virchow-Hirsch, Jahresber. pro 1869. II. S. 34.—Cheva- let, Par. asc. aig. d'origine syphil. Bullet, d. therap. 1869. Oct. 15.—Labadie Lagrave, Gaz. des hop. 1869. Nr. 148.— 0. Bayer, Heilung einer acut. ascend. Paral. unter antisyphil. Beh. Arch. d. Heilk. 1869. S. 105.—A. Eulenburg, Lehrb. d. funct. Nervenkrankh. Berlin, 1871. S. 603.—Reincke, Fall v. Paral. asc. acut. Deutsch. Klin. 1871. Nr. 23, 24.—Bernhardt, Beitr. z. Lehre. v. d. acut. allg. Paral. Berl. klin. Woch. 1871. Nr. 47.— Chalvet, Gaz. des hop. 1871. Nr. 93.—Leyden, Klinik d. Riickenmarkskrankh. I. S. 94. II. S. 201. —Rerm. Levy, Paralysis asc. ac. Correspondenzbl. d. arztl. Ver. d. Rheinprov. 1873. Sept. (Centralbl. 1874. Nr. 11.)—Petitfils, Consider, sur l'atroph. aig. des cell, motrices. Paris, 1873.—Eisenlohr, Zur Lehre v. d. acut. spin. Paral- yse. Arch. f. Psych, u. Nervenkrankh. V. S. 219. 1874.—Calestri, Gazz. Lom- bard. XXXIV. Nr. 20. 1874. (Schmidt's Jahrb. Bd. 168. S. 18.)—Salomon, Schnelle Heilung einer schwer. ac. Riickenmarksaffection u. s. w. Correspon- denzbl. d. arztl. Ver. im Rheinl. 1875. Nr. 15.—Goltdammer, Ueber einige Falle von subac. Spinalparalyse. Fall. 3. Berl. klin. Wochenschr. 1876. Nr. 26.— Baumgarten, Eigenthuml. Fall von Paral. asc. aigue mit Pilzbildung im Blut. Arch. d. Heilk. XVII. S. 245. 1876.—C. Westphal, Ueber einige Falle von acut. todtl. Spinallahmung. Arch. f. Psych, u. Nervenkrankh. VI. S. 765. 1876. —Dejerine et Goetz, Paral. asc. aigue. Arch, de Physiol, norm, et path. 1876. p. 312.—R. v. d. Velden {Leyden), Fall von acut. aufsteigend. spinaler Para- lyse. Deutsch. Arch. f. klin. Med. XIX. S. 333. 1877. History, In the year 1859, Landry described some cases of disease, under "Paralysie ascendante aigue," which had terminated in PARALYSIS ASCENDENS ACUTA. 733 death, with the manifestations of spinal paralysis advancing rapidly from below upward, and finally paralyzing the medulla oblongata, and in which no appreciable anatomical lesions were found. In the same year Kussmaul also described two cases observed by him of similar, rapidly fatal spinal paralysis, with entirely negative results on post-mortem examination. No doubt cases of disease belonging to this category had pre- viously been described in literature—thus, by Ollivier, in his work, under the head of Hyperemia of the Spinal Cord, by Wal- ford, and others. It appears that the distinguished Cuvier also died of this disease in 1832. But it was not until after Landry's publication that reports of cases of this form of disease began to accumulate. Much, however, was included under this head which evidently does not belong here. Thus, cases of acute, central or diffuse myelitis (for instance, the cases of Levy, Picard, and others), or of subacute poliomyelitis anterior (cases of Behm and Taylor), or of infec- tious myelitis (Baumgarten); perhaps it is also wrong to place here those syphilitic affections which run their course presenting the picture of acute ascending paralysis. We may learn how difficult it is to keep these different forms of disease separated when we remember that Petitfils has but recently made an attempt, in the most detailed manner, to estab- lish the identity of acute ascending paralysis and acute or sub- acute anterior poliomyelitis,—to regard the former merely as a variety of the latter, and to refer it likewise to acute alterations in the large ganglion-cells of the gray anterior horns. In view of a series of well-established, more recent, and most recent facts, this theory may be regarded as overthrown. Even before this theory was advanced, cases had repeatedly been observed which might be regarded as typical of acute ascending paralysis, and in which even the most careful examina- tion by a skilled and practised hand discovered no trace of any change in the central nervous system (the cases of Vulpian, Pel- legrino-Levi, Cornil and Eanvier, Hayem, Bernhardt, and others). The most recent observations of Westphal are decisive, and to a certain degree conclusive. In a number of cases that were clin- ically well marked, he could not find any trace of anatomical 734 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. alterations in the spinal cord, even on the most careful anatomi- cal examination, carried out in every direction. Almost at the same time, Dejerine and Goetz published a case belonging here, with the same negative anatomical result. Westphal has also rendered the clinical diagnosis of the disease more definite in various directions. It is thus settled, for the present, that the disease cannot be considered as identical with any of the previously named forms of spinal disease, but rather that it is a clinically well-charac- terized—undoubtedly spinal—form of disease, the anatomical conditions of which are entirely negative, so far as our present means of investigation show. The disease may, and must, there- fore, as yet be regarded as systemic ; to be sure, we stand but at the threshold of our knowledge thereof, and it will require addi- tional clinical, pathogenetic, and also anatomical investigations to give us any satisfactory idea of the same. The material thus far at our command is far too inadequate for this purpose. Definition. The disease designated by the name of paralysis ascendens acuta is clinically characterized by a motor paralysis (ascending paralysis), which generally begins in the lower extremities, spreads pretty rapidly over the trunk to the upper extremities, and usually also involves the medulla oblongata, which some- times runs its course without fever, sometimes with more or less active fever, which but slightly involves the general sensibility and the functions of the bladder and rectum, and which runs its course without any notable atrophy of the muscles, and without any diminution or change of their electrical excitability. In the majority of instances the disease terminates fatally, by asphyxia, paralysis of deglutition, and the like ; but lighter cases may also end in recovery. The anatomical characteristics of the disease are at present purely negative. No pathologico-anatomical alterations are to be found anywhere, and especially not in the spinal cord, which might explain the picture of the disease. In particular are PARALYSIS ASCENDENS ACUTA. 735 there no signs of hyperemia within the spinal cord, of myelitis, of acute destruction of the ganglion-cells or nerve-fibres. If the disease is therefore to be localized within the spinal cord at all, it is a question of finer, so-called impalpable disturb- ances of nutrition, not accessible to our present means of exam- ination. Etiology and Pathogenesis. On this subject very little is known, and, in fact, nothing positive. Sometimes the disease arises without any demonstrable pre- disposing or exciting causes. Men are most frequently attacked ; among the sixteen cases collected by Pellegrino-Levi, only four were in women. Most cases of the disease occur between the ages of twenty and forty, but it may also occur at later periods of life. Nothing is known of any hereditary or neuropathic influences. Taking cold is mentioned first in the line of exciting causes. It is not necessary here to mention the individual possibilities of the same, as they proved to be effectual in an entire series of cases. Not a few instances have been seen to arise during the course of, or during the convalescence from, acute diseases (typhoid fever, diphtheria, pleurisy, varioloid, etc.). Some few have fol- lowed suppressed menstruation (through taking cold or emo- tional disturbances). Bablow saw the disease break out after a man had indulged in the act of coition while standing up. It is at least doubtful, as yet, whether syphilis is an actual cause of genuine acute ascending paralysis. We are accustomed always to find palpable alterations in syphilis, so that a syphili- tic affection of the spinal cord with an impalpable lesion does not seem to us exactly probable ; at the same time, such a thing is possible. At all events, various authors (Kussmaul, Landry, O. Bayer, and others) have decided on the syphilitic nature of the disease, partly from the antecedents and partly from thera- peutic results. 736 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Westphal has recently taken up the idea of an intoxication as the cause of acute ascending paralysis. The same had already been announced by Landry, and briefly touched on by Hayem and Bernhardt. Baumgarten's case, in which the bacteria of splenic fever (Milzbrand) were found in the blood and in the spinal cord, appears to give some support to this supposition; still, in this case, there was undoubted myelitis present, therefore it probably does not belong here. Westphal considers it proba- ble that some intoxication—thus far, to be sure, of an entirely unknown variety--is the actual and final cause of acute ascend- ing paralysis. This can only be decided by numerous further observations. It readily occurs to us to draw a parallel between this and another affection, likewise spinal, which sometimes terminates fatally within a few days, and sometimes runs a longer course to recovery, likewise appearing in lighter and severer attacks, and for which, up to the present time, there has likewise been found no anatomical lesion. We refer to tetanus. This parallel does not need to be carried out any further ; but close observation cannot fail to detect the manifold analogies of the two forms of disease, although in the one (tetanus) it is a question principally of manifestations of motor irritation, and in the other (acute ascending paralysis) principally of manifestations of motor par- alysis. Pathological Anatomy. The few convincing and sufficiently careful reports of post- mortems now before us (Vulpian, Cornil et Kanvier, Bernhardt, Westphal, Dejerine et Goetz) unanimously teach that there are absolutely no anatomical changes present to which the symptoms could, with any reason, be referred. The examinations fulfil all the requirements that can be made of them at the present time ; they have furnished entirely nega- tive results, as well with reference to the brain as with reference to the spinal cord and the medulla oblongata, and likewise with reference to the sympathetic nerve, the peripheral nerve-trunks, and the muscles. The future alone can tell whether the changes PARALYSIS ASCENDENS ACUTA. 737 in the anterior roots found by Dejerine and Goetz, but unfortu- nately not thoroughly enough examined, are of any significance. It is not probable that they are so. On the other hand, the older investigations, which claimed to have proved the presence of hyperemia here and there, of soft- ening of the spinal cord, even of myelitis and the like, lose all their significance ; at best they belonged to other clinically some- what similar forms of disease. This also holds true of the very newest observation recently published by Leyden (v. d. Velden), under the name of acute ascending paralysis. This decidedly does not belong to the form of disease which we have here, in harmony with the views of Westphal and others, described under this name, as is abundantly evident from the clinical symptoms (a high grade of fever, delirium, paralysis of the bladder, loss of electrical excitability, stiffness of the back, tension of the mus- cles, etc.). What is here presented seems rather to be an admi- rable instance of acute disseminated myelitis, especially affecting the antero-lateral columns and the anterior gray substance. It may be a matter of some significance that in single cases similar alterations have been found in the spleen, the liver, the lymphatic glands, and intestinal follicles, etc., as they are also so frequently found in diseases of infection—such changes as cloudi- ness, swelling, enlargement, more abundant blood-contents, etc. Pathology of Acute Ascending Paralysis. Symptoms. In most instances, though not always, the appearance of the characteristic manifestations of paralysis are preceded by vari- ous prodroma, such as slight febrile action, general discomfort, pulling and shooting pains in the back and the limbs, pares- thesia of various kinds, as formication, numbness in the feet and finger-tips, and the like, generally also a feeling of great weari- ness and striking weakness. These may last for a longer or shorter period, for one or for several days, even a week and longer; such premonitory symptoms have been observed for as long as six weeks. VOL. XIII.—47 738 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. The actual beginning of the disease is marked by a striking weakness of the lower extremities, which increases more or less rapidly, either gradually or with sudden greater steps, and very soon amounts to well-marked paresis. Standing and walking are soon rendered impossible, while when lying down the indi- vidual movements of the legs can still be executed, although with a growing diminution of force. Gradually these movements also fail, first in the joints of the feet, then in the knees, and finally in the hips; and so in the course of a few days, seldom earlier or later, there is complete paralysis of the limbs. The legs then lie there, lax and immovable, show no traces of muscular tension or contractures, exhibit no fibrillar twitchings, nor any other spasmodic manifestations, do not present the slightest resistance to passive movements, and are not subject to pain, or but very slightly so, either spontaneously or on touch or pressure. The paralysis now gradually advances upwards, uniformly and steadily, but seldom interrupted by a prolonged arrest of the malady. The muscles of the trunk are next attacked ; sitting up and sitting straight are gradually rendered impossible by the paraly- sis of the muscles moving the spinal column ; the acts of expira- tion, of coughing and sneezing, of defecation, etc., become weak and powerless through paralysis of the abdominal muscles. Not long after—though here, it is true, the rapidity of the progress is very variable in different cases—the upper extremities are also attacked with the weakness and paralysis. First the hands grow weaker and less steady, the strength of grip dimin- ishes rapidly, ordinary acts, such as writing and feeding one's self, grow impossible. Then the movements of the arms grow increasingly more difficult, finally the movements in the shoulder- joint, too, become more or less feeble and paralyzed, so that at last the arms, like the legs, are entirely relaxed and immovable. Then, too, disturbances of inspiration also appear, owino- to paralysis of the intercostal and other respiratory muscles of the trunk. When the disease has become developed up to this point an objective examination shows very little that is marked aside PARALYSIS ASCENDENS ACUTA. 739 from the motor disturbances. As a rule, the very slight disturb- ance of sensibility is especially noticeable. Subjective disturbances of the same, it is true, are not rare; patients complain of a feeling of numbness and formication in the lingers and toes, a diminution of feeling in the soles of the feet, rarely of higher grades, of loss of feeling in the lower extremities. There is generally no pain, or but an insignificant amount only at the beginning. The spinal column is not painful, the spinous processes not sensitive on pressure. Objective tests of sensibility, in the majority of cases, give quite normal results; occasionally it is found slightly though distinctly lowered, especially towards the periphery of the ex- tremities. More rarely higher grades of ana:sthesia are demon- strated, and it may be a matter of doubt whether these cases belong in this category at all. These statements hold equally good for sensation of the skin and muscles. In single cases a tolerably high grade of hyperesthesia of the skin (hyperalgesia) has also been demonstrated. At all events, however, the disturbances of sensibility play a subordinate role, in the picture of the disease, as compared to the motor paralysis. No ataxy can be demonstrated, as long as any movements are capable of being carried out, although the feeble, trembling movements of the paretic limbs sometimes remotely remind us of this condition. There is likewise no considerable atrophy of the paralyzed muscles. During the progress of the disease more or less con- siderable emaciation may appear, as in any one long confined to a sick-bed ; but there is no question of a high grade of rapidly progressive atrophy, as in poliomyelitis anterior, and the few cases in which such has been reported were probably wrongly classified. Another fact which stands in most intimate relation to the one just stated, and which appears to be of no less value in a dif- ferential diagnosis, is that the electrical excitability of the para- lyzed nerves and muscles remains entirely normal. In all the more recent cases, carefully investigated by skilled hands (Pel- legrino-Levi, Bernhardt, Westphal, etc.) no anomaly of electrical 740 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. excitability worth mentioning has been found, even after the disease had existed for a number of weeks. By this very means the disease seems to be distinguished, in a very significant manner, from all progressive paralyses caused by gross anatomi- cal lesions within the spinal cord (myelitis centralis, poliomyelitis anterior subacuta, etc.). At all events the careful testing of electrical excitability is worthy of special attention in all future cases. But little is said with regard to the existence of vaso-motor disturbances. In Eisenlohr's case there was transitory oedema of the skin, with redness of the integument over various joints. In some cases a profuse secretion of sweat is reported. The nutrition of the skin does not usually suffer. Bed-sores do not occur. The conditions of reflex action certainly deserve more careful attention, as they are probably also of diagnostic significance. Statements with regard to the reflex action of the skin are very various; it also appears that this changes gradually during the course of the disease. It is but rarely that an elevation of reflex action is reported (Eisenlohr's case); histories of cases generally show that reflex action is preserved during the first days and weeks of the disease, that it then diminishes more or less rapidly, and is finally entirely extinguished. If, as a general rule, reflex action thus entirely fails in well-marked and complete paralysis, still this does not seem to occur as rapidly and completely as it does, for instance, in poliomyelitis anterior. Special attention might be paid to this point. The reflex excitability of tendons has, thus far, only been examined by Westphal, who, in one case, found it, as well as the excitability of the skin, to be lacking. The condition of the sphincters is a matter of no less impor- tance. The bladder and rectum are generally quite undisturbed in their functions ; there are no involuntary evacuations, there is no retention of urine—this is the rule. In individual instances, however, slight disturbances of the bladder occur; generally, however, even if they become more severe, they are merely transi- tory. Usually there is no trace of the severe paralysis of the bladder and rectum which occurs as a rule, for example, in central myelitis, and it is only exceptionally that the use of the PARALYSIS ASCENDENS ACUTA. 741 catheter is required (cases of Dejerine and Goetz). In one case Pellegrino-Levi found the urine alkaline. There is usually con- stipation, which may, under some circumstances, become very obstinate. Statements vary considerably with regard to the general con- dition of the patients; it may be more or less disturbed, although, in some instances, it is remarkably good. In the majority of in- stances there is said to have been no fever ; at all events, it does not belong to the essential manifestations of the disease. In some cases active fever has been found, in others only a moderate de- gree of the same. At other times, again, single severe attacks of fever, with a chill, have been encountered ; or there might merely be slight, transitory, febrile movement, extending over several days. This question, too, requires further more careful investi- gation. In most striking contrast to the severe manifestations of spi- nal paralysis (for we can hardly regard it as being anything else) is the complete integrity of the functions of the brain, at first and during the earlier period of the disease. Intelligence and memory, consciousness and the functions of the special senses remain entirely normal; there never is any dizziness, delirium, and the like, and even complaints of headache belong to the rari- ties in this disease. Even the cerebral motor nerves either take no part at all in the general paralysis, or are not involved until very late. Actual paralysis of the muscles of the eye has not been observed; transitory amblyopia has been reported in two cases. Only those motor nerves which are directly dependent on the medulla oblongata are, as a rule, sooner or later involved in the paralysis. After the disease has once reached the stage heretofore de- scribed, its further course may vary somewhat. In most instances the disease advances still further upwards. The movements of the head and neck now begin to be disturbed ; the muscles of the neck grow paralyzed; patients complain of weakness or of a feeling of stiffness in the neck ; sometimes dis- tinct weakness in the domain of the facial nerve sets in. Respi- ration grows increasingly difficult; a high degree of dyspnoea 742 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. occurs, with very frequent and anxious respiration ; the activity of the diaphragm has been impaired, and the danger of asphyxia draws threateningly nearer. Simultaneously herewith, or it may be earlier or somewhat later, disturbances of articulation of the voice, of speech set in, caused by paralysis of the muscular ap- paratus pertaining to these functions. To these are added weak- ness and paralysis of the muscles of mastication, paresis of the soft palate (nasal speech, the regurgitation of fluids through the nose), difficulty of swallowing, and finally complete paralysis of deglutition ; in a word, the complete picture of severe bulbar par- alysis. If we add that not infrequently differences in the two pupils may be observed, and that the frequency of the pulse often rises to a very alarming height, we shall therewith have completed the clinical picture which indicates an advance of the process to the uppermost divisions of the cervical spinal cord. All these manifestations continue to increase, while evidences of hyperemia and hypostatic congestion of the lungs appear, and the danger of asphyxia is augmented, until the fatal termi- nation is more or less rapidly ushered in. The period of time which elapses before this termination is reached may vary considerably. Sometimes it is but a few days; the disease has been seen to run its course and end in death within two or three days, although it may last for two, three, and four weeks; it seems to be rare for the disease to extend over as long a time as six weeks. The average duration of fatal cases seems to be eight to twelve days. But another termination is possible, having occurred in a series of cases which may probably be counted as belonging in this category, viz., a termination in improvement and recovery. Landry even speaks of eight recoveries in ten cases, and Pelle- grino-Levi found at least five cured out of fourteen diseased. The disease may come to a stand-still at any stage of its de- velopment ; then, some day, the paralysis extends no further. This generally appears to be the case before the paralysis has reached the nerves of the bulb, though instances have also been known in which recovery took place in spite of the existence of disturbances of respiration, deglutition, and mastication. The favorable turn usually takes place after the disease has PARALYSIS ASCENDENS ACUTA. 743 lasted but a comparatively short time ; some single movements appear to be a little better and stronger, others return once more ; those parts last attacked by the paralysis are the first to show improvement. This gradually increases ; the strength and power of function of the muscles grow from day today; first the patients can use their hands again, gradually they learn to sit up, finally again to stand and walk. This may occupy a con- siderable time ; it is always to be counted by weeks, and whether it be many weeks or few, varies very much in individual cases, and depends on circumstances entirely unknown to us. Usually the patients feel very weak and poorly for quite a while ; fluctu- ations and relapses in this favorable course also seem to be pos- sible. Exceptionally the disease may be seen to progress downwards within the cord, instead of pursuing the more frequent ascending course. The paralysis then begins in the nerves of the bulb, and successively seizes first the upper and then the lower extremities. So in the case of the distinguished Cuvier, as reported by Pellegrino- Levi. It may seem doubtful whether Westphars Case 4 belongs under this head. This was likewise an instance of acute, fatal paralysis, with a perfectly negative result of post-mortem examination, but confined to the nerves of the bulb; there was paral- ysis of the tongue and lips, of deglutition, mastication, and respiration. This case would have to be considered as one of a more rudimentary character, more limited in its localization, and rendered rapidly fatal by this very localization. But it is probably better for the present to regard it as doubtful, and to leave it unclassi- fied. Diagnosis. The picture delineated in the preceding pages is probably sufficiently characteristic to admit of a diagnosis of the disease being made in a fair proportion of the cases. The paralysis, chiefly of a motor character, progressing rap- idly from below upwards, the small amount of fever, the insig- nificant disturbances of sensibility, the absence of paralysis of the bladder, the slow extinction of reflex excitability, the ab- sence of muscular tension and muscular atrophy,- the non-occur- rence of bed-sores, and the final involvement of the functions of 744 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. the bulb would seem to be sufficiently indicative of this disease to point suspicion that way. At the same time a positive decision will often not be pos- sible, especially during the first few days, and the diagnosis may for a time be unsettled. The affections with which acute ascend- ing paralysis may be confounded are particularly the different forms of acute and subacute myelitis, but on careful considera- tion of all the symptoms one will generally be able—especially in the course of several days—to arrive at a tolerably certain decision. This affection is hardly liable to be confounded with acute poliomyelitis anterior (section 15) because the latter has no progressive character, never attacks the medulla oblongata, and never directly induces death; because it generally sets in with fever, with very rapid loss of faradic excitability and rapid mus- cular atrophy, etc. It is only in the light and temporary forms of acute poliomyelitis anterior—which, however, are very rare— that a doubt might perhaps arise. But these may perhaps be distinguished from the light forms of acute ascending paralysis by the entire failure of reflex excitability (?), and certainly may be distinguished by the lowering of faradic excitability—even though it be but slight,—and by the non-progressive character of the paralysis. It is an easier matter to confound this malady with those cases of subacute anterior poliomyelitis, which pursue a com- paratively rapid course in an upward direction. Indeed this disease has, by a number of writers, been regarded as identical with Landry's paralysis. This is certainly incorrect, as will appear on a careful comparison of the symptoms of the two forms of disease. The first argument in favor of the existence of acute ascending paralysis is to be found in the absence of atrophy and in the fact that the electrical excitability remains intact; then the longer preservation of reflex action, the possible presence of slight disturbances of sensibility and of the bladder, the more rapid and generally fatal termination, and the early appearance of severe symptoms of bulbar trouble, also point in the same direction. Generally, however, we shall be able to conclude with certainty that a given case of paralysis is due to anatomical PARALYSIS ASCENDENS ACUTA. 745 changes in the spinal cord, only on the development of atrophy and of the reaction of degeneration. As a rule, Landry's paralysis can easily be distinguished from acute central myelitis (see above, p. 416). In the latter there is always a high degree of disturbance of sensibility, the early fail- ure of all reflex actions, great paralysis of the sphincters, fever, acute bed-sores, a lowering of faradic excitability, and a rapidly fatal termination. Hence the distinction is not difficult. The spinal forms of syphilis, which run their course under the form of acute ascending paralysis, may be distinguished from the latter, if, indeed, they are not identical with it, only by the evidence of former or still existing syphilis in the patient, and by the results of anti-syphilitic treatment. Infectious myelitis, of which Baumgarten has certainly not given us a very complete clinical picture, ought to be distin- guished from Landry's paralysis by the same signs which char- acterize any other diffuse or central myelitis. The rare cases of acute multiple neuritis, one of which Eich- horst1 has recently described, could only be mistaken for acute ascending paralysis by a very careless observer. The severe pains, limited to single nerve-roots, the anaesthesia and paralysis, similarly limited, and especially the rapid lowering of electrical excitability, should be enough to guard against this error. Prognosis. Acute ascending paralysis is always a disease of very doubt- ful prognosis. If it is far enough developed to be diagnosticated with certainty, then the prognosis is generally very serious. It becomes worse the more rapid has been the ascending course of the disease, the earlier respiration has been attacked, and the more pronounced the evidences of bulbar paralysis. But we have seen that there are also exceptions to this rule, that no small number of cases even terminate favorably. It is difficult, however, to recognize these favorable cases early ; as a rule, this is impossible until improvement has begun. Perhaps 1 Neuritis acuta progressiva. Virchow's Arch. Vol. 69. 1877. 740 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. further experience will give us some fixed points for such a dis- tinction. Therapeutics. It is difficult, in view of our entire ignorance with regard to the true essence of the disease, to decide on any definite thera- peutic course. One will be inclined, in general, to employ the treatment ap- plicable to the acute ascending forms of myelitis. But it is a question whether the good results of this treatment have not been observed in those very cases which have been falsely diag- nosed as acute ascending paralysis. The main object of treatment certainly is to bring about a change in the nutrition of the nerve-elements of the spinal cord. This is an indication more easily set up than fulfilled. It is more than doubtful whether the energetic application of derivatives to the spinal column is justified by this indication. The favorable results attained by Levy and Salomon with the actual cautery occurred in cases which most probably did not belong under this head. At the same time, in so serious a dis- ease, one would not shrink from the frequent application of dry or wet cups, from repeated blistering, and, in case life was threatened, even from the use of the actual cautery. Careful stimulation of the activity of the skin is more likely to prove of benefit. This may be accomplished by frictions of the skin with cold water, the repeated application of Priessnitz' s "packs" to the trunk or to the entire body, lukewarm baths, cold affusions, etc. Of internal remedies, iodide of potassium is generally used as the nearest refuge in this therapeutic extremity, or nux vomica. Their effects are doubtful. An agent which promises much, and is certainly worthy of being more carefully tested, is the galvanic current. While its value has been established beyond a doubt for the later stage of the cases that terminate favorably, the question still remains to be decided, when its application is to be commenced. A priori, we would seem to be justified in beginning it very early, as there INTRAMEDULLARY TUMORS. 747 is no fever, no inflammation, but merely an impalpable disturb- ance of nutrition in the spinal cord. And it is against just such a condition that the galvanic current, perhaps, shows itself espe- cially efficacious. The application of a constant, moderately strong current the length of the spinal column might be tried first. As a matter of course, these patients require the most careful nursing; their nourishment must be tonic and abundant; and on the appearance of symptoms of paralysis which threaten life, the free and energetic use of all the various stimulants (alcohol, coffee, musk, camphor, ammonia, nux vomica, etc.) must not be omitted. In those cases which terminate favorably, subsequent treat- ment with electricity, baths, cold water, mountain air, etc., is indicated. 18. Tumors of the Spinal Cord.—Intramedullary Tumors. Lebert, Traite" d'anatom. patholog. Tom. II.—Ollivier, 1. c. 3. 6d. Tom. II. p. 503. 1837.— Foerster, Handb. der pathol. Anat. II. 2. Aufl. S. 628. 1863.— Virchow, Die krankhaften Geschwulste. Bd. 1 u. 2.—Leyden, Klinik der Ruckenmarks- krankh. I. S. 468. 1874.—M. Rosenthal, Klinik der Nervenkrankh. 2. Aufl. S. 349. 1875.—Hasse, 1. c. 2. Aufl. S. 729-735. 1869. Eager, Arch, ggngr. 1834. Tom. 4. p. 605.—Brown-Sequard, Course of Lectures, etc. Phila. 1860. p. 60, p. 101, etc. Paralysis of the Lower Extremities. Lon- don, 1861. p. 92-99.—Gendrin, Tubercule comprimant, etc. citg par Brown- Sequard. Journ. d. 1. Physiol. T. VI. p. 233.— IV. Gull, Cases of Paraplegia. Guy's Hosp. Rep. VIII. S. 113. 1858.—Schueppel, Gliom u. Gliomyxom des R.-M. Arch. d. Heilk. VIII. S. 113. 1867.— W. Scholz, Paraplegie u. s. w., Bindegewebsneubildung im R.-M. Allg. militararztl. Zeitung, 1868. Nr. 28— John Grimm, Ein Fall von progress. Muskelatrophie. Virch. Arch. Bd. 48. S. 445. 1869.__E. K. Hoffmann, Gliomyxom im oberen Theil des Lendenriicken- marks. Zeitschr. f. rat. Medic. III. Reihe. Bd. XXXIV. S. 188. 1869.— J. Sa?i- der, Fall von Paralysis atrophica. Arch. f. Psych, u. Nervenkrankh. II. S. 780. 1870.—Habershon, Clinical Cases, etc. Tubercle in the Spinal Cord. Guy's Hosp. Rep. XVII. p. 428. 1872.—G. Hayem, Tubercule d. 1. moelle ep. Arch. d. Physiol. V. p. 431. 1873. — Charcot, Lecons sur les maladies du syst. ner- veux. II. S6r. 2. Fasc. 1873.— Chvostek, Zwei Falle von Tuberkulose des R.-M. Wien. med. Presse, 1873. Nr. 35. 37-39.— Westphal, Fall von Hohlen- und Geschwulstbildung im R.-M. Arch. f. Psych, u. Nervenkrankh. V. S. 90. 1874. — Th. Simon, Ueber Syringomyelic u. Geschwulstbildung im R.-M. Ibid. V. 748 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. S. 120. 1874.—Liouville, Nouv. exempl. de 16s. tubercul. dans la m. 6p. Arch. gener. 1875. Janv. p. 92.—Klebs, Beitr. z. Geschwulstlehre. Leipzig, 1877. S. 89. Prag. Vierteljahrschr. Bd. 126 u. 133. In this section we shall consider those pathological neoplasms which are developed within the substance of the spinal cord itself, in so far as they occur in the form of tumors, and are more or less sharply distinguished from the substance of the cord. Tumors of the substance of the spinal cord are very rare affections; they are also, clinically, very difficult or impossible to recognize with certainty, and therefore seem to be of but little practical importance ; consequently, we shall treat the subject briefly. Pathological Anatomy. There are but few forms of neoplasm that have thus far been observed in the spinal cord itself, and but single ones of these have acquired some degree of practical importance through the comparative frequency of their occurrence. Such are gliomata and tubercle of the cord. The majority of medullary neoplasms appear to be developed in the midst of the substance of the spinal cord ; only in rarer instances do they grow from the spinal meninges into the cord. It cannot as yet be determined whether the white or gray matter of the cord affords the principal soil for the development of the various neoplasms. Some writers assert one thing, some another. Perhaps the relations vary according to the various forms of neoplasm. According to the observations of Th. Simon, it would almost appear as though the anterior portions of the white pos- terior columns were the favorite seat of some neoplasms. This much, however, is certain, that intramedullary neoplasms may be developed from the most varied points in the gray and white substance of the cord. The size of the tumors can never be very considerable, on account of the narrow space within the spinal canal. They are generally round or longish growths, from the size of a hemp-seed to that of a hazel-nut, or even of a thumb. In single cases however, extraordinarily elongated tumors have been found' INTRAMEDULLARY TUMORS. 749 which have stretched, in various degrees of thickness, through- out the entire cord, from the conus medullaris to the medulla oblongata. The substance of the spinal cord is at first only crowded apart by the tumors, more or less compressed, and finally caused to disappear entirely ; more rarely the substance of the cord passes directly into the mass of the tumor. An inflammatory softening is always developed in the neighborhood of the neoplasm, a transverse myelitis, whence in many instances the first severe clinical symptoms proceed. Aside from this, the secondaiy ascending and descending degenerations so often spoken of are generally developed. In the tumors themselves processes of softening are not rare ; the same is true of the secondary development of cavities (syrin- gomyelia), extravasations of blood, etc., as we shall see when studying the individual forms of the affection. Among the tumors thus far observed in the cord, glioma is probably the most frequent variety (cases of Sander, Simon, Case VII.; Schueppel, Case I.; Klebs and others). It usually appears as a soft, grayish-red or grayish-white mass, of a roundish or more elongated shape, often very long drawn out and irregular in form. In many places it is merged impercebtibly in the surrounding tis- sue. It is very vascular, disseminated with numerous larger and smaller blood-vessels, and not rarely shows more or less extensive hemorrhages into its substance and in its neighborhood. The secondary development of cavities is very frequent in gliomata, especially of the softer form, and part of the cases of disease described under the name of syringomyelia evidently belong here (Westphal, Th. Simon). The very vascular forms have probably also been described as teleangiectatic gliomata. This variety, in particular, shows especially extensive hemorrhages. According to Virchow, gliomata proceed from the neuroglia, and represent nothing else than a hyperplasia of the neuroglia. They consist of cells which are imbedded in a granular or fibril- lated, or sometimes also in a more mucous basement membrane. Their wealth of cells varies more or less ; their wealth of vessels is generally very considerable. The nerve-elements (fibres and cells) have generally entirely disappeared within the tumor, 750 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. according to the reports of the majority of authors (Virchow, Charcot, and others). On the other hand, Klebs has recently undertaken to show that all these tumors principally proceed from the nerve-elements, partly from true ganglion-cells, partly from medullated nerve-fibres, and that associated herewith there is a mighty devel- opment of blood-vessels and lymph-vessels. He therefore calls these tumors neuro- gliomata. It is claimed that the interruption of nervous conduction occurs much later in these hyperplastic tumors than in those forms of tumor which act upon the nerve-tracts through mechanical pressure. This might be of value from a clin- ical point of view. Further investigations may reconcile these differences. Gliomata of the spinal cord are said to occur principally in the cervical portion of the same, and, according to Schueppel, to arise chiefly from the gray substance. Myxoglioma (Simon, Case VIII. ; Schueppel, Case II. ; Hoff- mann) is to be regarded as a variety of glioma. It is a bright red, translucent, viscid tumor, in which the cell-elements are im- bedded in a basement substance containing mucine, and which otherwise acts just like the simple glioma, with which the myxo- glioma is sometimes combined. The same is true of gliosarcoma, of which Westphal has described one case. Pure sarcoma (Foerster, Tuengel in his clinical communica- tions, Hamburg, 1864, p. 27) is certainly a very rare form of tumor within the spinal cord. Virchow has never seen an instance of it. Myxosarcoma has been observed here and there as a long-drawn tumor with the development of a number of central cavities. The cases of Hutin and Scholz, and the case of Sonnenkalb, re- ported in Ollivier, 1. c, II., p. 402, perhaps belong in the cate- gory of fibrosarcomata. On the other hand, tubercle is one of the most frequent tumors, perhaps the most frequent, of the spinal cord (Charcot). It has been observed in numerous cases (Gull, Eisenschitz, Virchow, Hayem, Liouville, Habershon, Chvostek, and others). Tubercle of the spinal cord occurs at all periods of life, most frequently between the ages of fifteen and forty, and compara- tively oftener during youth. These growths may be developed in all portions of the cord, but are especially fond of the two enlargements of the same, and according to Hayem are especially liable to occur in the lumbar INTRAMEDULLARY TUMORS. 751 enlargement. Sometimes they occupy principally the white, and sometimes principally the gray substance. Their size varies from that of a hemp-seed to that of a hazel-nut, or larger ; they gener- ally occur singly, rarely several are found at once, or a whole group of them. Tubercle of the spinal cord is seldom the only localization of tuberculosis within the body; there is almost always simultaneous tubercle of the brain, or tuberculosis of the lungs and other organs of the body can be demonstrated. Very generally gray miliary tubercles are at the same time to be found in the meninges of the cord. Tubercles of the spinal cord have quite the appearance of the well-known, far more frequent tubercles of the brain; they are roundish, hard tumors, of a dry quality, of yellowish-white, cheesy color, of a lamellar arrangement on their cut surface; the peripheral layers are often more gray and hard, and contain young tubercle granulations. Sometimes a central cavity is met with, containing softened matter of a cheesy or pasty consist- ence (Chvostek, Habershon). In the vicinity of the neoplasm there is always more or less extensive softening of the spinal cord, of an inflammatory nature; a secondary myelitis which is especially pronounced in the gray substance, and extends to a variable degree upward and down- ward within this substance. Sometimes, too, a species of encap- sulation through sclerotic tissue is met with in the vicinity. According to circumstances—according to the position of the tumor—there will be secondary ascending or descending de- generation. Sypldlomata, gummata, are, on the whole, but rarely found within the spinal cord (cases of E. Wagner, Moxon, Charcot and Gombault, and others). They are then generally multiple, and occur simultaneously also in the brain. They have the same peculiarities as other gummata of the central nervous system. Carcinoma seems never to occur primarily in the spinal cord, if we ignore the earlier, very doubtful reports with regard to "cancerous" new growths in the cord. Even the case of tumor of the cord, reported by John Grimm as medullary carcinoma, is probabty somewhat questionable. Very frequently, however, carcinomatous growths, taking their origin from the vertebre, 752 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. grow into the spinal cord, but then they run their course quite in accord with the clinical picture of meningeal tumors. Probably those alterations within the cord which have been described under the names of hydromyelus and syringomyelia may also be in part counted among tumors of the cord. Although they are not exactly rare, they are of very little practical impor- tance on account of frequently running their course entirely unac- companied by any symptoms. Their method of development seems to be various ; sometimes there is an actual malformation, sometimes a secondary widening of the central canal, sometimes a secondary development of cavities, such as occur from processes of softening in myelitis,or more frequently (Th. Simon) in actual neoplasms (gliomata, myxogliomata, myxosarcomata, etc.). Etiology. The causes of intramedullary tumors are as yet quite obscure. Xaturally enough, here too, as in meningeal tumors, the blame has been attached to all sorts of conditions, but it is generally very hard to tell with what degree of justice. Traumatic lesions, a blow, a jar, a fall upon the spinal col- umn, are among the causes, the efficacy of which we should be most inclined to recognize. The influence of pregnancy and the puerperal state are quite uncertain. These might more readily be believed to give occasion for the appearance of the first symptoms where the neoplasm already existed but was as yet latent. It cannot be regarded as settled whether severe frigid, pro- longed trouble, and the like, are capable of causing the develop- ment of a tumor of the spinal cord. It is certain, however, that some general diseases and dyspa- sias are capable of occasionally becoming localized in the spinal cord. This is true of scrofula and tuberculosis, as shown by tubercle of the cord ; of syphilis, as shown by spinal gummata. We know of nothing further to say with reference to the etiol- ogy of intramedullary tumors. INTRAMEDULLARY TUMORS. 753 Symptomatology. The picture of disease by which tumors of the spinal cord betray themselves is exceedingly variable in different cases ; it is manifold, and generally at the same time so uncertain that there can ordinarily be no such thing as a positive recognition of the same. This lies in the very nature of the case. Either a more or less complete paraplegia appears, with all the usual signs observed in every myelitis from compression (paralysis of motion, sensation, and of the bladder, increased re- flex action ; finally, atrophy, bed-sores, etc.). The development of this paraplegia sometimes, though by no means always, occurs with lively excentric pain, shooting pains in the limbs, constrict- ing pains like a girdle, etc., similar to the symptoms in meningeal tumors, with parsesthesia, local atrophy, and the like ; sometimes it comes on with vague and uncertain symptoms (paresthesia, weariness, stiffness, slight atrophy, etc.) lasting for a long time, until the paraplegia then suddenly and somewhat rapidly de- velops itself, evidently caused by a rapidly spreading transverse myelitis, or it may be by hemorrhage into the tumor itself and its surroundings. Or a quite partial paralysis is at first developed, which may remain for a long time confined to one upper extremity, for in- stance, and then, in an irregular manner, seize the other extrem- ities until the paraplegia has become complete. In such cases, too, the symptoms of a unilateral lesion have been observed for quite a long while (cases of Scholz, Gendrin), which have then, in the further progress of the affair, developed into complete para- plegia. Or various other groups of symptoms are called forth (progressive muscular atrophy, symptoms of tabes, signs of spasmodic spinal paralysis, etc.) according to the position, seat, and principal direction of development of the tumor. In not a few cases the manifestations during life are exceed- ingly insignificant, and one is astonished, on making a post-mor- tem examination, to find such extensive changes in the spinal cord. This seems to be especially the case when a tumor quite centrally developed crowds the substance of the cord apart, and VOL. XIII.—48 754 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. does not entirely destroy it. Th. Simon has even reported sev- eral exceedingly remarkable cases which ran their course entirely without any symptoms. But when it is not a question of just such quite exceptional instances, then the picture of the disease is usually that of a transverse myelitis, being more or less rapidly developed and extending over a transverse section of the cord. Sometimes the disease runs a more acute, sometimes a more chronic form, and it is but seldom that in this picture the presence of a tumor can be recognized as the cause of the transverse myelitis. In some single instances the disease also appears under the picture of a slowly ascending, chronic, spinal affection, which runs its course under the most complicated manifestations, and does not present the picture of the previously described chronic diseases of the general system ; therefore, represents more the picture of a diffuse ascending myelitis. In still rarer instances one may also recognize a descending extension of the neoplasm, or of the myelitis caused thereby, within the gray substance, by the subsequent disappearance of reflex excitability, the occur- rence of extensive muscular atrophy, etc. The attempt has thus far been made in vain to secure, from amongst the individual symptoms, at least a few fixed points on which to base the diagnosis of intramedullary tumors. The following have been claimed as such. A somewhat long antecedent history of active local manifestations of irritation, belt-like pains, excentric pains, definite paresthesias, local paral- yses, as in meningeal tumors; early and well-marked atrophy, which points to a larger involvement of the gray substance; striking fluctuations in the course of the disease, spontaneous improvement, and equally spontaneous growing worse again (Schueppel) ; and finally, Schueppel has also tried to connect the occurrence of scoliosis (curvature of the spinal column to the side on which the tumor is situated) with the presence of a tumor. In this he is doubtless wrong, as this manifestation merely depends on unilateral paralysis of the muscles of the back, which may depend on all sorts of causes. Whoever is at all familiar with the story of chronic spinal diseases will readily see that all these symptoms are of but very subordinate signifi- INTRAMEDULLARY TUMORS. 755 cance, and will never justify a positive conclusion as to the pres- ence of a tumor. The termination of tumors of the spinal cord is doubtless in the majority of instances fatal, with the single exception of syphilomata, in which energetic specific treatment may bring about a cure. The fatal termination may be brought about in various ways. After the disease has perhaps remained latent for a considerable time, or has only betrayed itself by slight and insignificant mani- festations, an acute aggravation thereof suddenly occurs, and the disease then runs its course to death under the picture of an acute or subacute transverse myelitis. Or the affection progresses slowly, more and more compli- cated and severe symptoms showing themselves gradually ; the evidences of paralysis take an ascending course, disturbances of respiration, paralysis of deglutition, etc., are added thereto, and bring about the end. Or death is induced by intercurrent diseases developed dur- ing the progress of the spinal difficulty (typhus, variola, and the like), to which the patient is perhaps able to offer less than the usual amount of resistance. The duration of the disease is not easily determined, as we can generally arrive at no certainty with regard to the beginning of the development of the tumor, unless very positive causes for the same can be demonstrated. As a rule, however, but a few years elapse from the beginning of the symptoms to the fatal termination—sometimes but a few months. Diagnosis. It is evident, from what has been said above, that the diagno- sis of an intramedullary tumor is but very rarely possible. As a rule, one will have to be content with making out a distinctly localized, more or less extended, chronic spinal affection, under which one may only in exceptional cases, with a certain degree of probability, conjecture the presence of a tumor. This prob- ability may rest upon the etiological conditions which may hap- pen to be present; upon the demonstration of some previous 756 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. traumatic cause, or existing scrofula, or tuberculosis, or syphi- lis. Among the symptoms those which perhaps deserve special consideration are the fluctuations in the intensity of the paraly- tic manifestations, the not complete interruption of spinal con- duction ; furthermore, it may awaken suspicion of a tumor if the evidences of central myelitis or of haematomyelia supervene upon those of a long-continued, insidious spinal affection. If once the general presence of a tumor within the spinal canal has become probable, it will still be difficult to distinguish an intramedullary from a meningeal tumor. An argument in favor of the former will be found in the slighter intensity of the initial signs of irritation and in the frequently occurring gradual upward advance of the disease. A positive conclusion, however, will but rarely be possible. Prognosis. The prognosis of spinal tumors—with the exception of the syphilomata—is, of course, absolutely unfavorable. In the ma- jority of cases, however—in view of the defective diagnosis—this is first clearly brought to our view by the fatal termination of the case. Therapeutics. Consistently with the above statements we have to admit that our therapeutics are generally quite hopeless. It is only when syphilis exists that we shall attain any results by energetic med- ication directed against this disease. We know at present of no remedy for the other neoplasms. And yet we would not for that reason oppose any attempt that may be made with iodide of potassium, arsenic, iodide of iron, cod-liver oil, etc. As a rule, we shall have to confine ourselves to the treatment directed against subacute and chronic myelitis, which has been explicitly set forth in previous sections, until we have convinced ourselves and the patient of the hopelessness of all further at- tempts at a cure. SECONDARY DEGENERATIONS. 757 19. Secondary Degenerations of the Spinal Cord. L. Tuerck, Ueber ein bisher unbekanntes Verhalten des R.-M. bei Hemiplegien Zeitschr. d. Ges. d. Aerzte in Wien 1850. Heft. l.—L. Tuerck, Ueber secun- diire Erkrankung einzelner Riickenmarksstrange und ihrer Fortsetzungen zum Gehirn. Sitzungsber, d. kais. Akadem. d. Wiss. Mathem.-naturw. Classe. Bd. VI. S. 288-312. 1851 und Ibid. Bd. XL S. 93. 1853.—Leyden, Ueber graue Degener. des R.-M. III. Deutsch. Klin. 1863. Nr. 13.—Bouchard, Des degen- erations secondares d. 1. moelle epin. Arch, gener. de med. 1866. Vol. I. pp. 272, 441, 561. Vol. II. p. 273.—Charlt. Bastian, Case of Concussion-lesion with Extensive Secondary Degeneration of the Spinal Cord, etc. Med. Chir. Trans. L. pp. 499. 537. 1867.— H 0. Barth, Ueber secund. Degener. des R.-M. Arch. d. Heilk. X. S. 433. 1869.— Vulpian, Experiences relat. a" la pathogenie des atrophies second, d. 1. m. ep. Arch. d. Physiol. II. p. 221. p. 661. 1869. III. p. 521. 1870.— Westphal, Ueber ein eigenth. Verhalten secundiir. Degenerat. des R.-M. Arch. f. Psych, u. Nervenkrankh. II. S. 374. 1870.—Ueb. kiinstl. erzeugte secund. Degener. einzelner Riickemarksstrange. Virch. Arch. Bd. 48. S. 516. 1869. und Arch. f. Psych, u. Nerv. II. S. 415. 1870.— W. Mueller, Beitrage zur pathol. Anat. und Physiol, des R.-M. Leipzig. 1871. Beob. 1.— C. Lange, Forelaesninger over Rygmarv. Patologi. 1. Heft. Kopenhagen. 1871. Fall von Myelit. interstit. chronica. Hosp. Tid. 14. Aarg. 1871 (s. Virchow- Hirsch, Jahresber. pro 1871. Bd. II. S. 77).—G. Lange, Om lednings forhol- dene i Rygm. Bagstrange, etc. Nord. med. Arkiv IV. Nr. 11. 1872 (s. Vir- chow-Hirsch, Jahresber. pro 1872. Bd. II. S. 79).—Th. Simon, Tumor im Sack der Dura spin., die Cauda equina comprimirend, mit fortgeleit. Degener. d. Hinterstrange u. s. w. Arch. f. Psych, u. Nerv. V. S. 144. 1874.—Leyden, Klinik der Riickenmarkskrankh. II. S. 301-317. 1876.—F. Schultze, Zur Lehre von der secund. Degener. des R.-M. Centralbl. f. d. med. Wiss. 1876. Nr. 10. —A. Pitres, Atroph. muscul. consgcut. a une sclerose descend. Progres med. 1876. Nr. 8.—Des degenerat. second, d. 1. m. epin. dans les cas de lesions cor- ticales. Gaz. m6d. de Par. 1877. Nr. 3.—Charcot, Le9ons sur les localisat. dans les malad. du cerveau. 1. fasc. 1876. p. 145-168.—P. Flechsig, Die Lei- tungsbahnen im Gehirn und R.-M. des Menschen. Leipzig, 1876. S. 230 ff.— Ueber Systemerkrankungen im R.-M. Arch. d. Heilk. XVIII. S. 101 S. 289. 1877.—p Schiefferdecker, Ueber Regeneration, Degenerat. u. Architectur des R.-M. Virch. Arch. Bd. 67. S. 542-614. 1876. A. Vulpian, Influence de I'abolition des fonct. des nerfs sur la region d. 1. m. epin., qui leur donne origine. Exam. d. 1. moelle dans des cas d'amputat. d'an- cienne date. Arch. d. Physiol. I. p. 443. 1868.—Sur les modific. qui se pro- duis. dans 1. m. epin. sous l'influence de la section des nerfs d'un membre. Ibid. II. p. 675. 1869.— Dickinson, On the Changes in the Nervous System which Follow the Amputation of Limbs. Journ. of Anat. and Physiol. Nov. 1868.— Friedreich, Ueber progress. Muskelatrophie u. s. w. Berlin, 1873. S. 138.—Ley- 758 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. den, 1. c. n. S. 314. 1876.—.4. Genzmer, Veranderung im R.-M. eines Ampu- tirten. Virch. Arch. Bd. 66. S. 265. 1876. G. Hayem, Des alterations d. 1. moelle, consecut. & Tarrachement du nerf sciatique chez le lapin. Arch. d. Physiol. V. p. 504. 1873.—Compt. rend. Vol. 78. p. 291. 1871. History. We are indebted to L. Tuerck (1851 and 1853) for the discov- ery and the most thorough examination of certain secondary processes of degeneration which frequently occur within the spi- nal cord. He was the first to make extensive reports with regard to these processes, and his observations, which, in spite of the defective methods of examination then employed, still pass mus- ter at the present day, gave us a well-nigh exhaustive explana- tion of the state of things, to which the most recent research has added but little. Some few observations belonging under this head doubtless received passing notice even before Tuerck's time; thus, for instance, in the " Sepulcretum" of Bonetus. Cruveilhier also found secondary atrophy extending to the pons and the pyra- mids in diseases of the brain, though he found nothing of this in the spinal cord itself. Rokitansky had the same experience. Tuerck, however, was the first one who thoroughly and almost definitively cleared up the question of secondary degenerations within the spinal cord. His statements, however, chiefly refer to the localization and extension of the process under various circumstances. The first somewhat more accurate teachings with regard to the histological conditions in secondary degeneration are those of Leyden, in 1863. After various French and other observers (Charcot, Cornil, and others) had published single cases which belonged under this head, Bouchard (in 1866) issued a work treating of this question in all its phases, in the most masterly manner, wherein he not only sets forth the pathologico-anatomical relations, but also most specifically the pathogenesis and symptomatology of sec- ondary degenerations. SECONDARY DEGENERATIONS. 759 The communications which followed, consisting chiefly of reports of cases, developed nothing new that was of any signifi- cance. The only thing of importance was the demonstration furnished by Westphal—previously sought in vain by Vulpian, but afterwards confirmed by him—that secondary degeneration could also be experimentally produced in dogs. This is a fact of which, alas ! no one has as yet availed himself for the purpose of submitting to an experimental test various still obscure ques- tions connected with secondary degeneration. Quite recently again the doctrine of secondary degenerations has been materially advanced, and in some respects cleared up, by two important and larger works. Flechsig, in his compre- hensive work on the paths of conduction within the human spi- nal cord, has also examined and tested secondary degenerations more carefully, has compared the results of this testing with the very noteworthy results of his investigations into the history of development, and has found them to agree in a way that is en- tirely satisfactory.1 Schiefferdecker too, has, at least in one direction, most carefully worked up a large amount of experi- mental material (in dogs whose spinal cord von Goltz and Freus- berg had divided at a certain point, for purposes of physiological investigation). He has fully confirmed the former doctrines and somewhat extended them. In spite of all this, manj^ a problem still remains to be solved, and although the examination of secondary degenerations has already been of the greatest value in advancing our knowledge of anatomical, physiological, and pathological problems, yet just at this very point there is still a rich field for experimental inves- tigations, which will undoubtedly lead to numerous and impor- tant results. Etiology and Pathogenesis. Since the investigations of Tuerck, it is known that certain diseases of foci lying outside of the spinal cord (especially within 1 In his work, in the Archiv der Heilkunde, which is as yet but partly made public, Flechsig returns, in a more detailed manner and with more positive declarations, to the question of secondary degenerations. 760 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. the brain), and having a definite seat, are followed by a secondary disease of quite definite paths of conduction, which disease is extended for great distances into the spinal cord ; and that simi- larly, in certain diseases within the cord, secondary disease of quite definite paths of conduction extends upward as well as downward, far beyond the limits of the original focus of disease. Finally, the same tiling, even though to a more limited degree, holds true of certain diseases of the peripheral nerve-tracts. Therefore, in diseases which are either developed in its own substance or in some portion of the nervous system lying outside of the same, the spinal cord, in a portion of its tracts, is seconda- rily involved in disease, and, indeed, as has appeared on more care- ful observation, this occurs in a perfectly regular manner and according to certain laws. Those changes in the spinal cord which are thus caused are designated as secondary degenera- tions. They act quite differently, according to the seat of the lesion which causes them. We must therefore distinguish seve- ral groups. a. Secondary degeneration of the spinal cord in diseases of the brain. This is, of course, always descending in its progress, and is as good as exclusively confined to the so-called "pyram- idal tracts" (Flechsig); that is, on the one hand, to the motor conduction-tracts united into a large bundle in the posterior half of the lateral columns ("Pyramidenseitenstrangbahnen "); on the other hand, to the uncrossed pyramidal tracts lying together, usually in a narrow bundle at the inner surface of the anterior columns (" Pyramiden-Vorderstrangband"— Flechsig, "Hiilsen- Vorderstrangband''—Tuerck). This degeneration can be followed upward through the pyra- mids and the pons into the crura cerebri and the fibrillations of the inner capsule ; it extends downward, always growing nar- rower and becoming limited to a smaller number of fibres, into the lumbar portion of the cord, to disappear gradually in the lower half of the same. Descending secondary degeneration of the pyramidal tracts occurs in all destructive diseases of the brain which involve the direct motor paths between the pyramids and the corona radiata (perhaps more accurately the direct motor tracts of the inner SECONDARY DEGENERATIONS. 761 capsule—Charcot). This degeneration is called forth by effusions of blood, foci of softening, neoplasms, scleroses, and chronic inflammations, which to any considerable extent involve the pons, the peduncles, the optic thalamus and corpus striatum, the lenticular nucleus, etc. It has also been found in chronic hydro- cephalus (F. Schultze). An indispensable prerequisite to the occurrence of this degeneration, however, seems to be that the direct motor tracts which run from the pyramids to the inner capsule' must be involved in the lesion ; affections which are rigidly confined to the gray substance of the lenticular nucleus, the optic thalamus or the corpus striatum, call forth no secondary degeneration (Charcot). It is furthermore demonstrated that lesions of any consider- able extent in the centrum ovale, in case they are not situated too far from the foot of the corona radiata, call forth this degener- ation. Finally, it appears, from both older and more recent observa- tions (Tuerck, Bouchard, Charcot, Pitres, Flechsig), that this descending degeneration also takes place in diseases of the cortex of the brain (if they are not very superficial only); but this is only true when such lesions are situated in the so-called " motor sections " of the hemispheres—in the central convolutions and their immediate neighborhood. Here even a comparatively small focus of disease is sufficient to cause the degeneration, while in the ?zc>7i-motor portions of the brain-cortex even larger lesions exist without seconda^ degeneration. In all these brain affections, therefore,—and they constitute no small number of brain diseases generally,—after the lesion has existed for some time, descending degeneration of the pyram- idal tracts takes place, and in the spinal cord this is situated on the opposite side from the brain-lesion in the lateral columns 1 I see by the continuation of Flechsig's work in the Archiv der Heilkunde, which has appeared since the completion of ray manuscript, that the statements of Charcot and Flechsig materially differ with regard to the position of the pyramidal tracts with- in the inner capsule. Charcot places them in the anterior, Flechsig in the posterior divisions of the inner capsule. This question, which can doubtless be definitely settled by further investigations, is of primary interest in connection with the pathology of the brain. 762 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. (therefore crossed) and on the same side with the brain-lesion in the anterior columns. Flechsig has shown that these two tracts are doubtless physiologically of the same significance or function, and that the pyramidal tracts are distributed variously to the lateral and anterior columns, so that in one case all the pyram- idal tracts run through the crossed lateral column, in another case a great part of the same take their way through the anterior column of the same side. In secondary degeneration, therefore, the circumstances of this distribution may also vary. The ease made public by F. Schultze must, thus far, be considered as standing alone. In a sarcoma of the anterior division of the corpus callosum there was de- scending degeneration in the external posterior columns [" Keilstrang "—" Funi- culus cuneatus" of Burdach], reaching down to the dorsal portion of the cord, while Goll's columns and the lateral columns were free. The microscope showed absence of the greater part of the axis-cylinders and marked atrophy of those that remained ; the medullary sheath was chiefly preserved, the neuroglia not increased, no proliferation of nuelei, no granule-cells, no fatty degeneration of the vessels— therefore a picture differing from the one usually found in secondary degeneration. The entire condition of things in this case is unique, if not inexplicable, and it may therefore seem doubtful whether it belongs here at all. b. Secondary degeneration of the spinal cord in diseases of the cord itself.—In all severe diseases of the spinal cord (trans- verse myelitis, myelitis from compression, hsematomyelia, sclero- sis, tumors, etc.), as we have already stated in various places in this book, if these diseases involve the entire transverse section of the cord, or also certain definite portions of the same, second- ary degeneration of definite divisions of the cord will take place. If the disease involves the entire transverse diameter, or at least the greater portion thereof, ascending as well as descending degeneration will be found as soon as the affection has lasted a certain length of time. Ascending degeneration extends: a, to the posterior columns, and especially to the inner halves of the same, which, in the up- per division of the spinal cord, are more sharply divided from the outer halves, and are generally known under the name of "tender columns," or "Goll's columns." In the immediate neighborhood of the lesion the degeneration extends to the entire width of the posterior columns, but it very soon becomes strictlv SECONDARY DEGENERATIONS. 763 limited to Goll's columns, diminishes in extent as it ascends, but can always be followed into the restiform bodies, where it ends. This form of ascending degeneration is very frequent, and is generally easy to recognize by its sharp limitation, and usually very distinct gray discoloration. /3. Ascending degeneration, again, may occupy a narrow zone at the outer periphery of the posterior lateral column, which begins with its greatest width at the point of the gray posterior horn, and extends forward over the greater part of the periphery of the lateral column, as a border which is all the while growing narrower. This degenerated zone can be followed upward to the cerebellum. It was known, although but imperfectly, to Tuerck, was afterwards often overlooked, and has recently again been restored to its legitimate place, and more carefully studied by Flechsig and Schiefferdecker. The tract thus degenerated, which closely and intimately touches the descending degenerated pyram- idal tract of the lateral column, is designated by Flechsig as the "direct cerebellar tract of the lateral column" ("directer Kleinhirn-Seitenstrangband "). Descending degeneration in affections of the spinal cord also extends almost exclusively to the "pyramidal tracts," just in the same manner as in diseases of the brain, that is, with variable distribution to the tracts in the posterior lateral columns and the tracts in the internal anterior columns, only with the non-essen- tial difference that here the gray degenerated spot in the lateral column usually has a somewhat larger extent. Naturally in spinal affections the descending as well as the ascending degener- ation is generally bilateral. Aside from this, Schiefferdecker states that transverse section of the anterior and lateral columns shows scattered fibres of de- scending degeneration, but they are only to be found in the neighborhood of the point of lesion. In lesions which only affect a portion of the transverse section of the cord, we shall also find only correspondingly partial second- ary degenerations. Thus, for example, in traumatic unilateral lesions, the ascend- ing as well as the descending degeneration is confined to the side of the injury. 764 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. In affections that are confined to the fundamental bundles of the posterior columns (" Keilstrange"—" bandelettes externes ") we meet only with ascending degeneration of Goll's columns (perhaps also of the cerebellar tracts of the lateral columns), a condition which probably exists with tolerable regularity in tabes dorsalis. In case of partial lesion of the lateral columns (a circum- scribed sclerosis, effusion of blood, wound, tumor, etc.), we shall find only descending degeneration of the lateral column of that side. It has not yet been determined whether certain lesions of the gray substance can also call forth secondary degenerations, and so far as we know the question has not yet been very closely investigated. It would doubtless be worth the while more care- fully to test the anatomical conditions, with reference to this point, in amyotrophic lateral sclerosis, in the spinal paralysis of children, in progressive muscular atrophy, etc. c. Secondary degeneration of the spinal cord in disease of the peripheral nerves. Such a condition is, thus far, known with certainty to exist only in lesions of the spinal nerve-roots, and, indeed, it would appear, only of the posterior roots. A certain number of observations exists (Cornil, Th. Simon, C. Lange, Leyden) in which tumors on the cauda equina compressed the nerve-roots lying within the same without directly injuring the spinal cord itself, and in which an exquisite ascending degenera- tion of the posterior columns was found, extending to the entire transverse diameter of the same in the lumbar region, and being limited, higher up, to Goll's columns. Lesion of the motor roots, or lesion (section, crushing, etc.) of the peripheral nerve-trunks is not followed by any secondary de- generation in the cord. After having thus enumerated the causes of secondary degen- erations in the spinal cord, we have to add that the pathogenesis of the same is by no means, as yet, satisfactorily cleared up. Closer observation teaches that descending degeneration oc- curs in undoubtedly motor pyramidal tracts, that is, in those leading in a centrifugal direction, only when conduction in these tracts is interrupted at some point of their course. SECONDARY DEGENERATIONS. 765 Furthermore, that ascending degeneration occurs when the posterior roots—therefore, tracts leading in an undoubtedly cen- tripetal direction—are interrupted in their conduction ; likewise, if the posterior columns, which are probably to be regarded as in great part leading in a centripetal direction, are injured ; and finally, if the same thing happens to certain tracts of the lateral columns (the direct cerebellar tracts of the lateral columns). Whether the latter lead in a centrifugal or centripetal direction is not yet determined; at all events, this is not indicated with entire certainty by the direction in which these tracts degenerate on the interruption of conduction. Some authors, then, explain secondary degenerations simply as follows : that the degeneration follows in the direction in which the conduction of physiological excitation occurs, and that the interruption of these processes of conduction—the functional inactivity of the nerve-tracts—is the actual cause of the degener- ation. Therefore the motor tracts have always been found de- generated in a centrifugal, the sensitive always in a centripetal direction. If this were true, then, when a peripheral nerve was cut through, the sensitive fibres ought to degenerate only in a cen- tripetal direction, that is, in the central piece, the motor fibres only in a centrifugal direction, that is, in the peripheral piece. But this is notoriously not the case, both kinds of fibres degen- erating in a centrifugal direction and only in the peripheral division of the nerve. If this were true, then in every descending secondary degen- eration of the pyramidal tracts, in consequence of lesion of the brain or cord, the anterior roots and the motor peripheral nerves would have to degenerate, for these, too, are entirely disturbed in their function. The contrary, however, is true ; the anterior roots and the peripheral motor tracts remain intact in the vast majority of cases (if no special complications exist). The view, therefore, that the degeneration is due to the func- tional inactivity cannot be looked upon as sufficiently well found- ed, as has, indeed, been satisfactorily proven by Bouchard. In my opinion, the only conclusion which can thus far be drawn is, that secondary degeneration occurs as soon as certain 766 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. definite conduction tracts are separated from their trophic cen- tres, their centres of nutrition (Bouchard, C. Lange, and others) Where these centres (centres of development ? Flechsig) lie, and how they are related to the different tracts, is, to be sure, as yet tolerably unknown. There are only some points in regard to which we can thus far draw conclusions with more or less prob- ability of being right; thus, for instance, that the trophic centres for the sensitive tracts ascending with the posterior roots (there- fore, probably, also for the greater part of the tracts subject to ascending degeneration) are probably situated in the spinal ganglia ; that the trophic centres for the anterior roots and the motor nerves are certainly to be sought in the gray anterior horns. But it is as yet entirely unknown where the trophic centres for the pyramidal tracts lie; they may, perhaps, be situated in the gray cortex of the brain, in which, according to recent investiga- tions, large, multipolar ganglion-cells have also been found, such as exist in the gray anterior horns of the cord. The trophic cen- tres for the direct cerebellar tracts of the lateral columns are also as yet entirely unknown. Consequently quite an array of important problems still re- mains to be solved. And however great the advantages which have already accrued to our knowledge of the anatomical struc- ture and physiological functions of the spinal cord, through the study of secondary degenerations, it is equally to be desired that still further and particularly experimental investigations on this highly important question should be undertaken. Those changes in the spinal cord which have been seen to arise after amputations and the resection of nerves only stand in a very distant relation to actual secondary degenerations. After amputation, a non-symmetrical condition of the spinal cord has been found, with narrowing of the entire half of the cord on the side of the amputation, sometimes mostly affecting the anterior, and sometimes the posterior column, and generally also involving the gray substance. Some observers report slight histological changes, diminution in size of the ganglion-cells and nerve-fibres, very slight increase of connective tissue, possibly some diminution in the number of the ganglion-cells; but in the majority of instances the histological condition of the spinal cord was quite normal. The asymmetry was generally more marked in pro- portion to the youth of the individual at the time of the operation, and the length of time that had elapsed since the operation. No doubt here it is a question in part of an arrest of development through the early disuse of the part; probably partly, SECONDARY DEGENERATIONS. 767 also, of simple atrophy from the same cause; and, least of all, also, of the results of a chronic irritative process travelling along the nerves from the point of amputation upward into the spinal cord. All this requires still further investigation. Thus much, however, appears to be certain already, that these changes in the cord arising after amputations, etc., have nothing to do with the secondary degenerations we are here considering; also that they are of very little practical significance. An entirely different matter is the condition of things which Hayem found in the spinal cord of squirrels after tearing out the sciatic nerve. Here it is a question of a direct wounding of the spinal cord, and of a traumatic myelitis arising thence, the more careful study of which promises to be of great importance to the doctrine of acute central myelitis. Exceptionally such a central, ascending myelitis (which leads to progressive atrophy of the muscles) also arises after simple resection of the trunk of the sciatic nerve in the squirrel. Pathological Anatomy. The macroscopic appearance of secondarily degenerated por- tions is, in general, that of gray degeneration, more or less dis- tinct and pronounced ; gray or grayish-yellow discoloration some- times disseminated with fine, whitish lines (vessels with an abun- dance of granule-cells). In more recent cases, a brilliant, pure, milk-white color is also to be recognized (C. Lange). Not seldom, however, in the fresh preparation, nothing at all, or nothing very definite, can be seen with the naked eye; and thus, in a fresh specimen of the cord, no correct idea can be obtained of the existence and extent of the secondary degeneration. This is generally brought out with great distinctness by the familiar coloration of the specimen with chromic acid (a bright yellow appearance), and can then be very well recognized ; but a truly accurate conclusion, especially with reference to the extent of the degeneration, can, after all, only be reached by microscopic examination. After the affection has lasted a considerable time, there is generally no trouble in recognizing distinct atrophy and shrivel- ling of the degenerated columns; the form of a transverse section of the cord may appear somewhat altered thereby, the gray horns being somewhat displaced in one direction or another. In one- sided degeneration, particularly, the asymmetry of the two halves of the spinal cord, on transverse section, thus stands out dis- tinctly. 768 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. The microscopic conditions have not yet been developed with the completeness which we might wish, in all the different stages of the degenerative process, so that a complete account of the histological processes in the same cannot, as yet, be given with certainty. The statements and views of different investigators, with regard to the method and the essential character of the process, also differ as yet in a manner that is not pleasing. In considering them, we must separate the earlier stages (which are far from being satisfactorily investigated as yet) from the later stages (which come under observation by far the most frequently). In the earlier stages of the process we meet principally and almost exclusively with alterations in the nerve-fibres. Their medullary sheaths are found strikingly altered in their reaction with carmine and osmic acid; they break down and become fissured, suffer fatty degeneration, and finally disappear alto- gether. For some time the axis-cylinders alone remain (or per- haps also the horny sheaths recently discovered by Kuehne and Ewald). Along with these processes of degeneration an exceed- ingly abundant development of granule-cells also sets in, which gives a characteristic appearance to the microscopic picture, and which formerly served exclusively for the recognition of second- ary degeneration. During all this the connective tissue is not materially increased ; this does not occur until much later. On the walls of the vessels an abundant deposition of fat-granules and fatty degeneration may be recognized. Aside from this, there is always a not inconsiderable number of well-preserved and apparently normal nerve-fibres to be observed. In the later stages the degenerated tissue appears shrunken, as a whole ; most of the nerve-fibres have entirely disappeared, or their remnants alone can still be demonstrated as narrow, rigid fibres (axis-cylinders? horny sheaths?). The tissue of the neuroglia is materially increased, and is changed into a dense, finely fibrillar tissue, wdiich contains numerous nuclei and spider-like cells. The granule-cells have become more scanty, or have entirely disappeared; not rarely numerous corpora amy- lacea can be seen. In this entirely degenerated tissue, likewise, SECONDARY DEGENERATIONS. 769 single, more or less numerous, well-preserved nerve-fibres are still to be seen. It is evident, then, that these later stages of the process are in no way to be distinguished from ordinal gray degeneration (in tabes, multiple sclerosis, chronic myelitis) ; the histological picture is almost exactly the same. Whether this is also the case in the earlier and earliest stages, we must leave undeci- ded, as no investigations especially directed to this point exist; indeed, the two processes (secondary degeneration and primary sclerosis) have certainly often been confounded with one another. We should think that quite considerable differences would cer- tainly appear, and we consider it as one of the most important tasks devolving upon the students of the pathological anatomy of the spinal cord, finally to clear up these fundamental ques- tions. Not until this is done shall we be able to give a decided opinion as to the method and the essence of this degenerative process, with regard to which the views of different authors at present materially differ. By some the entire process is regarded as an irritative or inflammatory one, which propagates itself directly from the point of lesion by definite tracts, or which is developed in these very tracts by the breaking down of the nerve-fibres. Almost all the facts in the case argue against the theory of an inflammatory process propagated directly from the point of lesion ; and if the more recent statements of careful observers are correct, that the first changes are to be recognized exclusively in the nerve-fibres, and that alterations in the con- nective tissue do not occur until man}7 weeks later, then it will be impossible to sustain this view. After comparing all the statements now before us, it appears to us most probable that we have here to deal with a process entirely analogous to those changes which arise in peripheral nerves after they have been divided; that secondary degeneration, therefore, is nothing else than the degenerative (neurotic) atrophy of certain definite tracts of the spinal cord separated from their nutritive centres. We shall have to leave it undecided for the present, whether the pro- liferation of connective tissue which arises later is called forth by the irritation caused by the products of degeneration of the VOL. XIII.—49 770 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. nerve-fibres, or whether it constitutes an essential part of that degenerative atrophy. Statements differ materially with regard to the period within which secondary degeneration is developed after the occurrence of a lesion which causes it. Tuerck's opinion, that about half a year is required for this purpose, is evidently incorrect; all more recent observations have approximated the end of the period much nearer to the occurrence of the causative lesion, and in cases falling under this head we may be sure of finding the degeneration distinctly developed and easily recognizable after four, six, or eight weeks. Schiefferdecker, in his experiments on dogs, found the beginning of the degeneration at the end of fourteen days. At the end of four to five weeks the well-marked picture of the same was completed, and it was not until the eighth week that he saw changes arise in the connective tissue. The peculiar form of degeneration in ring-shaped figures, which Westphal described, and which was caused by a massive, peculiarly localized accumulation of granule-cells, has not been seen by others, and its significance is as yet entirely unknown. C. Lange thinks it was not a case of secondary degeneration, but a peculiar form of myelitic alteration ; perhaps it belongs under the head of what Schiefferdecker calls " traumatic degeneration." The distribution, as to space, of secondary degeneration in the spinal cord is, in almost all cases, strictly according to rule, and extremely characteristic. Descending degeneration spreads first, in all cases, to the pos- terior half of the lateral columns—not entirely, but in greater part filling out the space between the periphery, the posterior gray horn, and the region near the point of attachment of the ligamentum denticulatum. On making various transverse sec- tions, the transverse picture of the degeneration produced is somewhat varied (see Fig. 18). In the secondary degeneration which follows diseases of the brain, the degenerated portion, at least in the upper half of the spinal cord, does not reach the periphery of the lateral column, but remains separated from the pia mater by a narrow margin of sound tissue, and is generally also somewhat separated in the same way from the limits of the posterior gray horn. Further downward, on the other hand, this healthy peripheral margin SECONDARY DEGENERATIONS. 771 disappears, and the degeneration, although, as a whole, it has grown smaller, reaches entirely to the pia mater in the lower dorsal and lum- bar portions of the cord. The secondary degeneration in such cases can generally be first demonstrated in the me- dullary substance of the cms cerebri; then in the pyramid of the same side, to be followed through the crossing of the pyramids into the lateral column of the opposite side ; the greater part of the degenerated fibres takes this course, while a smaller part often remains on the side of the lesion, to continue its course downward in the pyramidal tract of the anterior column of the same side. The degeneration of the lateral column is most extensive in the cervical portion, and here has more of a triangular form, with the apex directed inward (Fig. 18, 1 to 3); in the dorsal portion it becomes gradually narrow and as- sumes more of a roundish form (Fig. 18, 4 and 5); in the lumbar portion it moves more to- wards the periphery, again assumes more of a triangular form, grows narrower and narrower, finally to disappear entirely at the height of the origin of the third or fourth sacral nerve (Fig. 18, 6 to 8). Aside from this, in descending degeneration, the inner surface of the anterior column (pyram- idal tract of the anterior column) on the same side with the cerebral lesion is usually found degenerated to a greater or less extent. It constitutes a narrow zone, which generally does not extend as far down the cord as the degeneration of the lateral column, but disap- pears entirely (Fig. 18,1 to 6). The occurrence of this degeneration depends on the distribu- tion of the pyramidal tracts in the transverse Pig. 18.—Secondary de- scending degeneration of the pyramidal tracts in primary lesion of the left half of tha cerebrum. The pyramidal tracts of the lateral columns of the right side of the coid are degenerated down to the lowest portion of the lumbar division (1 to 8); the pyram- idal tracts of the anterior columns of the left side are degenerated as far down aa the beginning of the lumbar enlargement (1 to 6). 772 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Fig. 19.—3fyeHtis trans- versa dorsalis, icith second- ary ascending and descend- ing degenerations (half sche- matic). Seat of the lesion at the height of section 5. Above this (1 to 4), second- ary ascending degeneration in Goll's columns and the di- rect cerebellar tracts of the lateral columns. Below the lesion (6 to 8), secondary de- scending degeneration in the pyramidal tracts of the late- ral and anterior columns. diameter of the spinal cord, as has been more carefully investigated by Flechsig; only the pyramidal tracts degenerate. Accordingly, in one-third of all the cases the lateral column alone is found degenerated ; in the remaining two-thirds the degeneration also involves the anterior column of the opposite side. Thus far no instance has been found of degeneration of the pyramidal tract of the anterior column alone. In diseases of the spinal cord the relations of descending degeneration are precisely the same. Only the transition into the original focus of disease is usually very gradual, so that the secondary degeneration is only sepa- rable, little by little, from the more diffuse le- sion of the spinal cord. Here the degeneration everywhere reaches the surface of the cord and can generally be recognized glimmering through the pia mater (Charcot, C. Lange). The distribution to the lateral and anterior columns is the same as in diseases of the brain (Fig. 19, 6 to 8). Naturally, in affections of the spinal cord the degeneration is generally bilateral; still it may also be the same in bilat- eral brain affections. Ascending degeneration of the posterior columns involves that portion of the posterior columns lying next to the posterior fissure, usually having a very sharp outline (Fig. 19, 1 to 4). In the upper portions of the cord it is strictly confined to the columns of Goll, its apex usually not quite reaching the posterior commissure. In the neighborhood of the orig- inal focus of disease the degeneration spreads over the entire transverse diameter of the pos- terior columns, thus gradually to pass over into the diffuse lesion. SECONDARY DEGENERATIONS. 773 Above, the ascending degeneration extends into the medulla oblongata and ends here with the ''Funiculi graciles" (of Bur- dach— "zarten Strange" of Erb), in the region of the nuclei of the same. In tumors of the cauda equina with secondary degeneration, the posterior columns are degenerated to their entire width, in the lower division of the spinal cord ; the degenerated zone grows gradually narrower and is finally strictly limited to the columns of Goll (Th. Simon, C. Lange). This diminution, according to Schiefferdecker, does not occur progressively and uniformly, but by steps. Ascending degeneration in the lateral columns is liable to occupy but a very insignificant amount of space. It appears in the form of a narrow peripheral zone, not sharply defined towards the inside, which begins at the hindmost end of the lateral col- umn and extends around the periphery of the same to a greater or less distance forward—often to the neighborhood of the ante- rior columns (Fig. 19, 1 to 4). Below, this degenerated zone arises gradually from the more diffuse lesion of the spinal cord; farther up it can always be traced on the outermost periphery of the cord in the restiform bodies and until the entrance of the same into the cerebellum. Schiefferdecker states that this sec- ondary degeneration also diminishes by steps. Secondaiy degenerations, in the vast majority of cases—in fact we may say regularly—confine themselves to the white col- umns of the cord. The gray matter generally remains entirely intact (Tuerck, Bouchard), and but very exceptionally takes part in the process. Nevertheless, in descending degeneration of the lateral columns a spread of the (irritative ?) process to the gray anterior horns has repeatedly been observed (Charcot, Pierres, Pitres), resulting in degeneration of the large ganglion-cells and muscular atrophy. This has thus far been observed principally in the cervical enlargement, but belongs, as above stated, to the rare exceptions. 774 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Symptomatology. Ascending secondary degeneration (in the posterior columns and in the cerebellar tracts of the lateral columns), so far as we are at present informed, appears to occasion no sort of clinical manifestations; that is, it adds no new disturbances to those caused by the fundamental malady. At the same time the ques- tion might be raised, whether the manifestations of sensory irri- tation in the paralyzed side of the body (paresthesia, formica- tion, pain, a sensation of burning, of heat and cold, etc.), which arise so often in the myelitis of compression and similar condi- tions, may not be connected with ascending degeneration of the posterior columns, and originate and be maintained thereby. This does not appear to us so entirely improbable, although it might, indeed, be hard to prove. However positively, therefore, we may expect the occurrence of secondary ascending degeneration in certain affections of the spinal cord when their diagnosis is once fairly established, and however regularly we also find evidence thereof on the dead body, yet this certainty is by no means founded upon any defi- nite clinical symptoms ; it rests, the rather, upon constant patho- logico-anatomical experience. It is somewhat different with the descending degeneration of the pyramidal tracts. Of course this can produce no change in the phenomena of paralysis caused by the original malady. But since the work of Bouchard it has become to a high degree proba- ble that the slowly developed contracture of hemiplegic subjects (the "contracture tardive" of the French), which becomes asso- ciated with the paralysis at a later period, stands in connection with the secondary degeneration of the pyramidal tracts, and is the result of the same. Bouchard is of the opinion that it is not so much the degeneration of the tracts directly affected by the paralysis which causes the contracture, as the irritation of other nerve-fibres, of different origin, running in the same region of the cord, which irritation is caused by a sclerosis arising in conse- quence of the degeneration. This will, at all events, be a hard matter to prove; and, indeed, it is not easy, as yet, to form SECONDARY DEGENERATIONS. 775 any satisfactory idea of the mechanism of the origin of contrac- tures. An argument in favor of this view is, nevertheless, found in the fact that the secondary contractures in hemiplegia are liable to occur about the same time at which one may expect the occur- rence of secondary degeneration—that is, one or two months after the first appearance of paralysis. Furthermore, that in the spinal affections, likewise, which lead to secondary degen- eration of the pyramidal tracts, muscular tension and contrac- tures in the lower extremities are developed after a short time —about simultaneously with the appearance of these degen- erations. Furthermore, that in amyotrophic lateral sclerosis contractures are regularly to be found along with the sclerosis of the pyramidal tracts, just as muscular tension and contractures belong to the most constant symptoms of supposed primary lateral sclerosis. It cannot be denied that these proofs are by no means conclu- sive, and that, thus far, there is merely a probability—to be sure, a pretty great one—in favor of the dependence of secondary con- tractures upon secondary degeneration of the pyramidal tracts. It will require further and varied material for observation in order to raise this probability to a certainty. Matters are still more uncertain with regard to another symp- tom which is likewise almost constant in all cases in which secondary degeneration of the pyramidal tracts exists, viz., in- crease of the reflex excitability of the tendons. There can scarcely be a doubt that this stands in connection with disease of the spinal lateral columns, but it is not certain whether it is the result of interruption in the conduction of certain tracts in the lateral columns (limiting reflex action ?), or of the subse- quently developed secondary degeneration of the same ; in other words, whether it is a symptom co-ordinate with the paralysis or with the secondary contractures. This question could only be determined by careful clinical observations on the point of whether the elevation of reflex excitability of the muscles oc- curred simultaneously with the paralysis, or simultaneously with the contracture, or earlier or later than either ; whether it always occurs in connection with secondary contractures, or may also 776 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. arise without them, etc. On account of the short time that has elapsed since the discovery of the reflex excitability of tendons, such observations do not exist in sufficient numbers. I only find some statements in Westphal,1 that after apoplexies and the like the elevation of reflex excitability of the tendons is present in from seven to twenty-one days after the attack, and in some cases was not present during the first four days. But we can- not form much of a conclusion from this, as the statements with regard to the time of occurrence of secondary degeneration are as yet very uncertain. It appears to me, for the present, the more probable that the elevation in reflex excitability of the tendons is the result of interrupted conduction in tracts control- ling reflex action, and is not the result of secondary degeneration of the pyramidal tracts. At all events, this question demands further investigation. It is at least not likely that the epileptic and epileptiform attacks, which are so frequent in hemiplegic patients, have any relation whatever with secondary degeneration of the pyramidal tracts (especially in the medulla oblongata), as was supposed by Bouchard. Diagnosis. From all that has hitherto been said, it is evident upon how unsafe a footing the clinical diagnosis of secondary degenerations as yet stands. Secondary ascending degeneration is simply not to be recog- nized by any clinical manifestations; but, in case of the well- established diagnosis of a definitely localized affection of the spinal cord (myelitis from compression, trauma, etc.), it is merely to be expected, with some certainty, as a necessary result of the same. In secondary descending degeneration the only sign which points towards it with some probability is the occurrence of late contractures (and of increased reflex excitability of tendons?). When, therefore, in the course of a hemiplegia or paraplegia, 1 Arch. f. Psych, u. Nervenkrankh. V. p. 810. SECONDARY DEGENERATIONS. 777 muscular tensions and contractures set in after some weeks, we may infer, with great probability, the existence of descending degeneration of the pyramidal tracts. If this should be confirmed in the future, then the demonstra- tion of the presence or absence of this secondary degeneration will perhaps admit of our arriving at a conclusion with regard to the localization of the fundamental cerebral affection. For, as we have before remarked, this degeneration does not by any means occur in all, but only in very definitely localized affections of the motor portions of the brain (Charcot). This is a question that will have to be decided by cerebral pathology. Prognosis. The more exact history of the course of secondary degenera- tions, under various possible circumstances, is a matter yet to be investigated. In general, the prognosis is the same as that of the funda- mental affection, and we have every reason to believe that, with the cure of the fundamental affection, the secondary degenera- tions may also tend towards resolution and recovery. But this is not so very certain under all circumstances, and although a com- plete regeneration of the degenerated nerve-tracts appears possi- ble in the earlier stages of the process (similar to what occurs in the degenerative atrophy of peripheral nerves), yet this is, to say the least, improbable in the later stages of the affection, and the prognosis of secondary degenerations, after they have existed for a long time, is, therefore, to be regarded as decidedly unfavor- able. Naturally, under some circumstances, the prognosis of the fundamental malady is seriously vitiated by this means, and Charcot unhesitatingly regards descending degeneration of the pyramidal tracts as one of the main causes of the persistence of motor paresis in hemiplegia, even when the fundamental affec- tion runs a favorable course. There is furthermore no doubt that secondary contractures often cause much greater interfe- rence with the use of the extremities than would result from the degree of paresis or paralysis actually present. And if these 778 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. contractures should be the results of the secondary degenera- tions, then Bouchard's statement might here be of interest, that he had never seen hemiplegia end in recovery when the develop- ment of secondary contractures had taken place. All this will therefore have to be taken into consideration in forming the prognosis of the cerebral or spinal fundamental affection. Therapeutics. There has thus far not been much talk of any special thera- peutics of secondary degenerations ; indeed, this could not well be the case, in view of the difficulties which stood in the way of the diagnosis of these alterations. The essential point, of course, is the treatment of the funda- mental affection, with regard to which we need not here expati- ate. But after what has been said above, the question may well be raised whether a further and not inconsiderable improvement might not be attained through direct treatment of the secondary degenerations at a certain stage of the fundamental malady; whether, after the causative cerebral malady had, to a great degree, undergone resolution, and after cerebral conduction had again been restored by direct or by vicarious tracts, the paresis and contractures which still remained might not be removed by the removal of the secondary degeneration. This question may doubtless be answered, with probability, in the affirmative; and it therefore appears to be indicated, when the fundamental disease has improved and is in the act of retrograde development, to institute direct treatment of the secondary degenerations. The ways and means to this end are, it is true, yet to be found. A priori, one will feel inclined to resort to the employ- ment of the therapeutic measures commonly used in chronic mye- litis and in sclerosis in general (baths, cold-water cures, galvanism, etc.). The galvanic current is doubtless entitled to the most confidence, and admits of the most practical and safest method of application. It is not necessary to say anything further here DEFORMITIES AND MALFORMATIONS. 779 with regard to the methods of its application in these degenera- tions of the cord. I will merely add that in some old cases of hemiplegia with contractures I believe I have seen decidedly favorable effects on paresis and contractures follow direct gal- vanic treatment to the spinal cord, instituted in addition to the other galvanic treatment. In such cases, however, it is naturally very difficult to be sure about our therapeutic experiences. 20. Deformities and Malformations of the Spinal Cord. Ollivier, 1. c. 3. gd. I, p. 159-240. 1837. — Cruveilhier, Anatom. patholog. Livrais. XVI. — Virchow, Die krankhaften Geschwulste. I. S. 169. 1863.— Foerster, Handb. d. path. Anat. 2. Aufl. II. S. 621. 1863.—P. Schiefferdecker, Asymme- trie d. grauen Subst. des R.-M. Arch. f. mikrosk. Anat. XII. S. 87. 1876. Bardeleben, Lehrb. d. Chirurg. u. Operationslehre. Bd. IV.—Lorinser, Spina bifida in Pitha-Billroth, Chirurgie. Bd. III. 2. S. 5.—Smith, An Unusual Form of Spina Bifida. Transact, of the Pathol. Soc. XXI. p. 1. 1871.—J". Roose, A Case of Spina Bifida. Philad. Med. Surg. Report. 1872. March 30.—A. Petit, Ana- lyse d'un liquide de spina bifida. Bull, ggner. de therap. 1873. p. 256.-7%. Simon, Ueber Syringomyelic und Geschwulstbildung im R.-M. Arch. f. Psych. u. Nervenkrankh. V. S. 121. 1874.— Leyden, Klin. d. Riickenmarkskrankh. I. S. 195. 1874 ; Hydromyelus u. Syringomyelic Virch. Arch. Bd. 68. S. 1. 1876. We have but little to say in this section that is of interest to the practical physician and really necessary for him to know. First in order comes quite a series of things which are of in- terest only in a pathologico-anatomical point of view and in con- nection with the history of development; and which, to the practical physician who is primarily concerned with living human- ity, will prove all the less interesting because they occur only in the still-born foetus, or at least in one incapable of sustaining life. On the other hand, there are certain anomalies in the configu- ration and position of individual divisions of the spinal cord which one must know in order to avoid the possibility of con- founding them with pathological changes. This also is a matter which more particularly interests the pathological anatomist or the special investigator of the pathology of the spinal cord. The practical physician will but seldom obtain a sight of these things, which do not betray themselves by any symptoms during life. 780 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Finally, we have to deal with conditions which are congenital, are carried into later life, and are perhaps still further developed at a later period—conditions of extension and widening of the cavities lying within the spinal column itself or surrounding the same, with more or less considerable accumulations of fluid within the same and corresponding degrees of secondary changes — displacements, adhesions, the development of clefts of the cord itself, or of the parts surrounding it (hydromyelus, hydror- rhachis, and spina bifida). These things, being, in part at least, forms of disease susceptible of clinical diagnosis and therapeutic interference, must be taken up and discussed. But, in view of the pre-eminently surgical interest which attaches to the most important of these anomalies—spina bifida—we may be tolerably brief in its discussion. Among the first group of anomalies, as mentioned above, are the following : 1. Amyelia, or absence of the spinal cord. This is a com- paratively rare malformation. Ollivier counts up a series of older observations of the same. If the spinal cord is missing, then the brain is always missing too (amyelencephalia). Entire absence of the spinal cord, when the brain is present, does not seem to occur. The peripheral nerves may be entirely preserved, the nerve-roots partly so ; remnants of the spinal membranes may also sometimes be found in connection with rudimentary development of vertebrae. It is not necessary here to enter upon any more minute description. It is also stated that during the latter months of pregnancy the greater part of the spinal cord may be destroyed by hydro- myelus—the brain, as well as the peripheral nervous system, being maintained intact. This, too, is of no practical significance. All such products of generation are incapable of life. 2. Atelomyelia, or imperfect development of the spinal cord. The upper end of the spinal cord is lacking, or is imperfectly developed, in all cases in which the brain is lacking (anence- phalia), or in which the greater part of the head is defective (acephalia). The medulla oblongata is then lacking, or exists only in a rudimentary form, sometimes still in conection with a part of the nerves usually given off from it. Farther down, the DEFORMITIES AND MALFORMATIONS. 781 development of the spinal cord may then be quite regular. Sometimes, however—in acephalia—a larger piece of the upper division of the cord is entirely wanting ; in that case there is also usually spina bifida of the cervical vertebral column. In rare instances the lower part of the spinal cord is also found stunted, ending in a club-shaped extremity ; this is gener- ally accompanied by still further anomalies of the organs of the trunk. The interference with development may also show itself in the fact that the two lateral halves in which the spinal cord is de- veloped do not unite, but either remain entirely separated, or unite only throughout a portion of their extent; so that the spinal cord, either for its entire length or merely at its upper or lower end, appears separated into two lateral halves—diastemato- myelia. This malformation generally occurs with anencephalia, and is, of course, of no practical significance. 3. Diplomyelia, or duplication of the spinal cord. Double monstrosities of various kinds and of various grades also show these malformations of the spinal cord, corresponding to the rest of their bodily development ; so that either the upper part of the spinal cord is single and is divided into two cords below, the vertebral column and the entire lower half of the body also being double, or the lower part of the cord is single and terminates in a double cord above. We are not yet in possession of more accurate information with regard to the method of duplication or the connection of the parts at the point of bifurcation, which would certainly afford very interesting pictures on transverse section. In such cases the form of the spinal cord probably has but little influence on the entire development and life-history of these monsters. Turning to our second group, we may first mention those slight anomalies in the length and thickness of the cord which are now and then met with. In some men the spinal cord is found strikingly thick and voluminous, in others strikingly thin 782 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. and insignificant, without either the one class or the other hav- ing presented any spinal symptoms during life. If, at the same time, microscopic examination demonstrates no alteration in the structure of the spinal cord, then we are evidently dealing with irrelevant, individual anomalies. This is regularly the case with abnormal length (the cord has been seen to descend to the third lumbar vertebra) or abnormal shortness of the cord (sometimes it ends at the eleventh or twelfth dorsal vertebra), if there are no other special malformations or diseases present. Abnormal smallness of the entire spinal cord and medulla oblongata, with corresponding smallness of the nerve-cells and fineness of the nerve-fibres and axis-cylinders, has lately been demonstrated by F. Schultze,1 in one of Friedreich's cases of "hereditary ataxy," and he propounds the interesting query, whether this faidty development of the entire organ is not the predisposing cause of the sclerosis of the spinal cord developed at the time of puberty. This question would be well worth test- ing in future cases. Thos^e alterations which sometimes show themselves in the configuration of the spinal cord, and which must not be con- founded with pathological changes, with actual diseases, are more noticeable. This is especially true of asymmetry of the gray substance; unequal width, depth and form of the symmetrical gray horns, on a transverse section. Starting with the supposition that the symmetry of these parts was very complete, some observers have often declared deviations from the same to be pathological; but this is not permissible, unless accurate histological examination demonstrates actual pathological changes which account for such asymmetry (atrophy, sclerosis, the loss of ganglion-cells, etc.). Schiefferdecker has demonstrated that such asymmetry is not rare, occurring even to a very considerable degree, and may be confined to single divisions of the spinal cord; the same thing was stated long ago by other observers, and every one who occu- ' Friedreich, Ueber Ataxie mit besonderer Beriicksichtigung, u. s. Virchow's Archiv. Vol. 70. p. 140. 1877. DEFORMITIES AND MALFORMATIONS. 783 pies himself with the histology of the spinal cord will often meet with this fact. The non-uniform distribution of the pyramidal tracts upon the two sides of the spinal cord, as demonstrated by Flechsig,1 whereby each pyramid may send its mass of fibres into the spinal cord either entirely crossed or only partly crossed, sometimes leads to very pronounced asymmetry, which here affects the white substance exclusively, and, indeed, the antero-lateral col- umns. In cases of congenital absence or intra-uterine stunting of cer- tain extremities, we not rarely see secondary atrophy of definite portions of the spinal cord, and thereby the production of asym- metry which is limited to the cervical or lumbar enlargement, according to the extremity that is affected. Thus Troisier/ for example, found a unilateral diminution in size of the spinal cord especially affecting the gray matter, running through the entire extent of the cervical enlargement, in a case of congenital stunt- ing of the corresponding upper extremity (heinimyelia). In this case, without any further demonstrable changes, the only thing that could be shown was a diminution in the number of the ganglion-cells. Unusual outgrowths of the gray matter, or the absence of portions of the same, which are generally present (for instance, the tractus intermedio-lateralis of Clark's columns), are condi- tions occasionally met with; likewise, in some cases, duplications of the one or the other gray horn, for a longer or shorter distance. These are matters the true value of which we can generally arrive at, without much difficulty, on careful investigation. In the third group we turn our attention first to congenital enlargement of the central canal in the spinal cord, what is generally called hydrorrhachis interna, also hydromyelus (or better, hydromyelus congenitus). 1 Die Leitungsbahnen im Gehirn und Riickenmark des Menschen. Leipzig, 1876.— Ueber Systemerkrankungen im Rfickenmark. Archiv der Heilkunde. XVIII. 1877. - Arch, de Physiologie. IV. p. 72. 1871-72. 784 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. This anomaly is not so very rare ; but by no means all those cases in which this condition has been thought to exist have been actual congenital malformations ; they have oftener repre- sented changes acquired at a later period, as the result of disease; and more frequently yet these have not been cases of dilatation of the central canal itself at all, but of newly-formed pathologi- cal cavities—cavities which have only been confounded with true hydromyelus on account of their central position in the spinal cord, and which would be better designated "syringomyelia." This subject will be touched on again at greater length, in the following section (No. 21). The malformation which concerns us here depends on an accumulation of fluid in the foetal central canal. This may reach very varied grades. In the lighter grades we recognize the formation of a central cavity in the spinal cord, more or less extensive in length, and varying in width from that of a knitting-needle to that of a crow's quill. This may extend throughout a greater or less portion of the cord, sometimes running through the entire length of the same, at other times restricted to certain portions thereof (the cervical or lumbar portion) ; sometimes the dilatation assumes the form of a string of beads (moniliform), dilated portions alternating with those of normal width ; sometimes, too, the canal is obliter- ated in the centre, its anterior and posterior walls having grown together, leaving both sides open, so as to produce the appearance of a double canal, etc. In such cases, as a rule, the dilated central canal can be rec- ognized as such, with certainty, by the position of the cavity relative to the other portions of a transverse section of the cord (relative to the anterior and posterior commissure, to the central veins, the gray matter, etc.), by the lack of any trace of another structure which might be the central canal, by the fact of its being lined with cylindrical epithelium, etc. The spinal cord itself is otherwise well developed, and appears to be without any other pathological changes, aside from the displacement which its other portions may have been subjected to through the great dilatation of the canal. This is also a positive test for the separation of congenital DEFORMITIES AND MALFORMATIONS. 785 dilatations of the central canal from those caused by pathologi- cal processes. The latter are not rare, for instance, in periepen- dymal myelitis, in transverse myelitis, in neoplasms of the spinal cord, and we shall recur to them again later. Simple congenital hydromyelus appears to produce no symp- toms whatever ; much of the observations under this head have been made accidentally, in persons who had complained of no spinal symptoms during life ; and where such symptoms have existed and "hydromyelus" has been found on post-mortem ex- amination, these pathological processes have undoubtedly, as a rule, co-operated in the production of the same. In the higher grades of hydromyelus entire disappearance of the spinal cord takes place, or it appears split in two halves, for a greater or less length ; the cavity of the central canal is in free communication with the cavity of the dura mater and the hydror- rhachis interna is merged into hydrorrhachis externa, as not rarely occurs in spina bifida. This condition of things, too, may be developed in very different grades and to a variable extent. An abnormal accumulation of fluid within the cavity of the dura mater—that is, in the subarachnoidal spaces, in connection with a greater or less degree of alteration and deformity of the vertebral column, constitutes what is called Spina bifida (partial hydrorrhachis, hydromeningocele, and hydromyelocele). We shall have to spend a little more time on this, as being, practically, the most important malformation, although, for all more minute details, we refer our readers to the text-books on, Surgery and Pathological Anatomy. Spina bifida presents itself as a sac-like dilatation and pouch- ing of a more or less circumscribed portion of the cavity of the dura mater, which is generally coincident with the cleaving (or absence) of one or more vertebral arches, and protrudes like a hernia through the cleft thus formed, raising the skin in the form of a more or less considerable tumor. This pouching but seldom, occurs between two vertebral arches without cleaving of the same, and if it does, is always a comparatively small tumor. (If the vertebral column remains quite normal, and there is only an in- creased accumulation of water in the vertebral canal, then we VOL. XIII.—5J 786 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. have simple hydrorrhachis externa—a common manifestation in hydrocephalus.) Opinions still differ as to the exact method of origin of spina bifida, and it is at least probable that this condition may be brought about in various ways. It is either a question of a pri- mary dropsy of the central canal, with disappearance of the cord and secondary widening and distention of the spinal membranes, or merely of a dropsy of the sub-arachnoideal spaces, which dis- tends the membranes and pushes them forward like a hernia. If these changes take place before the vertebral arches are closed, their closure is prevented, and thus the cleft of the vertebral column takes place. But it is also possible that this is the pri- mary step, and that the hydrorrhachis is not developed until afterwards. Spina bifida is not exactly a rare malformation. Chaussier found it present in about one case in every thousand births. The more special relations of spina bifida are about as fol- lows : Its general seat is in the sacral and lumbar region, much more rarely in the dorsal or cervical portion of the spinal column; generally there is but one tumor present, more rarely, several; these are almost always situated in the median line, seldom deviating to one side or the other. They differ very much in size, varying from that of a nut to that of a head. Inform they are usually round or elliptical, or also pear-shaped; but they may also be extended in length, stretching over a more or less considerable portion of the entire spinal column. The tumor is either fiat or pedunculated, some- times lobulated or divided into two. The skin over the tumor is either quite normal or highly stretched, thinned, reddened, involved in ulceration; not rarely an umbilicated depression may be seen at some point on the height of the tumor, caused by the insertion of the end of the spinal cord in the interior of the sac. Passing beneath the skin, one usually comes upon the dura mater, which may be thickened or normal, or also very much thinned ; sometimes it has entirely disappeared or has split, and the soft membranes alone protrude. Next conies the arachnoid, DEFORMITIES AND MALFORMATIONS. 787 which, in most instances, actually encloses the fluid. If hydro- myelus exists, the pia mater also takes part in the formation of the sac. The neck of the sac is more or less narrow and leads into the spinal canal. Not unfrequently it is closed by adhesion, and thus the cystic tumor tying under the skin is isolated from the cavity of the dura mater within the vertebral canal. The condition of the spinal cord varies in individual cases. In the majority of instances the spinal cord is certainly essen- tially normal, and takes no part, or but a very subordinate part, in the existing alterations. It happens still more frequently that its lower extremity is adherent to the sac at some point, and causes an umbilicated depression of the same, visible from with- out. The spinal cord is often materially lengthened by this means, its extremity being drawn clear out of the vertebral canal, and not seldom thinned and flattened. The nerve-roots then run their course from this portion back along the walls of the sac (or floating free within the same), partly into the vertebral canal and to their intervertebral foramina, partly directly through the walls of the sac to their appropriate plexus. More rarely there exists simultaneously a hydrorrhachis interna, with its evil conse- quences so far as regards the form of the cord; then the lower extremity of the cord is more or less destroyed, atrophied, and the cavity of the sac communicates directly with the dilated and open central canal. The fluid contained in the spina bifida is generally quite light, colorless, and clear, and perfectly identical with the usual cerebro-spinal fluid, consequently very rich in water and poor in solid ingredients ; it is but rarely turbid or bloody ; its quantity majT amount to from 500 to 1,000 grammes (3 oz. to 2 lbs.) or more. Symptoms of Spina Bifida. Children affected with this deformity are generally born with- out hindrance, are capable of sustaining life, and show nothing abnormal except a more or less extensive tumor in the sacral or lumbar region, rarely at a higher point of the spinal column. 788 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. If the tumor is very large and the skin over it thinned, the sac may burst during birth and its contents escape ; the child is then ordinarily born highly asphyxiated, and perishes within a couple of hours, or, at the outside, in a couple of days. If this is not the case, however, the tumor either remains un- changed, or, more frequently, gradually increases in size, the skin over the same becoming more and more thinned, etc. It is but rarely that such a tumor is first developed some time after birth. See Genga's case in Ollivier. The tumor itself, varying veiy much in size, is roundish, pear- shaped, or divided into two parts and lobulated, tense, elastic, and distinctly fluctuating. In smaller tumors the skin over the same is unaltered, in larger ones it is more or less stretched and thinned, bluish or reddish ; at the same time the entire tumor not rarely looks translucent, like a hydrocele. In worse cases, the skin is superficially ulcerated and secretes a watery, purulent fluid ; it may in part be entirely destroyed or absent, so that the distended spinal membranes alone constitute the wall of the sac. A characteristic found in many cases is that the fluid con- tained in the sac can be pressed away. In other words, it can, by pressure, be partly emptied into the spinal canal, so that the tumor grows smaller ; but this does not occur without sometimes causing disturbances of cerebral innervation—drowsiness, sleep, twitchings, etc. If there is coincident hydrocephalus, swell- ing and increasing protrusion of the fontanelles can be demon- strated during such pressure ; on the other hand, pressure on the hydrocephalic skull increases the tension and size of the spina bifida. The swelling likewise somewhat increases on as- suming the erect attitude, on screaming, on pressure, etc. ; an increase of swelling has also been observed associated with move- ments of the pulse and of respiration. Not infrequently the tumor is sensitive on pressure. In those cases, however, in which communication with the spinal canal has been cut off by closure of the sac, all these manifestations are, of course, no longer to be found. In the majority of cases the manifestations above described are the only ones in spina bifida. The children thus affected are DEFORMITIES AND MALFORMATIONS. 789 otherwise normal, show no sort of manifestations of paralysis, develop well, learn to walk, and may arrive at a considerable age without being troubled by their deformity otherwise than, at most, in a simply mechanical manner. This, however, is the exception; as a rule, the tumor ad- vances in growth, and not long after birth all sorts of severe dis- turbances begin to show themselves, caused by compression of the lower division of the spinal cord and the cauda equina. Increasing paralysis and paraplegia set in, incontinence of urine and of fseces, bed-sores, etc., and the patients thus gradually perish. Much more rarely these severe manifestations exist at the very beginning, and this is regularly the case whenever there is coexistent hydrorrhachis interna. Paraplegia and paralysis of the sphincters are then present from the very start, and the days of the little patient are numbered. But these children by no means always perish as the direct result of the spinal paralysis thus caused ; much greater and more urgent dangers threaten them from the numerous acts of violence and accidental wounds to which the tumors are exposed. Knocks, pressure, dragging, direct wounds, prolonged lying upon the back, and the like, are all of them capable of bringing about a rupture of the sac. This results in purulent inflammation of the same, which—if the communication with the spinal canal is still open—extends into the latter, and induces a purulent spinal meningitis which ordinarily puts an end to the life of the little one within a few days. It has happened, although but very rarely, that such an occurrence has passed over favorably and has even led to the cure of the malady ; this is only to be ex- pected when the perforation is very minute and the fluid flows out quite slowly. If the opening is large and the fluid is, by any accident, rapidly evacuated, death may follow very quickly, within a few hours, under general convulsions and increasing debility. The terminations of the disease have been sufficiently indi- cated in what has just been said. Life is but rarely maintained for any considerable length of time ; still, isolated cases have been known to live to the age of 20, 30, 35, and even 50 years. Prob- 790 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. ably in all these the communication with the cavity of the dura mater was closed early, or was very narrow. In most cases death occurs much earlier, and, indeed, the more certainly and quickly the larger the tumor. The immediate cause of death is most frequently rupture of the sac ; this comes about either through the fact of the tumor gradually grow- ing in size, and finally bursting of itself or through some acci- dental wound ; or through the fact of some traumatic injury, wound, blow, or the like, causing a sudden rupture ; or through the fact of the sac being purposely opened and emptied for thera- peutic purposes. If, in such cases, the emptying takes place quickly and in a stormy manner, death may occur within a few hours, under general convulsions and increasing weakness ; or— and this is more frequently the case, especially after operations —an acute purulent meningitis is developed, which leads to the death of the child in a few days. In a minority of instances death follows without bursting of the sac, through general prostration in consequence of the severe spinal disturbances. The rarest result of all is that such an accidental perforation is survived, and becomes the starting-point of a positive cure. More frequently, though by no means frequently enough, this favorable result follows in consequence of a carefully undertaken operative evacuation of the sac. Diagnosis. The recognition of spina bifida is generally not difficult; only in the smallest forms of the same, when the orifice of communi- cation is very small or entirely closed, can this present any con- siderable difficulties. The following may be mentioned as distinguishing marks : a tumor on the vertebral column, of the form and size described above; tense, fluctuating, translucent; its size capable of being reduced by pressure, whereupon the fluid is emptied into the spinal canal, causing the appearance of severe nervous disturb- ances (finally also protrusion of the fontanelles) ; the edges of the cleft vertebra?, the ends of the vertebral arches being some- DEFORMITIES AND MALFORMATIONS. 791 times distinguishable to the touch as light prominences. By these means spina bifida will, as a rule, be easily diagnosticated. It is of special importance—in a prognostic point of view, as well—to demonstrate the presence or the absence of communica- tion with the spinal canal; this is not easily done in all cases. The distinction between this and the displacement of abdomi- nal and pelvic viscera (bladder, rectum, etc.) resulting in a sacral tumor, to which Lorinser calls attention, will generally be easy. There will likewise be no difficulty in recognizing the other malformations and defects which not rarely coexist with spina bifida ; viz., hydrocephalus, deformities of the lower extremities, anomalies of the genital apparatus, inversion of the bladder with congenital fissure of the abdominal walls, and the like. Prognosis. The prognosis of spina bifida is by no means very favorable. Very many cases perish by the spontaneous accidental opening of the sac or through the progressive growth of the tumor ; not a few, likewise, die in consequence of operations undertaken to effect a cure. The prognosis becomes more unfavorable the larger the tumor is, as a whole ; the higher it is situated on the vertebral column (the cases where it is on the sacrum and coccyx are by far the most favorable) ; the larger the orifice of communication with the spinal canal; the more it is a case of true myelocele, and not mere meningocele—therefore, the more there is of hydromyelus; the more distinct the signs of hydrocephalus; and, finally, the feebler the constitution of the child thus affected. Keeping these points in view, one will generally be able to form a conception of what is to be expected during the further course of the malady. Therapeutics, Nothing at all is to be expected from the treatment of spina bifida with internal remedies, with inunctions, baths, etc. The attempts to cause the disappearance of this condition by deriva- 792 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. tion to the skin, by blisters, the actual cautery, etc., may be designated as downright objectionable. But it is just as little permissible in most cases to leave the thing to itself and expect time to effect a cure. Experience teaches that this trouble is almost always of a progressive char- acter, and sooner or later leads to death. Nothing remains, therefore, but surgical treatment, which must, however, be undertaken with the greatest caution and care, if the results are not to be altogether too unsatisfactory. Very different operative measures have been undertaken, naturally with very various results. Lorinser is opposed to all operative interference as long as a communication with the spinal canal can be demonstrated. This is probably, after all, somewhat excessive caution, although it is evident, in and of itself, that those cases which have but a very narrow communication, or none at all, with the cavity of the dura mater, promise far better results than those with a very wide communicating orifice, as the main danger of the operation is always to be found in the exten- sion of an inflammatory process to the membranes of the spine. Among the operative procedures hitherto proposed, there are a number that are to be positively rejected, because almost always accompanied by fatal results. First among these is the passing of a hair cord through the tumor; this is inevitably followed by inflammation and suppuration, and could only be considered reasonable if one were quite sure that the external tumor was entirely shut off from the spinal cavity. The incision or amputation of the tumor is likewise commonly followed by fatal meningitis, and is therefore to be avoided. Ligature of the sac, which implies that it is pedunculated, seems to be almost equally dangerous ; the sac sloughs off, the orifice of communication cicatrizes, and a cure may thus be effected ; but here, too, purulent meningitis, with a fatal result, very often follows. At the same time a number of favorable results, following this method, have been reported. Thus, by Rizzoli and Oldoini,1 by Parona,2 who availed himself of a pair 1 Lo Sperimentale. XXXVIII. (Centralblatt f. d. med. Wiss. 1876. No. 50.) 2 Annal. universal Vol 235. Aprile, 1876. DEFORMITIES AND MALFORMATIONS. 793 of compressing forceps for carrying out the operation ; by von Brunn,1 who undertook the compression of the pedicle by means of an ovarian clamp ; by Colognese,5 who used an elastic liga- ture, a rubber tube, for this purpose. In view of the better results attending them, the following methods of operation are probably the only ones worthy of con- sideration at the present day: methodical compression of the tumor ; simple, repeated puncture of the sac, repeated according to the necessities of the case ; and puncture, with the subsequent injection of iodine. Methodical compression, by means of adhesive plaster, ban- dages, appropriate compresses, and the like, certainly in some cases effects nothing but an apparent improvement, inasmuch as it mechanically presses the fluid back into the cavity of the spine ; as soon as the compression ceases the tumor again returns to its former volume. At the same time, Heister claims to have attained a favorable result thereby. The carrying out of com- pression by means of painting with collodion is highly recom- mended by Behrend, and has been repeatedly employed with a good result. He first paints the tumor with a mixture of collo- dion with castor oil, afterwards with pure collodion, and finally applies a compressory bandage. Experience teaches that simple puncture must generally be often repeated before accomplishing its end. Still, even this method is not without danger, even when carried out with the greatest caution, to say nothing of the fact that it is often with- out any result. The best way is to evacuate the fluid through a very fine puncture (for instance, to draw it out with a hypoder- mic syringe), not to empty the sac altogether, and afterwards to apply a light compressory bandage. A surer result, although, perhaps, attended with somewhat greater risk, is to be attained by puncture with the subsequent injection of iodine. This method was first introduced by the French, is probably more employed at the present day than any other, and has been especially lauded in England (Morton,3 1 Berliner klin. Wochensch. 1871. No. 17. 8 Annal. univers. Vol. 239. p. 143. 1877. 1 Brit. Med. Journ. April 6th and June 15th, 1872. Lancet, Dec. 2d, 1876. 794 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. Watt,1 Ellis2). Morton, in particular, seems to have practised this method with great results; he recently reports fourteen cases, of which eleven were cured. Recovery followed in all the cases seated in the lumbar region—which constitute, as is well known, the great majority of such cases. He first makes a test puncture ; this is repeated in five days, and then only half the fluid present is withdrawn, whereupon an injection is at once thrown in, con- sisting of about four grammes of a solution of iodine in glyce- rine (pure iodine, 0.60 grammes [ten grains], iodide of potassium, 2 grammes [thirty grains], pure glycerine, 30 grammes [ 3 vijss.]). Others have used other solutions (tincture of iodine and distilled water, equal parts; alcoholic solution of iodine and iodide of potassium; and some merely alcohol), and have also modified the method of the injection in various ways, allowing the injected fluid to flow out again, etc. In all such cases it will be well to prevent, so far as possible, the penetration of the injected fluid into the spinal canal by compression of the pedicle during the injection. The subsequent treatment will be governed by the signs of irritation that may arise. The main point in any of these operations will always be the careful and accurate carrying out of the same, and the attentive after-treatment. In cases that are not suited to operative treatment—very large tumors, very wide clefts of the spine and orifices of communica- tion, very feeble subjects—we must endeavor to protect the tu- mor, so far as possible, by means of appropriate bandages, com- presses properly hollowed out, and the like. 21. Para et curiosa.—Pare and Doubtful Diseases of the Spinal Cord. In the foregoing chapters I believe I have presented every- thing that can now be regarded as to any degree established in the pathology of the spinal cord, and that may be of importance to the practical physician. That this does not, by any means, 1 Brit. Med. Jour., April 26th, 1873. 8 Philadelphia Med. Times, No. 114. 1874. SYRINGOMYELIA. 795 exhaust the entire pathology of the spinal cord, I am myself very well aware. There is another class of cases, in which even very serious alterations may be found in the spinal cord, but which are rare in themselves, and, furthermore, by no means admit of a positive diagnosis ; cases which are to be regarded more as curiosities, or, at best, as valuable material towards the construction of a future and broader pathology of the spinal cord. There are likewise cases enough which must, in all probability, be localized in the spinal cord, without our being able, at present, to adduce any positive proof to that effect. Finally, there are those in which severe spinal symptoms are merely a part of the manifestations of general processes of disease (severe intoxications, infections, and the like), and are, therefore, more or less disregarded in the general picture of the disease, and usually also receive no thera- peutic attention. Such and such-like matters will be briefly discussed in this section, while, at the same time, I wish to give special emphasis to the fact that, owing to the essentially practical tendency of this Cyclopedia, we are not justified in entering more minutely upon many questions of the highest scientific interest, which are, nevertheless, still awaiting their solution. I must therefore con- fine myself to more or less aphoristic notices, and would fain, by this means, give the practitioner some stimulus more accurately to observe, and to publish any cases he may encounter of such and similar rare forms of disease. a. The Pathological Formation of Cavities in the Spinal Cord.—Syringo- myelia.—Hydromyelus acquisitus. 0. Namias, Di una specie d'atrofia della midolla spinale. Gaz. med. ital. Lomb. 1851. Nr. 35. (Syringomyelia.)—W. Gull, Case of Progress. Atrophy, etc. Hy- dromelus. Guy's Hosp. Rep. VIII. 1861.—Koehler, Monograph, d. Meningit. spinal. Leipzig, 1861. Beob. 17.—Lancereaux, Cas d'hypertrophie de l'epen- dyme spinale, etc. Gaz. m£d. d. Par. 1862. Nr. 31.—0. Schueppel, Ueber Hy- dromyelus. Arch. d. Heilk. VI. S. 289. 1865.—Ein Fall von allgem. Anasthes. Ibid. XV. S. 44. 1874.—John Grimm, Ein Fall von progress. Muskelatrophie. Virch. Arch. Bd. 48. S. 445. 1869.—Leyden, Klinik der Riickenmarkskrankh. I. S. 199. 1874.—Hydromyelus und Syringomyelic. Virch. Arch. Bd. 68. S. 1. 796 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 1876.— Westphal. Hohlen- und Geschwulstbildung im R.-M. Arch. f. Psych, u. Nervenkrankh. V. S. 90. 1874.—Simon, Ueber Syringomyelic und Geschwulst- bildung im R.-M. Ibid. V. S. 121. 1874. Whereas formerly all central cavities developed in the spinal cord were regarded at once as dilatations of the central canal, and, in part, as congenital faults of development, the conviction has recently been reached, through the careful examination of a large number of cases, that there are not only pathological dila- tations of the central canal itself which have been developed secondarily, as the result of various diseased processes estab- lished in the centre of the spinal cord, the dilatations themselves not being developed till later in life, but that newly formed cen- tral cavities also occur within the spinal cord, which have noth- ing at all to do with the central canal, but lie within the patho- logically altered tissue, and have been developed out of the same by various processes of metamorphosis. All these cases may be grouped together under the name, already used by Ollivier, of "syringomyelia." After Hallopeau had shown, to a demonstration, that certain chronic inflammatory processes within the spinal cord, which he designated as periependymal myelitis, might lead to secondary dilatation of the central canal, Th. Simon, in particular, in a large and exhaustive work, established a correct understanding with regard to a great part of the conditions that had previously been thrown together under the name of hydromyelus. On the other hand, Leyden has again recently introduced some new fea- tures into the doctrine of syringomyelia which, it would appear, necessitate a modification of Simon's views. Pathogenesis and Pathological Anatomy of Syringomyelia. Simon sums up the results of his studies on syringomyelia as follows : that an extensive dilatation of the central canal is tole- rably frequent in foetal life, and is rare during later extrauterine existence ; that, on the other hand, most of the cases designated as hydromyelus are either of very doubtful authenticity, or cer- SYRINGOMYELIA. 797 tainly represent no dilatation of the central canal itself, but are, rather, newly-formed cavities, which are most fond of developing themselves in the foremost portion of the posterior columns, therefore, behind the central canal. It is a question here of pro- cesses of softening with complete absorption of the softened (and usually also newly formed) tissue. But undoubtedly genuine dilatations of the central canal also take place, arising secon- darily through shrinking of the newly-formed tissue which sur- rounds the central canal. Generally, however, it is a question of newly-developed cavities, which are especially easily formed through the breaking down of tumors that are rich in blood (gliomata, gliomyxomata, etc.), and which may sometimes even be lined with a coating of cylindrical epithelium. Such cavities may be looked upon as the true central canal only when their topographical position with reference to the other portions of a transverse section of the cord justifies this view. In addition to the above we may add that such newly- formed cavities may be developed in very different ways, and as the result of the most varied pathological processes, among which are the following: Through breaking down and softening in the centre of neo- plasms (gliomata, gliomyxomata, gliosarcomata, etc., cases of Westphal, Grimm, Simon, and others). Not infrequently there is such a complete breaking down that only remnants of the tumor remain, or even only the connective tissue outline of the same. The same tissue as that of which the tumor was formed can then often still be demonstrated above or below the cavity. These centres of softening arise in part through hemorrhage into the interior of neoplasms (so particularly in the telangiectatic forms), in part through simple softening and cyst-formation within the same. Sometimes there is a development of multiple cavities ; once Simon even found a cavity with an epithelial lin- ing (a shut-off portion of the foetal central canal ?). Through the breaking down and softening of apoplectic foci, by the same process, therefore, that leads to apoplectic cysts within the brain. Through more or less extensive central softening in areas of gray degeneration and chronic myelitis. To this category be- 798 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. long the formation of canals which Friedreich' found in a case of tabes of the cord ; the formation of cavities which Charcot and Joffroy" found in a case of progressive muscular atrophy ; the formation of a cleft which Langhans 3 describes in a case of lepra ansesthetica, and more of the same sort. Finally, through complete interruption of the continuity of the spinal cord at some point, as occurred in the experiments of Naunyn and Eichhorst.4 These observers found, in dogs in whom they had cut or crushed the spinal cord at some point, during their earliest youth, some weeks later, numerous most noticeable cavities, extending a considerable distance upward from the cica- trix. These cavities had, at first, nothing to do with the central canal, and were considered by these observers to be due to an ob- struction of the lymph-passages. Westphal, in his case, found something similar in man, and advocates the possibility of a tumor occasionally also inducing such obstruction. In addition to the foregoing we then still have the true dila- tations of the central canal, which may arise secondarily as the result of various processes, probably oftenest through the so- called periependymal myelitis of Hallopeau, which has also been fully recognized and confirmed by Simon. Here it is a question of a proliferation of the connective tissue surrounding the central canal and of subsequent shrinking of the same, whereby the canal is passively dilated. Adhesions of the pia mater to the dura mater, chronic menin- geal processes at certain definite points, appear, according to Simon, also to have a definite relation to acquired hydromyelus —perhaps by a simple extension of the inflammation from the pia mater to the periependymal tissue, perhaps, also, by means of the fact that shrinking meningitic layers of adventitious tis- sue, by their pulling, mechanically cause the widening of the canal. Finally, obliteration of the central canal at some point ' Ueber degenerative Atropine der spinalen Hinterstrange. Virchow's Arch Vol XXVI. Case IV. 1863. 2 Deux cas d'atroph. muse. etc. Arch. d. Physiol. II. 1869. Second case. 3 Virchow's Arch. Vol. LXIV. p. 175. 1875. 4 Arch, f. experim. Pathol, u. Pharm. II. p. 225. 1874. SYRINGOMYELIA. 799 (through inflammation, external pressure, and the like) may lead to dilatation of the neighboring portions. Leyden has again recently sought to re-establish a more inti- mate relation between syringomyelia and congenital hydromye- lus. He considers the two as essentially identical, basing his opinion on the observation of two two-year-old children who were affected with hydrencephalocele, and furthermore showed the development of cavities in the spinal cord. Inasmuch as he does not recognize the significance of the tumor-like masses in the neighborhood of such cavities as being that of true tumors, but regards them as mere hypertrophy of the ependyma and of the neuroglia, he comes to the conclusion that congenital hydro- myelus is the usual starting-point of the syringomyelia arising later in life, and that even the abnormal cavities situated in the posterior columns are merely remnants, that is to say, extensions of the central canal, hampered in its development. He considers this view as being supported by the history of the development of the central canal, and thinks such cavities should be regarded as portions of this canal which were early cut off. This view may be the correct one for a certain series of cases, but can hardty claim to hold good for all cases of syringomyelia. The pathologico-anatomical condition varies very much in different cases. Cavities of very variable length are met with; often only of a few millimetres or centimetres in length, but not rarely of a length extending throughout the entire spinal cord. These cavities are almost always more or less centrally located, and it is only on more careful examination that we can determine their precise situation and their relations to the central canal. The width of these cavities varies much—from one to ten mil- limetres, from the size of a needle to that of one's little finger. Their form, on transverse section, is roundish, oval, angular, sinu- ate, etc. Sometimes several cavities are found alongside of one another. Their contents consist of a fluid which is light and clear, or turbid yellowish, brownish, etc.; in many cases no ac- curate statement is made on this point. The walls of the cavities may be smooth and firm, often pro- vided with a layer of cylindrical epithelium, or sometimes rough, ragged, uneven, etc.;# In their vicinity we may, according to cir- 800 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. cumstances, find a hard, cirrhotic tissue or gray degeneration, or the various new formations spoken of above. The spinal cord, as a whole, is often materially altered there- by, thickened, misshapen ; but frequently, also, nothing unnatu- ral can be noticed about it externally. On transverse section the substance of the spinal cord either appears simply crowded and pushed out of place by the syringomyelia, or more or less exten- sively destroyed, partly through simple degeneration and atro- phy, partly through gray degeneration, neoplasms, extravasa- tions, and the like. Symptoms of Syringomyelia. All experience thus far teaches that the development of cavi- ties, as such, produces no sort of symptoms by which it could be recognized during life. In many instances the syringomyelia is only accidentally discovered in the bodies of persons who pre- sented no sort of spinal symptoms during life, and who died of some other disease. In other cases the most manifold spinal symptoms exist: paresis and paralysis, atrophy of muscles, disturbances of sensi- bility of various kinds, ataxy, paralysis of the sphincters, etc., in the most varied combinations. These are doubtless exclu- sively the results of the primary alterations (the neoplasms, chronic myelitis, apoplexy, etc.) with which the formation of cavities has been associated later and as an accidental complica- tion. No special symptom, no peculiarity in the course of the disease betrays this complication. Hence it appears that we are at present possessed of no means to establish the diagnosis of syringomyelia during life. As a rule we shall not be able to entertain anything more than vague conjectures on the subject. Consequently there is also no question about prognosis or therapeutics. The only indications for the same are to be found in fundamental disease when it is demonstrated. SALTATORY SPASM. 801 b. Saltatory Spasm Bamberger, Saltatorischer Reflexkrampf, eine merkwiirdige Form von Spinalirrita- tion. Wien. med. Woch. 1859. Nr. 4 u. 5.—P. Guttmann, Ein merkwiirdiger Fall von sog. saltator. Krumpien. Berl. klin. Woch. 1867. Nr. 13.—A Frey, Ueber den saltator. Reflexkrampf. Arch. f. Psych, u. Nerv. VI. S. 249. 1875. —P. Guttmann, Fall von saltator. Reflexkr. Ibid. VI. S. 578. 1876.—^1. Eulenburg, Lehrb. d. function. Nervenkrankh. S. 699. 1871. Under the name of saltatory spasm [" saltatorischer Krampf "] Bamberger, in 1859, first described two remarkable cases in which, as soon as the patients placed their feet upon the floor, such a lively clonic twitching of the lower extremities set in that the patients were thrown into the air over and over again, innumer- able times—in other words, they fell into a rapid and vehe- ment, involuntary act of hopping and jumping. Afterwards P. Guttmann reported two similiar cases from Griesinger's policlinic, and recently A. Frey, in communicating a valuable case from Kussmaul's clinic, has worked up the question in detail and presented us with a number of suggestive points. The form of disease under consideration is, on the whole, ex- ceedingly rare. Inasmuch as, according to the unanimous view of all authors, which I also share, it evidently represents a functional disturbance of the spine, I consider it justifiable briefly to discuss it at this time. For the information of the reader the five cases thus far ob- served will be narrated in outline. 1. Observation of Bamberger (Case 1). A man nineteen years of age had been taken sick with acute pneumonia; during convalescence from the same, severe spasms, of a remarkable character, occurred. At the moment when the patient's feet touched the floor a tetanic rigidity of his legs took place, accompanied by the most severe concussions, so that the patient was thrown into the air ; this was repeated with great rapidity as long as the patient was maintained in an upright position. At the same time his face wasvery red, his heart's action much accelerated ; he had no pain. In a lying or sitting posture there was not the slightest anomaly to be recog- nized in the patient. The sensibility and motility of the legs then appeared entirely normal. But when his feet were pressed against the foot of the bed similar convulsions took place; the spasm could also be originated by tickling the soles of VOL. XIII.—51 802 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. his feet, and then it sometimes extended to the arm. No atrophy; no pain along the vertebrae. In the further course of the case, while the reflex excitability of the lower ex- tremities still increased, twitchings of the face also set in, as well as increased heart's action, dyspnoea, oscillating movements of the iris, etc. The administration of morphine seemed to have a decidedly favorable effect on the spasm, and in the course of a few weeks recovery took place. 2. Observation of Bamberger (Case 2). A hysterical woman, thirty years of age, suffering from chlorosis and cardialgia, and complaining of a great general sense of weariness. One day when she got up, the same spasms were noticed in her as in the first case. As soon as her feet touched theflooi' she was at once tossed into the air and this was repeated as long as she maintained the upright posture. Her face was at the same time distorted into an anxious expression and the heart's action was very tumultuous. The spasm also extended as far up as her head; after the attack a certain rigidity remained, accompanied by slight twitchings, for a quarter of an hour after the patient was put to bed. Motility and sensibility seemed normal. Tickling the soles of the feet called forth no reflex action. On pressing the feet against the foot of the bed twitchings occurred only in the upper half of the body. Nothing else particularly abnormal was recognized. Subsequently excitability was still further increased, to sink again soon and then to remain stationary. At a later period all sorts of hysterical forms of spasm -were developed. The saltatory spasm did not disappear until after quite a while. 3. Observation of Guttmann. A man forty-six years of age. Sixteen years before, he had fever with congestion of the head and hallucinations. Afterwards he had had frequent repetitions of this congestion, with shooting pains in his limbs. Three years ago he had the same pains again, followed by trembling in the limbs, -first in the left foot on walking, then also in the right; at that time, already, he had saltatory spasm, which was sometimes stronger, sometimes weaker, but on the whole gradually grew worse. Now there is very well-marked bounding as soon as the patient touches the floor unless he has a strong support for his arms. He is flung into the air with great force and rapidity ; his head and trunk are, at the same time, bent back- ward, thereby putting him in danger of falling upon his back. He also suffers severe pain at such times, with a sense of oppression. The spasms are especially severe in the morning, towards evening they often disappear altogether. Psychical disturbances especially favor their occurrence. The attacks are generally preceded by a sort of aura in the form of a painful drawing sensation in the legs and back as far up as the back of the head. He complains of pain along the spine, also sometimes of paresthesia. Objectively, sensibility seems to be normal. The spinous processes of several ver- tebras are tender on pressure, and severe pressure on these is sometimes capable of originating a rudimentary attack. Cutaneous irritation of the soles of the feet is without effect. The spasms only occur at certain times; during the intervals the patient can walk about, stamp on the floor, etc., without inducing an attack. SALTATORY SPASM. 803 All therapeutic interference proved unavailing. The patient kept his trouble unchanged (with the aura, and influenced by psychical excitement) until his death, which followed five years later from typhoid fever. 4. Observation of Frey. A man seventy years of age, who had been very much reduced by previous diseases, suffered for two months from rheumatic pains in both legs and in the left arm, which have grown stiff and weak. At a later period trem- bling set in when motions were executed, first in the right leg, then in the left arm. The trembling assumed a more and more convulsive character, and after fourteen days fully developed spasms were present. On passive and active muscular move- ment, severe clonic spasms, starting from the left arm, which is in a state of moder- ately flexed contracture, show themselves in that arm, throwing the entire extremity upward with great violence about three hundred times in a minute; then they pass over to the right arm and enact just the same scene there. If the left arm is held up still longer, the spasms now pass to the right leg, and finally to the left leg. After a few minutes the intensity of the spasms abates, and they disappear again gradually in the reverse order from that in which they arose. All attempts to pro- duce the spasms by purely cutaneous irritation were unavailing. Quite the same state of things existed in the right leg. This showed distinct muscular tension; on the attempt to make active or passive movements, severe clonic twitchings (about 300 times in a minute) set up in this leg, which at once passed to the left leg, then to the left arm, and finally to the right arm, gradually disappearing again in the reverse order. Here, too, the spasm could not be called forth by irritation of the skin alone, nor by pressure upon the sole, as long as the foot was not moved. If the patient attempts to stand on the floor, as soon as the soles of his feet touch it he is thrown into the air with great force by clonic spasm of the muscles of the calf, which at first occurs in both calves at once and afterwards becomes alternating, so that a very curious tripping step, of extreme rapidity, results. At the same time there is intense pain in the legs. As soon as the patient sits down, the sj^asms cease. No disturbances of sensibility. Electrical excitability normal. Moderate atrophy of the muscles. A singular fact was observed, viz.: that the most violent spasms could be quickly quieted by pressure upon the bellies of the muscles of the left arm and forearm in the neighborhood of the elbow (control of reflex action). The same thing was true of the right leg through pressure on the quadriceps femoris a little above the knee. The malady underwent no improvement under the use of various remedies. 5. Observation of Guttmann: A soldier, nineteen years old, was taken sick with dizziness, headache, great sensitiveness of the spinal column and cramps in his feet. The manifestations quickly increased. At the end of five weeks, as soon as the pa- tient is set up alone on the floor he is at once thrown into the air, and this is repeated with increasing frequency and violence of the movements until, after a few minutes, the patient threatens to sink to the ground exhausted. At the same time he has pain in the lower extremities, palpitation of the heart, dyspnoea and a red face. The clonic 804 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. spasms are confined to the muscles of the leg and thigh; all the remaining muscles of the body are free. In the sitting posture, when the soles of the feet touch the ground, spasms also set in, but more feebly, in the form of a convulsive tremor of the feet. Lf the sole of one foot is tapped with the finger, as in percussion, the clonic twitchings are at once set up; on strong percussion, they are developed even in both legs. The same thing occurs on pressing the feet against the foot of the bed. The twitchings cannot be aroused through any other portion of the body. No disturbances of sensibility and none of mobility in the lower extremities. The spinal column was painful on pressure in three places. In the course of a year, gradual improvement set in. These are the only cases thus far known in literature, in which the symptom of "saltatory spasm" has so far stood in the foreground as to be deemed worthy of special notice. Simi- lar conditions of enormously increased reflex excitability are alluded to, here and there, in the pathology of the spinal cord, and yet only in cases that presented much more severe and com- plicated diseases of the spinal cord. From more recent litera- ture I mention, for instance, the case of Mosengeil,1 in which, after a traumatic injury of the spinal column, a very high degree of increase of reflex excitability was developed, together with simultaneous paralysis. A recently published case of Chouppe'sa no doubt also belongs in this category, even though it is not entirely identical with "saltatory spasm." The case is that of a man forty years of age who has been diseased for ten years without change. When he begins to walk nothing abnormal can be noticed, but when he has walked thirty to forty yards the extensors of his legs and thighs contract powerfully and sud- denly so that the patient makes a leap that raises him some eight or ten inches from the ground. Then the muscles remain con- tracted, the limbs are cold, hard, and painful. This condition lasts about a minute. If the patient goes on walking this attack either recurs again soon or he may walk great distances without noticing anything more. 1 Berl. klin. Wochenschrift. 1875. No. 43. p. 588. 2 Contracture des membres inferieures provoquee par la marche. Gaz. med de Paris. 1877. No. 11. p. 138. Soc. d. Biolog. SALTATORY SPASM. 805 The foregoing five cases have this characteristic in common, that in all there was a very extraordinary increase of reflex ex- citability, but only in certain nerve-tracts ; that, as a result of the same, on standing up, or on touching the sole of the foot to the floor, a singular spasm occurs, which has been very appro- priately designated as "saltatory ;" and finally, that this in- creased reflex excitability appeared as an isolated fact, without any other or with but insignificant spinal symptoms; that, in particular, there was no serious paralysis. An elevation of reflex excitability, even to a very astonishing degree, is by no means a rare manifestation in the pathology of the spinal cord; this can be demonstrated in every instance of myelitis from compression, in every high grade of spastic spinal paralysis, and several other forms of spinal disease. Here, how- ever, it is generally associated with paralysis and other severe spinal symptoms. On the other hand, the almost isolated and quite preponderating occurrence of increased reflex excitability is certainly very rare, and proves that the reflex apparatus as well as the tracts that control reflex action are certainly but rarely diseased alone. But it likewise appears, from the above cases of saltatory spasm, that such isolated or well-nigh isolated disease may yet occur. The method of action of saltatory spasm has something very peculiar about it; this being thrown upwards as soon as one's feet touch the floor, this severe spasm of hopping, which puts the whole body in motion with great rapidity, is extremely charac- teristic ; it constitutes the most prominent symptom and belongs to all cases of the disease, although in some instances various other spasmodic manifestations are also reported. With regard to the true essence and the starting-point of this peculiar cramp we are not yet altogether in the clear, in spite of the careful observation of cases, and in spite of the peculiarly accurate examinations of Frey. It is a pity that, at that time, the reflex excitability of tendons was unknown. Although Gutt- mann believes that no relation can be established between this and saltatory spasm, yet I cannot rid myself of the idea that the tendons are the very parts that must decidedly have something to do with these spasms. At least in Frey's case it was positively 806 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. demonstrated that the reflex action did not originate in the skin. Frey regards it as due to the tension and stretching of the mus- cles, but it is a question whether the tendons were not at the same time also stretched and irritated. The fact that in several cases pressing the feet against the foot of the bed, and that in Guttmann's case tapping on the sole of the foot (sic!) aroused the reflex spasm, speaks strongly in favor of my opinion. The well-known dorsal clonic spasm of the feet in its higher grades, in which both legs fall into a lively convulsive trembling (trepi- dation epileptoide) must, in my opinion, bear a very great re- semblance to saltatory spasm, and I can readily imagine that the patients who show this phenomenon would also develop salta- tory spasm if it were possible to set them on their feet and keep them standing ; but they are generally the victims of severe paraplegia. These considerations at all events inspire the wish in future cases more accurately to test the question of whether saltatory spasm does not bear a certain relation to the reflex excitability of tendons—whether it does not represent an increase —certainly to a very high degree—of dorsal clonic spasm of the feet. At the same time, Bamberger's first case seems to show that the reflex action may also originate in the skin ; this, how- ever, is in part also true of dorsal clonic spasm, and may be explained in other ways. There cannot be the slightest doubt that the phenomenon is really nothing else than a reflex spasm ; this appears, to a dem- onstration, from all observations, and quite particularly from the case of Frey, in which the subsidence of the reflex manifestations followed in quite a typical manner. The fact, too, of the check- ing of the reflex action by strong mechanical irritation of the structures lying beneath the skin may also be understood in the same sense. ^ We have, therefore, in all cases to deal with a peculiar form of spasm caused by extraordinarily increased reflex excitability of the spinal cord, and principally localized in certain nerve- tracts. But does this constitute a distinctive, well-characterized form of spasm, perhaps somewhat similar to tetanus, or is it only one —certainly very striking and remarkable, but yet single—symp- SALTATORY SPASM. 807 torn of disease which may occur in various affections of the spinal cord ? For the present I should be more disposed to accept the latter alternative. Just as is the case with ataxy, with muscular ten- sion, with partial paralyses of sensation, and many other things, so saltatory spasm might also only be a peculiar symptom be- longing to the localization of diseased processes in quite definite portions of the cord. Whether this symptom can be the main and essential one in a certain definite form of disease ; whether it will, therefore, be possible, in the future, to gather together cases of this increased reflex excitability under the name of l' sal- tatory spasm," taking only the purest cases and those most free from other manifestations ; can only be determined by future in- vestigations. And in these it would be desirable to give special prominence to the more accurate study of reflex action itself and its starting-points, and to settling the question, so far as possible, of all other concomitant manifestations. The cases at present before us, although they are bound together by the common symptom of "saltatory spasm," can hardly be considered as the same in kind and belonging to a definite form of disease. One case (Bamberger's 2d) is decidedly of hysterical origin ; in another (that of Frey) the paresis, the contractures, and the atrophy that wrere present, speak in favor of the existence of chronic myelitis ; in the other three cases (Bamberger's 1st, Guttmann's 1st and 2d) no other spinal func- tions seemed, to any considerable degree, affected ; sensibility and motility were quite normal. In these cases it would at least seem natural to regard them as peculiar forms of disease, whose main symptom was the saltatory spasm. They would constitute the germ of a subsequent more accurate array of cases of this form of disease. The main causes of this disease would seem to be previous illnesses, debilitating influences, neuropathic disturbances. The distribution of the spasms differs very much in individual cases ; sometimes they are confined to the legs ; sometimes they also extend to the back, the neck, and face, even to the organs of circulation and respiration, and to the pupils. In all cases the arms remained free during the actual saltatory spasm, and 808 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. could be used by the patient for his support. The spasm was almost always accompanied by lively pain in the legs. In one instance the spasm occurred only on standing ; in others it could also be called forth by appropriate irritation when lying down. Psychical influences could be shown in a number of instances either to favor or to control the spasm. After giving the above reports of all the known cases, it is not necessary further to delineate the picture of the disease. The diagnosis of saltatory spasm will, as a rule, be easy, on account of the extremely characteristic occurrence of the hop- ping movements as soon as the feet touch the floor. As regards the therapeutics of this manifestation, no great results can yet be shown. In most instances all possible thera- peutic measures (warm baths, cold sponging, ice to the back, gal- vanism, arsenic, iodide and bromide of potassium, etc.) proved entirely ineffective ; the trouble remained stationary, or ran its course to a favorable termination, apparently uninfluenced by therapeutic measures. Only in the first case of Bamberger did the administration of morphine seem to exert a decidedly bene- ficial influence on the spasm. The treatment of this peculiar condition is therefore still to be discovered. It might be desirable, first of all, to keep our eye on trials of bromide of potassium, calabar bean, ergotine, and atropia (see this Vol., p. 189). c Tonic Snasms [Crampsl in Muscles Capable of Voluntary Movement. Charles Bell, Affections of the Voluntary Nerves. Physiological and Pathological Investigations of the Nervous System. German by Romberg, 1832. p. 367.— M. Benedict, Ueber spontane u. reflector. Muskelspann. u. Muskelstarre. Deutsche Klin. 1864. Nr. 30-34.—Elektrotherapie. S. 134 ff. 1868.— Leyden, Klinik u. s. w. I. S. 128. 1874—j; Thomsen, Tonische Krampfe in willkurlich beweglichen Muskeln in Folge von ererbter psychischer Disposition. Arch. f. Psych, u. Nerv. VI. S. 702. 1876.-^1. Seeligmueller, Ton. Krampfe in wilk." bewegl. Muskeln (Muskelhypertrophie ?). Deutsch. med. Woch 1876 Nr 33 u. 34. After attention had been directed for a long time to certain conditions of muscular rigidity which occur in some diseases of TONIC SPASMS. 809 the spinal cord, and also in other nervous affections, cases were more recently described by J. Thomsen and Seeligmueller in which such muscular tension and regular tonic spasms, on volun- tary motion, formed almost the only demonstrable manifestations of disease. These were cases that probably depended on a con- genital anomaly of the nervous system that occurred repeatedly in one and the same family, and were hereditary through several generations—cases which caused the individuals thus attacked great annoyance, and often led to their being falsely judged and unjustly treated. As these cases are of decided practical importance, and may acquire the most serious significance to the individual—in case of his being subject to military duty, for instance—and as they are, furthermore, probably of spinal origin, they will here be briefly noticed. We will first, as a sample of this peculiar disturbance, com- municate the case very fully investigated and described by Seeligmueller. Richard Kroitzsch, a recruit, twenty-two years of age, had well-nigh driven his drill-sergeant to despair, because he could not learn to handle his musket with anything like the requisite rapidity and precision, and, furthermore, repeatedly let his piece fall, in the midst of the drill, or even fell to the ground himself, without losing consciousness. The recruit stated that a certain stiffness and tension in his arms and legs, especially after long rest of the extremities, prevented the rapid and precise carrying out of the movements. An older sister suffers from the same affection. The patient has been affected with this trouble from his earliest childhood. He never could execute rapid movements; was prevented for this reason from becom- ing a waiter, and was obliged to adopt a sedentary occupation. The stiffness is very great after sitting still for a considerable time, and also on getting up in the morning. It is claimed that his extremities always grow more supple, and are under better control after prolonged movement; this also proved to be the case after drilling for a long time. His speech is also somewhat hesitating. His legs and forearms often have the subjective sensation of being asleep and of formication. No pain and never any cramps in the calves of the legs. Objective examination showed a man of medium stature, with but a slight layer of fat, but with well developed, and in part even athletic, muscles. The domain of the facial nerve and the tongue were normal. Speech good. There was no tenderness on pressure over the spinal column, the nerves or muscles of the extremities. Reflex movement on tickling the soles of the feet increased. 810 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. There was an enormous development of single symmetrical groups of muscles, thus of the calves of the legs, the quadriceps and trapezius muscles, the glutaei, the biceps muscles, etc. The measurements given showed an unusual size of the individual parts. This massive development is comparatively uniform for the upper and lower extremities. There is considerable lordosis of the lumbar portion of the spinal column. Skin and panniculus normal. Almost all the muscles show an uneven, knobby surface, which becomes more distinct on motion. The muscles feel as hard as boards, especially when they are set in action, when they swell up into knotty ridges. This is also the case when they are irritated, mechanically or electrically. On tapping over them, the parts affected at once contract into firm masses, standing out in relief. The same thing takes place on irritation with the faradic current, and it appears, furthermore, that the tetanus thus called forth continues dispropor- tionately long (five seconds and more) after the action of the faradic irritation has ceased. The same manifestations were also called forth through a strong galvanic current. In the muscles of the upper arm and shoulder there were distinct fibrillar con- tractions. The active movability of the extremities did not appear to be materially disturbed, during the examination—only the rotation of the shoulder-joint was a little slow and hesitating. Considerable obstacles were opposed to passive motion in most of the joints, particularly the knee-joint. There were no disturbances of co- ordination. Climbing stairs was executed with the legs somewhat spread. No muscular tetanus could be called forth by compression of the trunks of the nerves or arteries. The galvanic and faradic excitability of the nerves and muscles proved to be quite normal. Seeligmueller was induced to report the preceding case by the description which Dr. J. Thomsen had given of this peculiar form of disease. Thomsen himself has suffered from the affection since his youth, and has demonstrated its existence in his own children, in his brothers and sisters, and in his ancestors, includ- ing numerous cases, and running through not less than four generations. The description which he gives, somewhat concisely, of him- self and of one of his sons who, by reason of the imperfect judg- ment formed concerning his case, had to suffer much at the hands of the military surgeons, agrees in all essential points with Seeligmueller's case. The difficulty begins in earliest youth ; Thomsen was able, in part, to recognize it in his children even in the cradle. It con- sists in a deficiency in the influence of the will on the muscles which fall into a state of rigidity and stiffness, and even into TONIC SPASMS. 811 complete tonic spasm when they attempt to obey the will. This appears the more prominently the more powerfully patients exert their will to overcome the obstacle, the more they are ob- served, or are the subjects of psychical excitement generally. This condition may become so extreme that patients fall to the ground and tumble around helpless until the spasm abates. On the receipt of sudden severe psychical impressions a sudden painful sensation shoots through all the voluntary muscles. Low temperature, taking cold, and all conditions of disease in- crease the evil, warmth and movement diminish it. The sphinc- ters are not involved. When the patients once get agoing, and the will has attained its influence over the muscles, then they are as capable of movement as well people. No other disturbances of any kind are to be observed. Psy- chically these people are well, although the fear of betraying their condition before people, and the wish to conceal it, rule them and influence their character. There is nothing abnormal to be found in their corporal condition; the muscular system, particularly, may be quite admirable and well developed. In Rostock they excised a piece of muscle from Thomsen's son and found it perfectly normal. The heredity of the trouble is very remarkable, as is strik- ingly manifested in Thomsen's family. The great-grandmother of Dr. Thomsen died of puerperal mania, and her two sisters were afterwards psychically diseased. His grandfather was also mentally weak. Of his four children, two had the stiffness to a high degree, the other two (including Thomsen's mother), to but a slight degree. Among the children of this generation, the evil, as well as conditions of psychical weakness, was very wide-spread; of thirteen children borne by the mother of Thomsen, seven suf- fered from this rigidity. Among the thirty-six descendants of Dr. Thomsen and his brothers and sisters, on the other hand, but six suffer from this complaint. Four of his own five sons have the disease. This is, therefore, a very classical example of '' neuropathic encumbrance " [" neuropathischer Belastung " ] in a family. I furthermore find a case in Leyden (1. c.) which plainly be- longs here, and some details of which I wish to mention, as it 812 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. may serve in certain respects to complete the description of Seeligmueller. A merchant, twenty-eight years of age, whose brother suffers from a similar muscular affection, and whose muscles are developed in quite an athletic manner, shows a striking stiffness in all his movements, which he has had from his earliest youth. Individual groups of muscles do not promptly obey the will, and, when a certain movement is intended, come to a stand-still half way in a state of tetanic rigidity. His speech is slow and awkward, as are also the movements of the tongue. Some of the motions of the eyes, and of those muscles controlled by the facial nerve, are also sluggish. If the patient clenches his fist powerfully it is impos- sible for him to extend his fingers again immediately; this is accomplished but slowly, as if he had to overcome a serious obstacle. After these attempts have been repeated a number of times the movements are accomplished more easily. The same manifestations occur in the lower extremities, etc. Aside from this the patient is perfectly well. The malady remained uninfluenced by any treatment. In Benedict, too, there are some observations in which this appearance of muscular stiffness stood out in a very prominent manner. This is particularly true of observation No. 88, in his "Electrotherapy," while observation No. 86 doubtless represents a somewhat more complicated, but, in certain respects, a similar case. Charles Bell, too, has undoubtedly seen the affection here dis- cussed, and has described it—even though in quite hasty lines—in that portion of his celebrated work cited above. I myself very recently observed a case which, at least, gave indications of quite similar manifestations. The patient, twenty- one years of age, came to me on account of symptoms indicating multiple sclerosis in process of development, and stated that from his youth up he had been the butt of his comrades on account of his being so stiff and unhandy. He had always felt a cramp- like stiffness in his limbs whenever he endeavored to use them rapidly, especially if he was being observed by others. This was noticeable in rising from a chair, in going up stairs, etc.; if he took a firm hold of any slender object with his hands, he was unable to let go of it again immediately, etc. This condition was worse in the cold. When once started in walking his movements followed much more easily. Signs of these conditions are often enough met with in per- TONIC SPASMS. 813 sons with disease of the spinal cord, but then they are always complicated with other and more severe spinal symptoms. This peculiar stiffness and awkwardness of motion, and the fact that many patients walk and move worse when they are being ob- served, are known to every experienced physician. On the other hand, the almost isolated occurrence of these disturbances, as it appears in the cases given above, is certainly a rarity, though it might be worthy of the special attention of military surgeons. Briefly stated, the picture of the disease, as based upon the scanty material at hand, is about as follows : From their earliest youth—doubtless, as a rule, under the influence of hereditary conveyance—these patients suffer under a peculiar disturbance of movement, which is but rarely developed for the first time in adults. This disturbance of movement con- sists in a peculiar stiffness and rigidity of the muscles which are intended to be set in action by the will; a stiffness which may increase to a regular tonic cramp, so that movements are entirely hindered, the patients fall to the ground, etc. Just as the vol- untary contraction of the muscles is opposed by a strong internal obstacle, so the termination of a contraction that has once set in also follows but slowly, as if overcoming an obstacle ; the con- tractions which were accomplished with difficulty persist long— patients cannot at once let go of articles which they have seized firmly. It is only when, after repeated powerful efforts of the will, the tracts for motor excitation seem, as it were, to have become free again, that movements follow with increasing free- dom and ease, and are but little to be distinguished from healthy movements. Psychical influences, sudden mental impressions, the effort of paying attention, the presence of strangers, cold, etc., act unfavorably on the condition ; warmth, moderate move- ment, a good state of mind, a high degree of self-confidence, relieve it. Aside from this these patients are well; their bodily and mental functions are accomplished normally; their muscular system may be admirably developed and even capable of accom- plishing a large amount of labor. Sometimes (always ?) tension of muscles takes place on making passive movement, and on mechanical and electrical irritation of the muscles strikingly 814 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. powerful tonic contractions of the same set in. With all this, such patients are unfit for many of the duties of daily life and for the exercise of various callings, and above all are unqualified for military duty. We will not here enter into far-reaching speculations with regard to the essence of this remarkable form of disease. Thom- sen thinks that it depends on a disturbance falling principally within the domain of psychical influences. Seeligmueller does not share this opinion. Whereas he originally thought it to be a peculiar form of muscular hypertrophy, the doctrine of a con- genital or inherited affection of the lateral columns of the cord afterwards appeared to him most probable. I must confess that I have thus far been unable to form any definite idea of the seat and the variety of affection lying at the foundation of this diffi- culty, although, owing to the occurrence of analogous symptoms in so many diseases of the spinal cord, I should first of all think of a spinal affection. The question can only be decided by fur- ther observation. There is also wide play left here for therapeutic endeavors, which, in the cases thus far reported, seem to have been entirely without results. d. Intermittent Spinal Paralysis. Macario, Gaz. meU de Paris. 1857. Nr. 6.— Romberg, Lehi'buch d. Nervenkrankh. I. p. 752.— Hartwig, Ueber einen Fall von intermittirender Paralysis spinalis. Diss. Halle. 1874. The occurrence of purely intermittent attacks of paraplegia and paralysis, which, according to all appearance, are of spinal origin, and which make a most striking impression as contrasted with the usual stability of spinal paralysis of similar severity,- is undoubtedly one of the rarest and most remarkable forms' of manifestation of malarial infection. Literature contains but very few instances of this form of spinal paralysis. I find one case of Macario's cited in Hertz,1 in which a 1 This Cyclopaedia, VoL IL, p. 601, foot-note. INTERMITTENT SPINAL PARALYSIS. 815 woman, two days after her confinement, was attacked with for- mication in her feet without any known cause, which extended over the trunk to the upper extremities. The extremities be- came paralyzed and anaesthetic, and the tongue, too, was para- lyzed. These manifestations were repeated in a quotidian type three times, and were cured by quinine. Romberg describes quite a similar case. A woman, sixty-four years of age, after being quite well the day before, was suddenly attacked with paralysis of the lower extremities and the sphincters. Sensi- bility was unchanged, consciousness clear, the temperature cool, pulse 80, small and empty, no pain in the spinal cord. The next day there was an astonishing change in the condition. The patient can walk again, and void urine voluntarily, and only complains of weakness in the legs. The next morning there was paraplegia again, which had set in at the same hour as two days before. A third paroxysm was awaited, which also set in at the appointed time, although without paralysis of the sphincters. Quinine effected a rapid cure. In a recent dissertation at Halle, Hartwig has reported in detail an observation belonging under this head. Tin's observation is in relation to a vigorous laborer, twenty-three years of age, who had suffered from tertian intermittent for a few weeks five years before, but since that time had remained perfectly well and strong. In November of 1873, he first noticed weariness in the legs, which gradually increased, and the arms, too, were attacked. On the third day he was obliged to take to his bed, and the night follow- ing he was completely paralyzed—his legs, trunk, arms, and even the movements of his head were paralyzed, but not the muscles of the face ; speaking, breathing, and swallowing were somewhat hindered ; there was no paralysis of the sphincters, sen- sibility was intact, the head entirely free, no pain. The secretion of sweat was excessive. After this condition had lasted for twenty-four hours it let up, and in half an hour, generally with an increased secretion of sweat, all the muscles again became movable. During the succeeding twenty-four hours the patient remained free from any sign of paralysis, merely complaining of weariness and heaviness of the limbs. Then the attack of paralysis recurred again, in the same way as at first, and then there followed regular successive free intervals and attacks, both of about twenty-four hours' duration. Gradually the time occupied by the attack extended to forty hours, the interval being much shorter. Under the use of arsenic the intervals also extended over a period of about forty hours. On first using quinine the attacks remained altogether absent for four days. After hypodermic injections of strych- nia the tertian type of the attacks was re-established. Between two days, on which the patient is completely paralyzed on both sides, he has a day of tolerably 816 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. free mobility of all his members. The sphincter ani was likewise affected a few times; the general condition of the patient had not materially suffered. At the end of March, 1874, the following condition was found to exist during an attack: The patient lay there completely paraplegic; only the muscles of his face acted normally; the flexors of the hands and feet show a minimum amount of motion. The pupils reacted well; the special senses were normal. The head could not be moved; on inspiration, it was principally the diaphragm that was active; expiratory efforts were reduced to a minimum. Speech and swallowing were somewhat difficult. Respiration 20, pulse 72, temperature 99.5°; sensibility of the skin and muscles normal. Reflex action is entirely wanting; the electrical excitability of the muscles is almost entirely extinguished (during the intervals it is only diminished). No pain, only formication and a feeling of numbness in the parts affected. Evacuations voluntary. In the course of the succeeding months greater and lesser irregularities occurred in the course of the disease. The use of quinine sometimes prevented the attacks for a number of days, but then they returned again in spite of its continued use. On the whole, however, the disease retained its intermittent or strongly remittent type, and gradually a certain degree of cachexia began to show itself, with marked emacia- tion of the muscles, etc. After the trouble had lasted for seven and a half months no radical improvement could, as yet, be demonstrated, and nothing is stated with regard to the final termination of the case. These three very remarkable cases have the following features in common: that they all present a rapidly developed paraple- gia, advancing to complete motor paralysis, with or without ansesthesia and paralysis of the sphincters ; that this paraplegia disappears again in the course of a few hours, sometimes with the appearance of a critical sweat, to give place to a complete or well-nigh complete intermission; that this process is then re- peated, in a more or less regular manner, in the quotidian, ter- tian, or quartan type; and that the entire affection is either promptly cured by quinine, or at least favorably influenced thereby. It is in the highest degree probable that we here have to deal with a malarial infection; the intermittency of the paroxysms, their termination in a sweat, and the efficacy of quinine, all argue strongly in favor of this intermittent paraplegia being nothing else than a masked intermittent. To be sure, this cannot, as yet, be considered as rigidly proven. It may probably be even more positively asserted that the seat and starting-point of this disturbance is to be found in the TOXIC SPINAL PARALYSIS. 817 spinal cord. The entire character and grouping of the symp- toms, the limitation of the paralysis to purely spinal nerves, the entire immunity of the brain, the great resemblance to other general paralyses of notoriously spinal origin, speak with such positiveness in favor of this belief that no reasonable doubt on the subject can be raised. But it is, unquestionably, a matter of the greatest difficulty to determine what actually takes place within the spinal cord in this malarial paraplegia,—whether any, and, if so, what anatomi- cal changes take place therein during the attack. Hartwig as- sumes that it is a question of transitory hyperaemias and serous transudations in the substance of the spinal cord ; a supposition which appears to me untenable, from the mere fact that the dis- turbance is always confined to the motor portions of the cord, leaving the sensitive portions entirely free. It is probably safer to say that the essential conditions of malarial spinal paraplegia are at present unknown to us, and that we can only hope for light on this subject from the future. The diagnosis of "intermittent spinal paralysis" is very easily arrived at from the picture of the disease. And when the diagnosis is clear the treatment is plain. The treatment ap- plicable to intermittent fever in all its forms—quinine, arsenic, removal from a malarial region, etc.—must be undertaken with energy. If this remains without results, then the therapeutic measures laid down in various portions of this work for acute and chronic spinal paralysis will claim consideration. e. Toxic Spinal Paralysis. Raoul Leroy d'Etiolles, Des paralysies des membres infeneures. II. p. 1-75. Paris, 1857.—Jaccoud, Les paraplegies et I'ataxie du mouv. pp. 321-334. Paris, 1864. Leyden, Klinik. II. 1. Abth. pp. 280-297. 1875. In connection with the foregoing cases of infectious spinal paralysis, it may, perhaps, be appropriate to give some particu- lars with regard to similar instances of paralysis called forth by known and actual poisons. It is claimed that such paralysis (in various forms, as paraple- gia, as paralysis of single groups of muscles or extremities, as VOL. XIII.—52 818 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. general paralysis, etc.) has resulted from intoxication with ar- senic, phosphorus, lead, quicksilver; furthermore, as the result of poisoning with carbonic oxide, sulphide of carbon, tobacco, camphor, ergot, lathyrus sativus, alcohol, absinthe, mushrooms, balsam of copaiba, etc., entirely apart from the severe acute paralysis of the nervous system, such as is called forth by opium, belladonna, strychnine, etc. All these poisons are distinguished for their powerful though varied influence on the nervous system; they cause lasting paralysis, as a rule, only when their action is slow and repeated, more rarely when it is quite acute. They cause the most varied forms of paralysis and paraplegia, from simple weakness and paresis to complete paralysis, sometimes acute, sometimes more chronic, with or without muscular atrophy, with or without dis- turbances of sensibility. In many cases, however, the causal connection between these and the antecedent intoxication is by no means placed beyond all doubt. Furthermore, we know almost nothing with regard to the changes that may exist in the nervous system (especially in the spinal cord) in such paralyses. We have virtually no anatomi- cal reports on this subject that carry any weight with them ; the localization in the spinal cord cannot even be asserted, with any degree of positiveness, on the ground of the clinical symptoms. Great uncertainty still reigns even with regard to the most fre- quent and best known of these forms of paralysis, viz., lead- palsy. What is to be said and conjectured on this subject has already been given in other portions of this work. The pathology of the spinal cord has, therefore, not as yet experienced any advancement through the study of toxic paraly- sis, and there is all the less reason wdiy we should here enter upon these matters in detail, because this would carry us into the domain of toxicology, this being the field where, for the pres- ent, the scientific working up of these questions will have to take place. The reader who is more particularly interested in this direction will find that, aside from the hand-books on Toxicology, the works above cited contain more detailed accounts of these matters, even though the results may still be unsatisfactory. PARAPLEGIA DEPENDENT ON IDEA. 819 f. Paraplegia dependent on Idea. J. Russell Reynolds, Remarks on Paralysis and other Disorders of Motion and Sen- sation dependent on Idea. British Med. Journ. 1869. Nov. 6. In a very readable essay, and one of importance to the prac- titioner, Russell Reynolds some time ago pointed out the fact that severe disturbances of the nervous system (paralysis, cramp, pain) may depend upon diseased action of the mind, and upon imagination ; that such disturbances, under the garb of affec- tions of the brain or spinal cord, may long bid defiance to all treatment, and only disappear after the removal of the erroneous ideas. Such conditions may occur quite independently of psy- choses, of hysteria, hypochondriasis or simulation; they are often associated with general debility, and even with actual, well- defined diseases of the nervous system, and, if a correct diagnosis is made, may easily be removed by appropriate treatment. Everybody knows the powerful influence which imagination and lively mental operations have upon pathological manifesta- tions in the nervous system, and we are not surprised if these influences make themselves felt in the domain of sensation and feeling ; we are less accustomed to the idea of such psychical impressions manifesting themselves in the form of severe motor disturbances also, although there is no reason, a priori, why this should be impossible. Taught by our own experience that such conditions actually do occur, and perhaps occur more frequently than one would think, we consider that it would not be amiss to give a brief rep- resentation of Russell Reynolds' views, so far as they refer to disturbances in the sphere of the spinal functions. The reader will agree with us that the easiest way to familiarize him with the subject is by the brief narration of the most significant one of Russell Reynolds' cases. A young lady who had seen better days was admitted into the hospital as para- plegic. She had become so gradually, and was much emaciated. She had been unable to stand for two or three months, and was now bed-fast. Her expression of countenance was anxious, mixed with a glimmer of hope; she expected to be cured 820 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. as the result of entering the hospital,—a step upon which she had resolved with difficulty. Her paralysis was almost complete; she could move the toes somewhat, and raise the heel a little from the bed. But the sphincters were normal, and there was no local atrophy. Sensibility was intact; electro-muscular sensibility and contrac- tility normal; reflex action hard to accomplish ; no conditions of cramp ; no pain, even on movement of the legs or on pressure over the spinal column. No hysteria; no traumatic injury; no cachexia demonstrable. Her previous history is as follows: Her father, who is her only relative, was brought from affluence to poverty, a year and a half ago, through commercial dis- asters. He bore it bravely, as did also his daughter ; he set to work again, and she assumed duties and responsibilities which she had never known before. At first all went well, but suddenly the father became paralytic, and his daughter nursed him with tender self-sacrifice. But they soon found themselves in actual want. The daughter worked as daily governess, was obliged, as a matter of economy, to walk a great deal, and walked fast, so as to gain time for her father. Thus she worked for many a weary week, the thought of paralysis always before her, her brain over- burdened with thought and anxiety, her limbs weary with walking, her spirits hardly equal to the constant effort to appear cheerful. Her legs often hurt her, and she thought, with shuddering, what if she should grow lame like her father ! This thought acquired an increasing power over her; she was gradually obliged to give up walking, then to stay at home, then in her room, and finally in bed. Her legs grew more inactive from day to day until complete paralysis was present. She was told, and all those about her were told, in confidence, that she would soon be able to walk perfectly well. A light tonic was administered ; her legs were faradized, though more for the sake of the psychical impression ; her legs and back were rubbed and she was obliged to walk up and down the hall for five min- utes every four hours supported by two nurses. The day after the beginning of this treatment she could walk with but little support. After four or five days she could walk quite well, and at the end of two weeks she was as strong and capable as ever before in her life. Not less interesting are the other examples which Russell Reynolds gives. I have likewise met with quite similar things in my own practice, even if not so well marked in degree, and have repeatedly seen improvement set in through appropriate psychical impressions made upon the patient. It is, of course, by no means always easy to recognize such conditions aright and to separate them from real diseases with an anatomical basis. Such conditions are by no means always associated with hypochondriasis or hysteria, or mental disturb- ances, although this may occur: still less are we to suppose that PARAPLEGIA DEPENDENT ON IDEA. 821 such patients are indulging in malicious simulation; they are themselves firmly convinced of the reality of their symptoms. A certain general debility not rarely accompanies such conditions, and all possible debilitating influences—diseases, cares, anxieties, overexertion, etc.—may be followed by the same. But it gener- ally requires, in addition, that the attention be habitually di- rected to certain portions of the body or to certain forms of dis- ease in order to call forth such "imaginary" disease. On this ground Russell Reynolds believes that a part of the neuroses caused by railroad accidents may be classed under this head, wherein the attention of the victim is influenced in the most un- fortunate manner by the stories of friends, by the inquiries of his physician, the talk of his attorney, and the sober face of the company's physician. The diagnosis of such forms of disease is based on the follow- ing circumstances: on the method of development of the symp- toms, and especially on the demonstration of some ruling idea of the mind ; on a judgment with regard to the symptoms present, and especially on the demonstration of such symptoms as cannot be reconciled with the theory of an organic lesion. In this re- spect Russell Reynolds calls attention to the following points: that the patient cannot lift his heel from the bed nor draw it up, while he can raise himself up or lie down without any help, or turn from one side to the other; that in apparently complete motor paralysis there are no signs of paralysis of sensation, no trophic disturbances and no diminution in the electrical excita- bility ; that sometimes there is complete inability to stand on one's legs, whereas the legs can be moved in every possible direc- tion. Finally, the diagnosis is also said to be aided by the fail- ure of ordinary treatment and the success of treatment directed to the removal of the false idea. That it will not always be pos- sible to make a positive diagnosis on the ground of these signs, is a fact which will be admitted by every one familiar with the pathology of the spinal cord. In the way of treatment Russell Reynolds gives the follow- ing recommendations : Let the case be taken hold of earnestly ; excite the hope of recovery, if a definite plan of treatment is fol- lowed out, and let this be done not only by the physician but by 822 ERB.—DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. those around the patient—hence the importance of hospital treatment; compel the patient to walk at certain definite times, supported on both sides; use faradization to the muscles, fric- tion and passive movements of the limbs; apply dietetic and medicinal treatment such as the general condition of the patient requires. So far as we know, these matters, which are certainly not without practical importance, have thus far not received the at- tention which they unquestionably deserve. It would be inter- esting to receive communications from others regarding similar manifestations ; perhaps it would be possible after a while to gain somewhat more insight into the pathogenesis of these processes, which thus far almost elude all scientific explanation. DISEASES OP THE MEDULLA OBLONGATA. ERB. I. Anatomical Introduction. The chief works to be consulted are : B. Stilling, Untersuch. lib. d. Textur u. Func- tionen der Medulla oblong. Erlangen. 1843.—Untersuch. fiber den Bau des Hirnknotens oder der Varol'schen Briicke. Jena. 184G.—Schroeder v. d. Kolk, Bau u. Function der Medulla spin. u. oblongata. Braunschweig. 1859.— Deiters, Unters. ub. Gehirn u. Riickenmark des Menschen u. der Saugethiere. 1865.—Stieda, Ueber denUrsprung der spinalartigen Hirnnerven. Dorpat. med. Zeitschr. II. 1873.—Meynerl, Strieker's Handbook. Vol. 2.—Skizze des menschlichen Grosshirnstammes, etc. Arch. f. Psych, und Nerv. IV. 387-431. 1874. —Henle, Handbuch der Nervenlehre. 1871.—Huguenin, All. Pathologie der Krankheiten des Nervensystems. I. Anatom. Einleitung. 1873.—Flechsig, Die Leitungsbahnen im Gehirn u. Riickenmark des Menschen. Leipzig. 1876. —Ueber Systemerkrankung im Riickenmark. Arch. d. Heilk. XVIII. 1877.— Fardbeuf in Diction, encyclo. des sciences medic. 2 Ser. tome VIII. p. 299. 1874.— W. Krause, Handbuch d. menschl. Anatomie. I. 1876.—Buret, Sur la distribution des arteres nourricieres du bulbe rhachidien. Arch, de Phy. norm. et pathol. 1873. p. 97. Many points, and these perhaps the most important, in the anatomy of the medulla oblongata, are still unsettled. Indeed, the relations here are, more than elsewhere, difficult to disen- tangle. The connections between the different structures of the medulla oblongata and those, first, of the spinal cord below, and second, of the central nervous system above, are so extremely complicated, numerous, and entangled, that even the most care- ful and thorough anatomical investigation can scarcely make them understood. This is quite sufficient explanation for the fact that the views of the best observers on the finer structure of the medulla oblongata are still at great variance with one another on several points. The space in this handbook does not allow of an accurate 826 ERB.—DISEASES OF THE MEDULLA OBLONGATA. and exhaustive description of the outward form and internal structure of the medulla oblongata. Yet we can scarcely avoid giving a short sketch of the principal points, in order to refresh the practitioner's memory on anatomical relations, to put him au courant with the latest investigations, and acquaint him somewhat with the present nomenclature, and thus, we hope, facilitate his comprehension of the morbid anatomical details in the following pages. The best way of attaining this object will be to begin with the structures of the spinal cord, with which we are already acquainted, and follow these into and through the medulla oblongata, and after this to give a short description of the other parts which are peculiar to the medulla. To suit the practi- tioner's interests, we shall endeavor, first of all, to give a clear and correct idea of the topography of the parts, leaving aside the details of the course of the fibres and their manifold connec- tions, partly because these are wholly uncertain, and in many instances in great part unknown. Even the external boundaries of the medulla are still a matter of dispute among anatomists, though every one agrees to bound it inferiorly with the roots of the first cervical pair of nerves. The superior border, however, is undecided, some considering it as formed by the inferior border of the pons (which would correspond on the posterior surface to the upper striae acusticse); but most writers include the whole floor of the fourth ventricle, i. e., the whole rhomboid sinus ; these latter boundaries, too, are better suited for clinical purposes. We should then take for the upper boundary the processus cerebelli ad corpora quadr. (which form the lateral walls of the fourth ventricle) and the entrance of the Sylvian aqueduct; thus, we may regard the pons as a cerebral structure, which bounds the medulla oblongata on one side, and then we need concern ourselves no more with its struc- ture or pathology in this article. From a superficial examination of the exterior, one would be led to think that the columns of the spinal cord run without ANATOMICAL INTRODUCTION. 827 interruption into the structures of the medulla oblongata ; but closer observation proves the error of this view, and shows that the most manifold transpositions take place, which contribute to bring new and important structures to the surface, and produce the characteristic appearance of the medulla. If we follow up the anterior spinal columns, they appear to ascend directly and run into the pons. But, on drawing apart pIO- 20.__View of the anterior surface of the medulla and pons. Enlarged. On the right side of the medulla'the roots of the nerves are removed. a, Anlerior column ; 6, lateral column ; c, decussation of the pyramids ; d, pyramids ; e, groove between anterior column and pyramid ; /, olivary body ; g, corpus resti- forme- A,'pons; i, fibra? arciformes; V-XIl, roots of the fifth to twelfth cerebral nerves; Ncla, anterior roots of the first cervical nerves ; Nclp, posterior roots. the lips of the anterior median fissure, we perceive that, at the level of the first cervical nerves, it is obstructed for a distance of from six to seven mm. by coarse bundles of fibres, which pass from one side to the other, decussating in fact, and then con- tinuing their course on the opposite side, along the anterior fissure. Here we see a crossing of fasciculi, which come to the surface from the interior, and then usurp the position of the 828 ERB.—DISEASES OF THE MEDULLA OBLONGATA. anterior columns in their course upwards. This is the so-called decussation of the pyramids (Fig. 20, c), and the columns which go from this to the pons, and take the place of the anterior columns, are called the pyramids (Fig. 20, d). They issue from between the anterior columns (Fig. 20, a), which latter retreat and disappear into the interior of the medulla. This arrange- ment is often rendered evident by a distinct groove (Fig. 20, e) running obliquely upwards, and forming the boundary between the pyramids and the anterior columns proper. The lateral columns of the spinal cord proceed directly upwards through the medulla, and are now surrounded by the (motor) roots of the hypoglossus (Fig. 20, XII) and the (chiefly sensory) roots of the glossopharj^ngeus (IX) and vagus (X), which replace the anterior and posterior roots of spinal nerves. In the upper half, almost immediately behind the pons, projects an almond-shaped structure, like a long prominence, and bor- dered on either side by attenuated stripes of the lateral columns ; this is the olivary body (Fig. 20, /). Its prominence is subject to considerable individual variation. The upper portion of the lateral column is here often called the olivary column. A small portion of the lateral column (Flechsig's direct cerebello-latero- columnar tract), belonging to the periphery of the postero-late- ral column, passes in the medulla obliquely backwards, and takes part in the formation of the corpus restiforme, and also of the pedunculi cerebelli. The posterior spinal columns at first continue their parallel course upwards; a little above the superior termination of the decussation, however, they part at rather a sharp angle, and pass into the cerebellum under the form of round columns, much increased in size. These columns are the pedunculi cerebelli (Fig. 21, g) or funiculi restiformes. The increase in size would alone indicate that these are not the mere prolongation of the posterior spinal columns ; in fact, new bundles contribute to the formation of the cerebellar peduncles. The components of the posterior columns proper appear to run directly into the pedun- culi; the funiculi graciles (Goll's cuneiform columns) (Fio-. 21 b), forming the internal portion of the pedunculi, at the point of the angle swell to nodules, the clava (Fig. 21, d), and are ANATQMICAL INTRODUCTION. 829 usually connected with the cuneiform column of the other side by a slender band of white substance, the obex (Fig. 21, e). The sulcus intermedins posterior (c), which divides the graci- lis from the cuneiform column proper, continues its course up to the striae acusticse. The cuneiform column runs upwards alongside the sulcus, increasing considerably in size, as it is rein- 7/. W* k^ Fig. 21.—View of the posterior surface of the medulla, the roof of the fourth ventricle being removed, to show the rhomboid sinus clearly. The two halves are drawn somewhat apart. Enlarged, n, funiculi cuneati, et 6, graciles; a + 6 = posterior spinal column ; <:, sulcus intermedius posterior; d, clava ; «, obex ; /, corpus restiforme ; g, pedunculus cerebelli (= a + b +/); h, crus cerebelli ad pont.em ; i. crus cerebelli ad corpora quadr. ; k. corpora quadr.: /, stria? medullares s. acusticaj; m, fibra± arciformes; n, eminentia teres (genu nervi facialis); o, fovea anterior; p, locus coeruleus; q, funiculus teres: r, nucleus of the hypo- glossal : * + t, ala cinerea ; a, nucleus of vagus ; t, nucleus of acces6orius; u, nucleus of acusticus; Nclp, posterior root of the first cervical nerve. forced by other fasciculi, which form the lateral half of the pedunculus cerebelli. These fasciculi receive the name, corpus restiforme (/), and are frequently marked off from the cuneiform column by a distinct groove (dotted line in Fig. 21), so that they have been divided by some (Henle) into median and lateral cune- iform columns ; this latter distinction can be more easily de- 830 ERB—DISEASES OF THE MEDULLA OBLONGATA. tected in a transverse section (Huguenin). The corpus restiforme is partly made up of superficially situated bundles, which have been described under the name of fibrce arciformes (Fig. 20, % ; Fig. 21, m). These arise partly from the bottom of the anterior median fissure, between the pyramids, and partly from the late- ral fissure, between the pyramids and olivary bodies. They appear to be derived from the anterior columns, and form an arch round the anterior and lateral surfaces of the medulla, sometimes of large, sometimes of small dimensions ; finally, they disappear almost completely into the cuneiform columns. They are generally best developed at the posterior angles of the olivary bodies, sometimes even covering these. But the corpora restiformia receive numerous other bundles of considerable size from the neighborhood of the olivary bodies, and probably, too, from the bodies themselves. The separation of the pedunculi cerebelli exposes the deep- seated gray substance to a considerable extent, thus producing a slight depression, which is bounded interiorly and laterally by the diverging pedunculi cerebelli, superiorly and laterally by the converging crura corporum quadr.—this lozenge-shaped depres- sion is called the rhomboid sinus, or floor of the fourth ventricle (Fig. 21). Its superior angle is formed by the union of the crura cerebelli ad corp. quadr. at the entrance to the Aquseductus Sylvii, and its inferior angle lies between the pedunculi cerebelli, behind the obex at the point of separation of the funiculi graci- les. Just here too the central spinal canal opens into the poste- rior longitudinal fissure, and thus communicates with the fourth ventricle. The obtuse angles on either side are formed by the junction of one crus with the peduncle of the corresponding side. The floor of the fourth ventricle is divided symmetrically by a longitudinal shallow groove. A superficial inspection shows us here a number of grooves, depressions, projections, and gray patches, etc., which are all connected with important structures in the interior, and thus of practical importance to us. Of these certainly the most striking are the strioz medullares (Fig. 21,1). In numbers varying from one to twelve, these bun- dles run horizontally at right angles to the median fissure, from which they emerge, and cross the pedunculi, and, passing round ANATOMICAL INTRODUCTION. 831 them, join the nervus acusticus. They divide the sinus into a superior large, and an inferior smaller space. Above the striae, and in the right angle formed by them with the median fissure, lies a small, rounded, white prominence, corresponding to the genu nervi facialis and the neighboring nucleus of the abducens (Fig. 21, n). Laterally and anteriorly to this we find the so- called fovea anterior (Fig. 21, o), a depression which is generally colored with a dark pigment, and presents the appearance of a contracted scar. At some depth below this lies the nucleus proper of the facial nerve. Going from this towards the superior angle of the fourth ven- tricle and slightly outw^ard, we strike another gray depression, called the locus cwruleus (p), which borders on the motor nu- cleus of the trigeminus. The gently elevated cords which traverse the inferior triangle of the rhomboid sinus, parallel to the median fissure, receive the name of funiculi teretes (Fig 21, q). Beneath them lies on either side a nucleus of the hypoglossal (Fig. 21, r), extending longi- tudinally for some distance. Passing outwards, we are met by a light-gray triangle, with its apex pointed to the striae, and its base resting on the clavae. This is called the ala einerea (s and t). Its anterior portion (s) is coextensive with the nucleus of the vagus, while the posterior (I) contains the upper end of the nit- cleus accessorii, wdiich extends far down into the spinal cord. In the interior of the medulla, somewhat anterior to the ala cine- rea, the nucleus of the glossopharyngeus comes in contact with that of the vagus. The posterior median nucleus of the acoustic forms the anterior and lateral boundary of the vagus nucleus. It comes nearer the surface than the glossopharyngeus, and oc- cupies nearly the whole space between the ala cinerea and pedun- culus, up to the upper border of the striae. Henle has described it under the name of nucleus acusticus superior. The internal structure of the medulla oblongata is so ex- tremely complicated that no one has yet been able to throw the slightest light on the general course of the fibres and the connec- tion between its paths of conduction. Though some structures have been recognized as undoubtedly analogous to certain com- ponents of the spinal cord (gray nuclei—gray columns, commis- 832 ERB.—DISEASES OF THE MEDULLA OBLONGATA. sures, etc.), still we meet with so many new and problematical forms, the different parts combine in so various and complicated manners, and the fibrils run in such entangled, tortuous and interwoven courses, that we must almost despair of ever follow- ing them up accurately. In fact, up to the present the most careful and exact investigations have thrown but a very feeble light upon the subject. Very little is known with certainty and accepted by all, and the few facts of this nature may be well described as landmarks in an unknown region. With the rest we need not further oc- cupy ourselves, since there is no practical value to be derived from studying all the conflicting views of the hour. Our task in this direction only extends to the indication of those regions about the structure of which next to nothing is known. The value and significance of successive sections, which are here too the chief method of investigation, can be studied in anatomical text-books. From the nature of the subject we can imagine how imperfect must be the results. The first material change in the spinal cord—that, indeed, which leads to the distinction between it and the medulla oblon- gata—takes place on a level with the first cervical pair of nerves, consisting chiefly in the decussation of the pyramids. Large bundles of fibrils collect from the posterior division of the lateral columns, and pass obliquely forward and upward, and simultaneously forward and inward towards the anterior longitudinal fissure. They appear here more or less as continu- ous bands, though frequently interrupted by vertical fibrils. They cross the fissure, and then run up the other side in the place of the anterior columns, which they have now displaced. There is likewise a considerably enlarged anterior commissure, here called the decussation. The bundles of the pyramids too divide the anterior gray columns from the central gray sub- stance, and displace them outward (Fig. 22). These decussating fasciculi are to be regarded as chiefly mo- tor. They form the coarse-bundled decussation which we see in the anterior fissure, and are called the inferior or motor decussa- tion of the pyramids. Higher up too we may perceive bundles of quite considerable ANATOMICAL INTRODUCTION. 833 dimensions, arising from the posterior columns, bending forward, passing the central canal, crossing the middle line, and finally running up in the pyramid of the opposite side, where they generally occupy the exterior portion. This is the anterior or sensory decussation. Huguenin describes a bundle from the posterior cornua as taking part in this, but Flechsig's latest investigations have, to say the least, thrown great doubt upon the significance of these fibres and the exactitude of their course. Flechsig positively denies any connection whatsoever between this anterior decussation and the pyramids proper. Still, these fibrils most undoubtedly alter the configuration of the gray sub- stance in the spinal cord, dividing the head and neck of the FlO. 22.—Transverse section through the inferor portion of the medulla oblon. at the level of the decus- sation of the pyramids, a, Anterior gray columns ; b. head of the posterior column and ascending rcot of the trigeminus; c, anterior columns (pyramids); funiculi,, d, cuneati, et e, graciles; /, decussation of the pyra- mids ; g, formatio reticularis; h, roots of the accessorius ; », nucleus of the gracilis; k, nucleus of the cunei- form. posterior gray cornua from the central gray substance (Fig. 22). At the same time, these parts are displaced somewhat outwardly towards the periphery, since the lateral columns diminish in size. The increase of volume in the posterior gray columns enables us to follow them on transverse sections through the greater part of the medulla and in their gradual outward course (cf. Fig. 22, b, Figs. 24-26, c). In the peripheral portion of these sections we observe large bundles of fibrils ascending vertically ; these are the large ascending roots of the trigeminus (Fig. 22, b), which may be followed down to the second and third cervical nerves and upward as far as the exit of the sensory trigeminal roots. VOL. XIII.—53 834 ERB.—DISEASES OF THE MEDULLA OBLONGATA. The motor decussation has lately been submitted to thorough investigations, and appears to be derived mainly from the pos- tero-lateral columns. The diagram (Fig. 23) enables us to see this, and observe how the fibrils, before crossing the middle line, bend gradually forward, and how they displace the anterior col- umns after their passage across. The figure demonstrates too the bundles from the anterior columns which join the pyramids C B Fig. 23.—Diagram of the motor decussation. Transparent longitudinal view of the medulla, with only the anterior and the decussation of the postero-lateral columns left, a, a. Anterior columns; b, b, pyramido- postero-lateral columns: the pyramidal columns of the right side (c), arising from the left lateral column, and reinforced by a slender bundle from the right anterior column, are left unshaded, those of the left side are dotted. The part of the anterior columns which disappears behind the pyramids is shaded with vertical lines. on either side and pass up along with these undecussated (Flechsig). Thus we see that the pyramids contain not solely the decussated fibrils of the postero-lateral columns, but also some additional undecussated elements, varying in number, from the anterior columns. Flechsig positively denies the association with the pyramids, at an anterior point, of bundles from the pos- terior columns and cornua, though it has been asserted that this takes place, and that these run with the pyramids into the pons. ANATOMICAL INTRODUCTION. 835 The deflection of so many bundles from the lateral and poste- rior columns produces a number of fibrils, which lie horizontally on a transverse section, completely interwoven, and embracing in their meshes the vertical fibrils, after these latter have split up in every direction. Thus from the reticular processes of the spinal cord we get the formatio reticularis (Fig. 22, g). This latter structure occupies more and more space in the transverse section as we follow it upwards, and connects all the fibrils and structures of the medulla. But its complicated mesh-work is scarcely to be unravelled. Thus the transverse section even of the inferior portions of the medulla assumes the altered ap- pearance we see in Figure 22. The four cornua are separated from the central gray substance, and the posterior are further very much dislocated. The centre of the section is occupied by the remaining gray substance and an enormous formatio reticu- laris. In addition, we see the development of new gray substance around the different bundles and columns. On particularly good sections one may often recognize the horizontal fibrils of the roots of the accessorius, arising from the neighborhood of the lateral cornua,/. e., from the tractus intermedio-lateralis (Fig. 22, h). Higher up, while the formatio reticularis is visibly increasing in size, we are met by new structures, the significance of which is only in part known. Of these structures the most striking are the olivary bodies (Figs. 24, 25, 26, b). They arise in the territory of the lateral columns, close upon the pyramids, and attain the length of 14 mm. They resemble an extremely irregular disc, and contain a number of small ganglion-cells. On the whole, they look like a bean or an almond, with the hilus directed inwards. A number of nerve-bundles, coming from all points, enter at this hilus, some terminating in the gelatinous substance of the olivary bodies, while others pass through in the form of fine bundles. This appears to bring about an extremely wide connection with all the different parts of the medulla oblongata. Further on we perceive here a number of gray nuclei, most of which are connected with some cerebral nerve, and must be regarded as medullary roots. The first of these is the hypoglos- 836 ERB.—DISEASES OF THE MEDULLA OBLONGATA. sal nucleus (Figs. 24, 25, 26, g), situated beside the middle line, and falling back with the central canal. At the entrance of this canal, just below the floor of the fourth ventricle, we find it lying on the edge of the median fissure. This nucleus attains the length of about 18 mm.; it is cylin- drical, attenuated, and contains a number of large ganglia, re- sembling in every respect the multipolar cells of the anterior cornua. It corresponds exactly to the anterior cornu, though it retreats along with the central canal, which opens posteriorly, while an increasing number of fibrils pass over into the anterior Fir. 24.—Transverse section of the medulla through the inferior portion of the olivary body and the superior termination of the nucleus of the accessorius. «, Pyramids; b, olivary body; c, gelatinous substance, and ascending root of the trigeminus; d, corpus restiforme; e, funiculi cuneati, f. graciles;/, nucleus accessorii; g, nucleus hypoglossi; fasciculus rotundus (respiratory fascicle of Krause); *', nucleus funiculo- rum gracilium et cnneatorum; XI and XIJ, radices accessorii et hypoglossi; internal parolivary bodies (.nucleus of the pyramids). portion of the medulla. Thus the anterior end of the hypoglos- sal nucleus comes to be situated on the floor of the fourth ven- tricle. The roots of the hypoglossus (Figs. 24 and 25, XII) run horizontally between the pyramids and the olivary bodies to join their nucleus, and their whole course is easily followed. Somewhat posterior to the nucleus hypoglossi, and in the inferior portion of the medulla, we find the nucleus of the acces- sorius (Fig. 24, /). It, too, is represented by a columnar, attenu- ated, gray structure, which extends to the tractus intermedio- lateralis of the spinal cord (cf. Part I., p. 16), and with this it gradually alters its position in relation to the other parts of the ANATOMICAL INTRODUCTION. 837 section. From it the superior roots of the accessorius run later- ally and somewhat posteriorly. The nucleus accessorii is immediately bounded by a gray mass, which is situated in this region, beside the nucleus hypo- glossi. This is the nucleus of the vagus. It contains a number of small and middle-sized ganglia, and lies in the fourth ventri- cle, along with the hypoglossal nucleus, in the so-called ala cinerea, immediately beneath the surface. Immediately adjacent to the internal portion of this nucleus comes a clearly defined, round fascicle of coarse fibrils (Figs. 24 and 25, It). We can trace this along the whole course of the Fig. 25.—Transverse section through the centre of the olivary body, and of the vagus-root, a, Pyra- midal fasciculi- b olivary body; c, gelatinous substance and trigeminus-root; d, corpus restiforme; e, fu- niculi graciles et c'uneati: /, nucleus vagi: g, nucleus hypoglossi; /i, fasciculus rotundus (respiratory fasci- cle); t parolivary body (external); £, fibrre arciformes; /, nucleus of the same; m, motor nucleus of the vagiis (Meynert); X, XII, fasciculi of the vagus and hypoglossal roots. nucleus vagi, and find it composed of fascicles from the vagus, glossopharyngeus, and accessorius. It runs down into the cer- vical portion of the cord, and is said to come into connection with the phrenic (Krause's respiratory fascicle). According to Stieda, the roots of the three above-mentioned nerves are derived from this lateral ascending longitudinal fascicle, and not from the gray structures, which are generally designated as their nuclei. The nucleus of the vagus is bounded, too, by another gray structure, which comes into immediate contact with it, and is not separated by any distinct boundary ; it lies, however, somewhat 838 ERB.—DISEASES OF THE MEDULLA OBLONGATA. less superficially, and is designated as the nucleus of the glosso- pharyngeus (Fig. 26, Jl). The roots of the glossopharyngeus run almost horizontally from it, outwards and forwards, making their exit from the medulla above the roots of the vagus. Meynert and Huguenin describe further a motor nucleus of the vagus and glos- sopharyngeus, which is situated more in the interior, between the olivary body and ascending root of the trigeminus. We have indicated its position in Fig. 25 by to. Stieda looks upon it as the nucleus proper of the vagus. The posterior median nucleus of the acusticus (Fig. 26) (nu- cleus acust. sup. of Henle ; median nucleus of the posterior root of the acusticus of Krause) comes likewise into contact with the Fig. 26.—Transverse section of the medulla through the superior end of the olivary body, where the pos- terior median acoustic nucleus occurs, a, Pyramids; b, olivary body; c, gelatinous substance and ascending trigeminus-root; d. corpus restiforme; e, funiculi cnneati et graciles ;/. posterior median acoustic root; _•. * . " J U"~VA Vessels of the medulla oblongata.—Uuret' s exhaustive inves- tigations have proved that the medulla gets nearly its whole supply of blood from the vertebral and basilar arteries, the lat- ter supplying the pons portion. Here we have chiefly to men- tion small, median branchlets which pierce into the raphe be- PHYSIOLOGICAL INTRODUCTION. 851 tween the pyramids, and are given off by the art. spin. ant. for the bulbus and by the basilaris for the pons. They run up to the floor of the fourth ventricle, and ramify here, forming a large, narrow-meshed capillary network, especially round the gray nuclei. Thus we see that they originate chiefly from the left vertebral, for this artery generally gives off the art. spinal, ant. when it is single, and wThen there are two anterior spinal arteries the median bulbar branchlets are generally derived from the ant. spin, sinistra. But besides these, small vessels pierce the me- dulla along with the nerve-roots, and run to the corresponding nuclei, where they take part in the formation of capillaries. The olivary bodies and pyramids are supplied by small branches from the vertebral and anterior spinal arteries. The restiform bodies receive vessels from the art. cerebelli infer, post., whilst the posterior spinal arteries send branchlets to the pedunc. cere- belli and floor of the fourth ventricle. Most of these little vessels are so-called terminal arteries (Cohnheim's "Endarterien^). Their ramification produces a comparatively open-meshed network in the white substance, while in the gray the meshes are very numerous and narrow. It need hardly be said that numerous varieties and abnormalities of origin and course occur amongst these little vessels, and these are of some importance in the explanation of certain clinical occurrences. There is nothing special to be said of the veins, and the lymph- vessels in the medulla are quite analogous to those of the spinal cord. II. Physiological Introduction. Amongst others we would direct attention to: Longet,TAnatomie et physiologie du systeme nerveux. T. I.—Schiff, Lehrbuch der Physiologie des Menschen. I. 1858-59.__Schroeder v. d. Kolk, Bau u. Function der Medulla spin, und oblong. 1859.— Wundt, Physiol. Psychologic Leipzig. 1874.—Laborde, Dic- tionn. encycl. des sc. med. 2. s6r. T. VIII. p. 604. 1874.—Poincare, Le systeme nerveux central, etc. 2me edit. T. I. 1877. Besides these, the text-books of L. Hermann, Wundt, Funke, Vierordt, etc., may be consulted, and innumerable monographs in all possible physiological periodi- cals. 852 ERB.—DISEASES OF THE MEDULLA OBLONGATA. The physiology of the medulla oblongata is just as imperfect and obscure as its anatomy, so that we have not become pos- sessed of any undisputed information on the most elementary and important facts. For instance, we know nothing of the con- duction of sensory impressions, or of the exact position of the chief centres. We are, indeed, acquainted with a number of facts, which teach us to recognize the medulla as one of the most important divisions of the central nervous system, and which give it a prominent part in several all-important physiological processes, such as respiration, the cardiac movements, vascular innervation, speech, and others. But we have got little beyond the confirma- tion of these facts, and we are in especial darkness as to the anatomical distribution of these functions and their components. There are very good reasons for all this, and the chief of them is the difficulty of experimentation. For the parts lie so deep and are so well protected, the slightest injury to them is so dan- gerous, the structures themselves are so extremely small, they are so wonderfully connected in a complicated manner with all possible adjacent structures, and the white and gray substances are so intimately mixed—all these circumstances are so many insurmountable difficulties in the way of physiological investiga- tion. Consequently we must not claim too much from physiology. We should undoubtedly look for most important explanations from careful clinical observation, combined with accurate post- mortem examination, though this has yet been scarcely at- tempted. In this state of things we can and must give the practitioner only a very brief account of the physiology of the medulla ob- longata. We shall first study the medulla as an organ of conduction. Nobody can entertain the slightest doubt that the motor im- pulses sent from the cerebrum to the spinal cord, and the sen- sory irritations on their way from the periphery to the brain, must pass through the medulla oblongata. Further, we are justified in assuming that the parts of conduction for several other irritations, which pass between the spinal cord, the cere- PHYSIOLOGICAL INTRODUCTION. 853 brum and cerebellum, must likewise be situated in the medulla. But the position of these has not yet been properly demon- strated. Motor Conduction. The investigations in this direction have gone further than any, and, indeed, have reached a certain degree of completeness. It is almost beyond doubt that the chief paths of conduction for voluntary motor impulses are to be sought in the pyramidal tracts (Flechsig). We should thus have the chief conductors for voluntary motions in the pyramids, in their inferior decussa- tion, and in their continuations with the lateral and anterior columns. But it appears from certain pathological facts (marked atrophy of the pyramids without any motor affection during life), that they are not the only conductors for voluntary impulses, and are not necessary under all circumstances. This function of chief motor conductor from the brain to the spinal cord has been assigned to the pyramidal tracts chiefly on the ground of modern anatomical and clinical discoveries. From the latest physiological experiments no binding conclusions can be drawn, and the older experiments would rather lead to an opposite view. The results, too, obtained by the most eminent physiologists are directly contradictory; one saw no particular muscular contractions on irrita- tion, while another observed convulsions; and again after section one saw no paralysis, and the other saw extensive paralysis. According to Schiff the pyramids are not motor conductors, whilst section of funiculi siliquse and laterales produces motor paralysis. Section of the lateral columns (between the first and fourth cervi- cal nerves in animals) stops the respiratory movements of the same side. The uncertainty and contradiction we meet in the experimental results are easily ex- plained by the difficulty in operating on the anterior surface of the medulla, and the probable variation in the course of the voluntary impulses. Nothing is definitely known of any motor conduction in the gray substance, except what can be determined regarding the nuclei of the nerves and their roots. The inferior decussation gives a perfectly satisfactory expla- nation of the decussation of the motor conducting tracts on a level with the medulla, a fact which has been proved by numer- ous experiments and still more numerous clinical facts. Cases that have been observed in which there was no decussation are 854 ERB.—DISEASES OF THE MEDULLA OBLONGATA. to be explained by the non-decussation of the pyramido-anterior tracts, and partly, too, by the striking variations the occurrence of which Flechsig has so clearly proved. The pyramido-anterior tracts, in fact, may not decussate before they reach the cord (in the anterior commissure); it is further possible that their decus- sation has taken place so far forward as the pons, namely in the raphe; thirdly, there is a possibility of their undergoing no de- cussation whatsoever ; but this remains to be proved. There are certainly enough tracts in the raphe and the pons above the motor pyramidal decussation, which would all allow of a decus- sation of motor impulses. Longitudinal section of the decussation of the pyramids does not produce a complete paralysis of the animal's body; this fact, too, argues against a total decussation, but of course we cannot directly transfer the results to the human subject. Schiff's experiments seem to prove that the decussation of the tracts which supply the muscles of the trunk, the lower and upper extremities, occurs at successively higher points. Schiff's assumption of a repeated (" return ") decussa- tion in some tracts requires fresh confirmation. Sensory Conduction. The tracts which conduct sensory impulses in the medulla are still quite undefined. Even in the spinal cord we cannot trace the chief tracts with any great certainty, and in the me- dulla this uncertainty is very considerably increased. On this point, too, the physiologists are completely at vari- ance. According to Schiff the tracts of the posterior columns, which convey painful impressions, push more and more outwards, and finally come to lie as if in direct continuation of the lateral columns. The floor of the fourth ventricle, he asserts, and like- wise the funiculi pyramidum and siliquse, do not react on irrita- tion. Vulpian, on the contrary, declares that the corpora resti- formia and the funiculi graciles et cuneati, and also the floor of the fourth ventricle, are all equally sensitive when irritated. The results of section are quite as contradictory, and can in no in- stance be called unambiguous or convincing. It is to be conjectured that the pedunculi cerebelli convey but few sensory impressions, and that this function belongs rather to PHYSIOLOGICAL INTRODUCTION. 855 the central gray substance (formatio reticularis), which conveys them in all directions, so that partial lesions of these tracts never produce any recognizable ansesthesia—of course the tracts which have decussated in the spinal cord continue their further course unaltered—/. e., the tracts belonging to the right half of the trunk are situated in the left half of the medulla, and vice versa. But this decussation is by no means a total one, as experiments show us, probably on account of the power the gray substance has of conducting in every direction. If one side of the medulla is cut through, one side of the face is deprived of sensation ; this is sometimes the same as, and sometimes the opposite side to, the section, a matter which seems to depend on the position and depth of the section. Thus our knowledge of the general situation of the sensory paths amounts to nothing more than a series of conjectures. Of course we know nothing whatsoever of the special tracts for tactile, temperature, and pain impressions. The functions of the medulla in the capacity of central organ are a little more thoroughly investigated and better known. For, in addition to the simple transmission of impressions, the medulla can transfer centripetal irritations to centrifugal tracts ; it can, in fact, bring about reflex functions, and these, too, of every kind and with every complication. These appear always to be con- nected with certain definite, more or less sharply bounded spots, which are for this reason termed centres of the several functions. Thus most of the centres are undoubtedly reflex centres, and it is only in the case of few that we can assume, with any degree of probability, that they can be thrown into activity without any previous irritation of a centripetal tract, that they act, in other words, as automatic centres. In the first place, the medulla accomplishes simple or slightly complicated reflex actions, such as those that pass from the trigeminus in so many ways to the facialis (winking when the conjunctivse are irritated, wry faces consequent on strong impres- sions of taste, secretion of saliva when the mucous membrane of the mouth is irritated, sucking motion, when we put a finger into the mouth of a new-born child, etc.). The arc of reflection must be situated in the medulla, and the same may be asserted of the 856 ERB.—DISEASES OF THE MEDULLA OBLONGATA. reflex actions between all the other nerves which have their origin in the medulla. But very much more extensive reflexes take place in the medulla. The so-called general reflexes, or the transfer of the reflex irritation to the whole muscular system, cannot be assigned to any other part of the central nervous system. According to Pflueger's laws of reflex action the medulla oblongata is the chief centre of irradiation for all the reflexes of every muscle, and these are never brought into action till the reflex irritation has extended to the bulbus. Ludwig and Owsjannikow have as- signed the centre of origin of these general reflexes to the region of the lateral columns in the formatio reticularis. It is probably the same point from which general convulsions arise in consequence of various direct or reflex irritations. Noth- nagel proposes to give it the name centre of cramps, and assigns it to the level of the pons in animals. This centre for cramps can be irritated directly (as probably occurs in epilepsy) or re- flexly in a great number of ways. According to Nothnagel the reflex irritation is produced with the greatest certainty from two definite points, one on each side of the median line on the floor of the fourth ventricle. In the human subject the exact situation of this centre is not yet known, but is probably to be sought in the pons portion of the medulla. Besides these we find in this organ a large number of centres for special processes, some of them, too, extremely important. Some of them effect very complicated reflexes, which display a combination of definite actions to accomplish a definite effect. Actions of this character follow one another in a perfectly regular order, which has its origin in the reflex mechanism and in the performance of certain processes within it. These centres are partly automatic as well, and their activity persists after all centripetally conducting tracts have been re- moved, the probable explanation being that they are excited by a certain condition of the blood, and by the changes of the fluid. The most important and best studied of these centres are probably those which preside over the respiratory mechanism. PHYSIOLOGICAL INTRODUCTION. 857 The Respiratory Centres. After Legallois had discovered the centre of respiration, Flou- rens endeavored to localize it more accurately, and arrived at the conclusion that it was situated in a point not larger than the head of a pin, exactly in the middle line and at the posterior angle of the calamus scriptorius. If this point be destroyed, res- piration ceases and life with it (nceud vital). But of late even Flourens himself admits two centres of somewhat larger dimen- sions. In point of fact, all more modern investigations point to the existence of two respiratory centres, one in each half of the me- dulla, situated in the superior external portion of each ala cinerea and a little posterior to the exit of the vagus. It is possible that the substance which connects the two may regulate the normal harmony that exists between the respiratory motions of the two sides of the body. Destruction of one centre only affects the respiration of the same side of the body. Gierke asserts that the "respiratory centre" is nothing but the sum of con- ducting tracts, which convey the irritations, that set in motion the respiratory reflex from the trigeminus and vagus to the motor-cells of the respiratory nerves. They take the form of a round fasciculus composed of fine nerve-fibres, which runs down on both sides parallel to the median line, and is identical with Krause's respiratory fasciculus mentioned above. So that, in the strict sense of the word, this is not a centre, i. e., a central apparatus composed of ganglion-cells, in which centri- fugal and centripetal tracts enter into anatomical and functional connection. Possibly a " respiratory centre " proper may be found in addition to this respiratory fasciculus. Farther down, too, in the spinal cord there may exist similar central structures for respiration (P. Rokitansky), but they certainly play nothing more than a secondary part, and can never come into action independently. The same relation probably exists between these centres as between the vaso-motor centres of the spinal cord and of the medulla. The centripetal tracts, which come from the periphery and excite or inhibit the respiratory centre, are for the most part situated in the vagus. The centrifugal tracts, which lead from the respiratory centre, run down through the lateral columns to the motor nerves of the different muscles of respiration. 858 ERB.—DISEASES OF THE MEDULLA OBLONGATA. As this is not the place for an accurate account of the physi- ology of respiration, we shall confine ourselves to mentioning that a certain amount of oxygen must be contained in the blood to maintain the irritability of the respiratory centres; that, further, the oxygen and carbonic acid contained in the blood must be present in certain fixed proportions to effect the irrita- tion of the centres ; that the irritation increases in proportion as the quantity of carbonic acid exceeds that of oxygen ; and that the want of oxygen produces a greater irritation than the accu- mulation of carbonic acid. But the respiratory centre can also be excited reflexly by a number of different sensible nerves, such as the vagus, trigeminus, and those of the cutis. We must add that the physiologists consider themselves compelled to assume separate centres of inspiration and expiration (making altogether four respiratory centres), which appear in certain respects to have an antagonistic action. But neither the anatomists nor experi- mental physiologists have yet been able to localize these centres accurately. When the respiratory irritation increases, more muscles are affected, till finally general epileptiform convulsions are pro- duced, being the result of an extension of the irritation within the gray substance of the medulla, as far as the cramp-centre. Sneezing, coughing, yawning, sobbing, and similar respira- tory (partly in- and partly expiratory) reflex actions, are also effected by the respiratory centres of the medulla, but they do not originate in the same sensory tracts as the simple movements of respiration. All these processes probably have their own spe- cial mechanisms, but the anatomical structure of these is quite unknown. Laughing and weeping belong to the same category of reflex actions, but they are distinguished by their combination with mimic and secretory reflexes. Centres for the Cardiac Movements. Although highly probable, it is not certain whether the me- dulla possesses a centre of acceleration of the action of the heart; its position is, of course, unknown. PHYSIOLOGICAL INTRODUCTION. 859 On the other hand, the excitement of the inhibitory fibres of the vagus is generally assigned to a centre in the medulla, though the position of this centre is equally unknown. This "inhibitory centre for the action of the heart" seems also susceptible of auto- matic and reflex irritation. Centres of Speech. The most important centre for voice, for the origination of tones, is undoubtedly situated in the bulbar portion of the me- dulla. For, after the pons has been divided from the bulbus, reflex crying may still be produced. By this process the respir- atory centres and the motor tracts of the accessorius (supplying the larynx) are brought into action. Kussmaul (Appendix to Vol. XIV. of this Cycl., p. 050) gives this centre the name of basal phonic centre, and considers it indispensable for the con- struction of articulated sounds. It is situated probably close to the centres of respiration. Exactly the same may be said of the chief centre of articula- tion, i. e., the structure which controls the complicated muscular actions necessary to transform simple tones into articulate vowels and consonants. The glossopharyngeus, accessorius, hypoglossus, facialis, and trigeminus, all take part in the pro- duction of articulate sounds, undoubtedly a matter of extremely fine, complicated and carefully combined movements. The anatomical fact that all these nerves and their nuclei lie so close together gives weight to the assumption that the most important centre, at least for the articulation of letters, is situ- ated in the medulla. And this view is further strengthened by numerous pathological facts, which show that diseases of the bulbus, and especially degeneration of the nuclei of its nerves, are particularly destructive to the faculty of speech (progressive bulbar paralysis). There is, however, a slight uncertainty in the case, as these muscles of articulation are always positively para- lyzed in bulbar paralysis, so that we are not fully entitled to assume any actual disturbance of co-ordination. It is further quite possible that the real centre of articulation lies higher up in the cerebrum or cerebellum, and that its centrifugal tracts 860 ERB.—DISEASES OF THE MEDULLA OBLONGATA. only pass through the medulla, or only set in motion a series of secondary medullary centres. We have, indeed, a parallel for this in the co-ordinate movements of the extremities where this process occurs farther down in the gray substance of the spinal cord. Certainly the centres for the combination of letters to syllables and syllables to words are situated anteriorly to the medulla. Nothing is known as to the position of this hypothetical centre of articulation in the medulla. Schroeder van der Kolk wrongly assigned it to the olivary bodies, but his view is now rejected by every one. Jaccoud tried to find it in the bulbo-cerebellar commissural system, in the olivo-peduncular region, etc.; but we cannot accept this proposition either. It is more to the point to say that this centre has not yet been discovered. Centre of Deglutition. Swallowing is a reflex act that is performed entirely by mus- cles the nervous supply of which originates in the medulla. It is, in fact, a combined act of the hypoglossus, facialis, glosso- pharyngeus, vagus, accessorius, and trigeminus. Consequently the centre of deglutition has been assigned to the medulla, an assumption which is well borne out by experimental and clinical facts. But it has not been further localized, nor do we know anything of its connections. According to Schiff, too, the centre of vomiting is situated in the medulla, but nothing further is known about it. Schiff like- wise asserts that the contractions of the abdominal muscles in defecation are co-ordinated and brought into action by a centre in the medulla. We can hardly assume a special reflex centre for the masti- catory movements, as mastication cannot properly be regarded as a reflex action. It is, in fact, only the co-ordination of cer- tain motor impulses in order to accomplish a definite compli- cated process ; the centre of co-ordination which serves this pur- pose is by no means necessarily situated in the medulla. At the same time, however, it is easy to comprehend that disease of the motor tracts in the medulla which are involved (nucleus of tri- PHYSIOLOGICAL INTRODUCTION. 861 geminus, hypoglossus. etc.) might impair the masticatory powers to a great extent. Vaso-motor Centre. Ludwig and Thiry demonstrated a centre in the medulla which can throw all the arteries of the body into contraction; and section of the cervical portion of the cord inferiorly to the medulla paralyzes and dilates all the arteries. Later investiga- tions, however (Goltz, Vulpian, Schlesinger, M. Nussbaum, and others), prove beyond doubt that, even if this is the principal one, it is still not the only vaso-motor centre ; and further, that other secondary centres exist in the gray substance of the spinal cord, as far down as the lumbar portion. The spinal centres are situated one above the other through the whole cord, and appear depen- dent, in the first instance, upon the principal medullary centre. When this latter is removed, the spinal centres come into action (but only gradually), and regain their influence over the vessels. Owsjannikow and Dittmar have defined the position of the vaso-motor centre in the medulla more accurately. They found it, in the rabbit, between the corpora quadrigemina and calamus scriptorius, somewhat removed from the middle line, in the late- ral columnar tract of the formatio reticularis. The nerves for vascular contraction which leave it are said to run down through the lateral columns to the anterior nerve-roots (Dittmar). In addition, centripetal fibres ascend to this centre, which produce a reflex contraction of the vessels; these, too, are said to lie in the lateral columns. In conclusion, this centre can be excited or depressed by some parts of the cerebrum (irritation of the pedunculi, blushing or pallor resulting from mental impressions). The latest investigations on the subject of vaso-motor nerves compel us to assume the existence of nerves which directly dilate the vessels. For these, too, a centre has been assumed in the medulla. 862 ERB.—DISEASES OF THE MEDULLA OBLONGATA. Nutritive Centres for Certain Nervous Regions. It seems probable that the gray nuclei of the motor medullary nerves have a nutritive effect upon their nerves and appertaining muscles, very similar to that which the large multipolar cells of the anterior cornua of the cord exercise over the nervo-muscular regions dependent on them. As may be seen in bulbar paralysis, degeneration and destruction of these cells produce granular atrophy of the lingual, labial, faucial, and pharyngeal muscles. Different clinical and experimental facts have led some to the hypothetical assumption of certain centres in the brain for the regulation of the temperature of the body. Should these, really exist, we should seek them also in the medulla. Centres for Certain Secretions. To Claude Bernard we owe the important discovery that the secretion of urine, and certain nutritive processes, can be influ- enced by irritation of the floor of the fourth ventricle. If we merely pierce the floor with a needle, half-way between the origins of vagus and acusticus, it suffices to produce a dia- betes mellitus. If the needle pierces at another point, closer to the acoustic, it produces a simple polyuria (diabetes insipidus). And, besides this, we can frequently succeed in producing albu- minuria by irritation of a point between these two. In spite of numerous investigations, wTe are still in uncertainty as to the manner in which this takes place, and as to the mech- anism and anatomical structures which bring it about. Claude Bernard conjectured that there was a nervous centre in the me- dulla which controlled the formation of sugar in the liver. But his view has met with many opponents, and most physiologists now incline to the explanation of this artificial diabetes by vaso- motor influences. This view is supported by the fact that irrita- tion of surrounding parts produces only an increased secretion of urine, unaccompanied by any secretion of sugar. But the question has not yet been definitely settled. Irritation of the anterior portion of the rhomboid sinus, close PATHOLOGICAL INTRODUCTION. 863 to the nucleus of the abducens, produces an active salivation on the same side as the lesion. The secretion is continuous and abundant. It is, perhaps, produced reflexly by irritation of some branches of the trigeminus. Possibly, however, it is a di- rect irritation of the secretion, with or without the intervention of vaso-motor processes. Gruetzner's experiments go to prove the existence of a centre of salivation in the medulla, which con- trols both the fibres of the chorda tympani, going to the salivary glands, and the fibres of the sympathetic. And this centre, when directly or reflexly irritated, produces active salivation. From all the details given in the preceding pages we can at least conclude that a great number of the most important phy- siological functions are united in the medulla. This very fact compels us to admit the extraordinary entangled and compli- cated course of the fibres, to which we so frequently drew atten- tion. III. Diseases of the Medulla Oblongata. Introduction. The pathology of the medulla oblongata is still in the first stage of its development. The material for study is relatively scarce, quite unsifted, and in great need of further enlargement; and the only way we can hope to enlarge it is by taking all the modern points of view, and devoting ourselves to a careful clini- cal study of the cases, and more especially to accurate anatomical investigations. As might be conjectured from its anatomy, the pathology of the medulla resembles, in some points, that of the cerebrum, and in others that of the spinal cord, so that diseases which are proper to each occur in the medulla. This gives the medullary pathol- ogy a very varied character. But, on the other hand, it is sim- plified, as we can, in many cases, merely refer to the cerebral and sjoinal diseases, which have in great part been very much better investigated. Some cases—for instance, meningitis of the me- dulla—we can pass over unmentioned on this account. 864 ERB.—DISEASES OF THE MEDULLA OBLONGATA. As yet we are acquainted with almost nothing but symp- tomatic forms of disease in the medulla. Our knowledge was most extensive on the subject of chronic progressive bulbar paralysis, which had been made known by Duchenne's investi- gations. Gradually we became acquainted with the character- istic symptoms of an acute apoplectic bulbar paralysis. And soon all chronic diseases of the medulla that resulted in paral- ysis were included under the first head, and all the acute forms were regarded as apoplectic. But further observation rendered matters more clear, and we can already distinguish several different forms that have been classed together under both of these heads, and we are probably in a position now to draw anatomical and clinical distinctions between these forms. In the following pages we have endeavored to draw these clinical and pathologico-anatomical distinctions. At the same time we are fully conscious that there are many shortcomings and gaps, and that the material at our disposition is very much too small, and in particular too inaccurate, to give us, as yet, a sure footing on this ground. The classification we have adopted must consequently only be regarded as a temporary diagram, to contain, for the present, the forms of disease with which we are acquainted. We shall first discuss the quantitative changes of blood in the medulla, its hemorrhages, and the obstruction of its vessels; secondly, the results of acute and chronic mechanical lesions—acute wounds and slow compression; thirdly, acute inflammation of the bul- bus ; fourthly, chronic (inflammational) bulbar degeneration, first described by Duchenne; then the other chronic and inflamma- tional diseases of the medulla; and, finally, the neoplasmata which occur in its substance. We must urgently crave the reader's indulgence for all the imperfections and defects contained in the following description. HYPEREMIA AND HEMORRHAGE. 865 1. Hyperemia and Hemorrhage of the Medulla Oblongata.— Apoplexia Medulla Oblongata. Ollivier (d'Angers), Traite des mal. de la moelle gpiniere. 3me ed. II. p. 138-167. 1837.—Mesnet, Apoplexie du bulbe rhachid. dans sa partie super, etc. Arch. gen. 1861. Sept. Monit. des Sc. med. 1801. No. 94.— Potain, Paralysie gSner. incomplete; polyurie; apoplex. foudroyante; ramollissement ancien, hgmor- rhagie de la protuberance. Gaz. d. hop. 1862. No. 93.—Levier, Beitr. zur Pathol, der Riickenmarksapoplexie. Dissertation. Bern, 1864.—Desnos, Cas d'hemorrhagie de la protub. annul, avec albuminuric, etc. Union med. 1869. No. 20.— Wilks, Labio-glosso-laryngeal Paralysis. Guy's Hosp. Reports. XV. p. 2-17. 1870.—Hughlings Jackson, On a Case of Paral. of the Tongue from Hem- orrhage in the Medulla Oblong. Lancet, 1872. Nov. 30. p. 770. — Dutrait, Hemorrh. sous le plancher du 4 ventricle; albuminuric, glycosuria Lyon mod. 1875. No. 45.—C. Browne, Hemorrh. into the Pons Varolii. Lancet, 1875. Feb. 6.—Leyden, Klinik der Ruckenmarkskrankheiten. II. p. 63. 1875.—M. Rosenthal, Traite des maladies du syst. nerveux. p. 249. 1878.—Lichtheim. Ueber apoplektil'orme Bulbarparalyse, etc. Deutsches Arch. f. klin. Med. XVIII. 1876. Pathogenesis and Etiology. Hyperemia strictly limited to the medulla must be an ex- tremely rare occurrence, and there is reasonable doubt as to whether such a case has ever been diagnosed with certainty, and a real pathological change ascertained. We are not justified here in adducing the capillary dilatations, which are so fre- quently found in the medulla, and which are always followed by hyperaemia. In the great majority of cases hypersemia of the medulla is nothing more than part of a general hyperaemia of the brain or spinal cord, for the medulla is most intimately connected with these in regard to its vascular supply. So that in every case of general cerebral Irypersemia, whether primary or secondary (eclampsia, tetanus, mental and meningitic diseases), the me- dulla will be found in the same condition. Naturally the same etiological and pathogenetic conditions, as those that were given at length in Volume XII., when treat- ing of cerebral hyperaemia, retain their force in the medulla. We have partly to deal with active inflammational hypersemia, VOL. NTII.-55 866 ERB.—DISEASES OF THE MEDULLA OBLONGATA. resulting from hypertrophy and increased action of the heart, or from vaso-motor disturbances, from collateral congestive in- flammation, and from certain poisons, exposure to the sun, or excessive mental activity, etc. But, on the other hand, it may be the result of passive stagnation consequent on cardiac and pulmonary disease—for instance, hindrance to the current in the jugular veins, .or violent expiratory exertions (coughing, strain- ing, vomiting, etc.). We need only say here that all these matters are to be re- garded as paving the way for hemorrhage in the medulla, and under certain conditions they actually produce it themselves. All that Nothnagel has said, in his exhaustive and lucid trea- tise on cerebral hemorrhage, is equally applicable to rupture in the medulla. In regard to hemorrhage the medulla is more closely related to the brain than to the spinal cord, i. e., hemor- rhage is much more frequent in the medulla than in the cord; and further, the frequency is greater in the cerebral than in the spinal end of the medulla, so that the great majority of apo- plexies are found in the pons division. This fact alone renders it difficult to draw a sharp line between hemorrhage in the pons and in the medulla. ' On the whole, rupture of a vessel is a rare occurrence in the medulla. As regards its pathogenesis we may pass it over with a few words, and refer the reader for details to Nothnagel's treatise. Undoubtedly the most important pathogenetic principle is disease of the vessels (miliary aneurisms, such as Heschl de- scribes in the pons, atheroma, fatty degeneration, capillary dila- tation, resulting from processes of softening so clearly demon- strated by Gerhardt1). We find extremely frequent cases of atheroma and aneurisms of the basilar artery accompanied by hemorrhage from its small branches in medulla and pons. Increase of arterial tension plays a prominent part in con- nection with these diseases of the vessels themselves; but even without the latter the rise of the blood-pressure alone can often produce hemorrhage. The same result is seldom produced by an increased tension in the veins from stagnation of their blood. 1 Jenaische Zeitschrift f. Med. und Naturw. I. 1864. HYPEREMIA AND HEMORRHAGE. 867 Under the head of Hemorrhage from Excessive Tension may be brought the cases caused by cardiac palpitation, by great excite- ment, fits of passion, physical overexertion, and by excessive indulgence in alcohol. Some diseases of the surrounding parts, which not infre- quently lead to hemorrhage of varying extent, seem to act in two ways, i. e., by impairing the walls of the vessels and by raising the collateral blood-pressure. To this class belong caries of the cervical vertebrse, purulent basilar meningitis, and tumors in or around the medulla, etc. In addition to this, hemorrhage, in greater or smaller degree, is frequently produced traumatically through injuries to the skull and back of the neck, though we can often recognize no direct, palpable lesion in these parts. Westphal produced capillary hemorrhage in the medulla of the guinea-pig by light blows of a hammer on the head. We can imagine something analogous to this occurring to the human subject. In conclusion it may be remarked, that in extensive cerebral hemorrhage, which breaks through into the ventricles, or in ex- tended rupture in the meninges (e. g., the rupture of an aneu- rism), the fourth ventricle is often filled with blood, and to this may be attributed some of the symptoms that occur in such cases. Pathological Anatomy. As hyperemia of the medulla is characterized by the same anatomical appearances as cerebral hypersemia in general, we need give no special description of it. Nor can we draw the slightest distinction between the apo- plectic clots in the medulla and those in the brain, either as regards their appearance, the changes they go through, or the condition of the surrounding parts. Fresh hemorrhage looks like a dark-red coagulum, and is often half fluid towards its centre. This very soon changes into a semi-solid, chocolate- colored mass, which gradually assumes a lighter color, and is partly absorbed. The last stage consists either in a rusty, con- tracted scar, or in a small cyst, with a wall of dense cicatricial 868 ERB.—DISEASES OF THE MEDULLA OBLONGATA. tissue, with fine threads of connective tissue passing through it, and filled with a cloudy, yellow fluid. In due course we observe the development of a secondary degeneration, which can be either unilateral or bilateral, according to the seat of hemor- rhage ; and this degeneration we can trace to some distance down the spinal cord. The size of these ruptures is usually very insignificant. Their shape is roundish, or resembles an olive or bean, but frequently it is quite irregular. Near the median line we often meet with small triangular spots of hemorrhage, with the apex pointing forwards, and the base towards the floor of the fourth ventricle, thus corresponding pretty closely in extent with the territory of a median bulbar artery (hemorrhagic infarct ?). As regards their situation, these ruptures can occur at any point in the whole medulla. If they occur near the floor of the fourth ventricle, they have a tendency to pierce through it, and then we find a coagulum of greater or less dimensions in this cavity. We sel- dom meet with more than a single rupture, but occasionally there are several together. Ollivier describes cases of from three to six hemorrhagic points in the medulla. In the medulla alone these effusions of blood seldom attain to any great size, though they are frequently very large when the pons is simultaneously attacked. In cases of the latter class we often see undefined cystic masses, as large as a walnut or an egg, running through the pons and medulla, usually piercing into the fourth ventricle, and filling it with a large clot. Capillary hemorrhage occurs, too, occasionally in the me- dulla, in the same characteristic form as in the cerebrum, and with just the same accompanying or causal circumstances. Symptoms. Very little is known of the symptoms of an inflammational hyperemia in the medulla. It is perhaps allowable to refer some of the symptoms of general cerebral hypersemia (dyspnoea, slow pulse, vomiting, general convulsions, certain defects of speech, etc.) to congestion of the medulla, but this is only hypo- thetical. The same, too, may be said of the assumption that HYPEREMIA AND HEMORRHAGE. 869 certain initial symptoms of acute bulbar disease (pains in the head and back of the neck, spasms in the face and tongue, formication, etc.) are to be attributed to hypersemia in the medulla. This assumption is quite arbitrary, and no proofs have been adduced for it. In the case of hyperemia from stagnation, we possess some experimental investi- gations made by Landois, Hermann, and Escher. These prove that retardation of the pulse and dyspnoea (irritation of the vagus and respiratory centres), likewise contraction of the vessels (irritation of the vascular centre), and, finally, general convulsions (irritation of the cramp centre), all result from intense venous stagna- tion. All these symptoms, without doubt, originate in the medulla, and we are forced to believe that something similar takes place occasionally in the human subject. Our knowledge of the symptoms of hemorrhage in the me- dulla is more extensive, and rests upon a greater number of observations. Hemorrhage in this organ, even of inconsiderable extent, is always to be regarded as extremely dangerous, commencing gen- erally with the most alarming symptoms, and not infrequently causing instant death. It is, in fact, these tempestuous apoplexies (apoplexie fou- droyante), from which death results in a few minutes or hours, accompanied by signs of failure of respiration or circulation, that belong usually to the medulla or pons. The patients fall down with a cry or in epileptiform convulsions, and die instan- taneously. Further, we know that large effusions of blood into the hemi- spheres and ganglia of the base, if they reach the fourth ventri- cle, and irritate and compress the medulla, very quickly produce death, accompanied by symptoms of vomiting and convulsions, along with deep coma and complete general paralysis. But slight hemorrhage in the medulla, too, generally pro- duces immediately symptoms of an alarming and very threaten- ing nature—symptoms which come more quickly and are more grave the nearer the effusion is to the centres of respiration, or when it affects these directly. In the latter case instant death may ensue, and, consequently, medical men are seldom called in for consultation or to treat the case. 870 ERB.—DISEASES OF THE MEDULLA OBLONGATA. Our principal interest is consequently attached to those cases in which the patient lives on for at least some hours or days, or in which a partial recovery takes place, and the sufferer enjoys a somewhat longer existence, though one that is always very materially impaired. In such cases the patients utter a loud cry, or are attacked by buzzing in the ears, dizziness, sudden headache, vomiting, or convulsive spasms of the body, and then follows, very quickly in general, an apoplectic attack—i. e., they fall down unconscious, and sink into a more or less deep coma. Motor and sensory paralyses characterize this, as well as all other apoplexies. But we may localize them often in the medulla—on the one hand, from their extent and combination, and, on the other hand, from their almost unexceptional complication with a large number of characteristic symptoms, the origin of which has been referred, with a certain amount of probability, to the same organ. The motor paralysis assumes very various dimensions, some- times attacking only the lower extremities, sometimes only the upper; at other times it takes a hemiplegic character, though this is only when the hemorrhage is extremely small, and then it is usually a decussating paralysis of the extremities; but in most cases all four extremities are either completely or partially paralyzed, which is very characteristic, because it is hard to find any point in the brain where all the motor tracts of the body can be affected simultaneously by an effusion of blood. Accompanying this paralysis of the extremities, we always find some of the bulbar nerves more or less completely par- alyzed, usually the hypoglossus, accessorius, facialis, and tri- geminus ; sometimes, too, the nerves of the orbit. These paraly- ses also occur on one or both sides. If we have a hemiplegia, (an effusion into one side of the medulla), the most characteristic symptom is that the paralysis of the bulbar nerves, caused by injury to its nuclei and root-fascicles, occurs on the same side as the hemorrhage, while the hemiplegia of the extremities occupies the opposite side of the body, owing to the decussation that takes place at a point inferior to the lesion. We thus get all the characteristics of a hemiplegia alternans, with the extremities paralyzed on one side, and the facial muscles (in certain cases HYPEREMIA AND HEMORRHAGE. 871 this applies as well to the tongue, the muscles of mastication, and to the abducens) paralyzed on the opposite side of the body. The above-mentioned nerves are affected in greater or less num- ber, according to the location of the hemorrhage. The paralysis of sensation follows the same rules as that of motion, only that it is on the whole not so well developed. In severe cases, when all four extremities are paralyzed, it is gener- ally impossible to ascertain anything about the condition of sen- sation on account of the coma in which the patients lie. If it is a case of motor hemiplegia, we may assume that the sensation decussates as well; but still, owing to the peculiar course of the sensory fibres in the medulla, we can hardly expect a sharply- defined anaesthesia. This, of course, depends altogether upon the extent of the effusion in transverse section. It would be ex- tremely interesting to investigate accurately the condition of sensation on both sides of the head and face in such cases of apoplectic hemiplegia. For a priori we should anticipate an alteration in the conditions dominant here, such as a simultane- ous, a decussating, or even a bilateral anaesthesia, always pro- vided the so-called ascending root of the trigeminus contains the sensory tract for the same side of the head and face. Respiratory disturbances, as they are most threatening to the life of the patient, may be regarded as the most important of the symptoms produced by a bulbar lesion, and they are at the same time very characteristic of such lesion. If fatal asphyxia does not at once ensue, still the respiration is always greatly im- paired ; it becomes irregular, stertorous, often intermittent, and accompanied with the greatest dyspnoea ; the Cheyne-Stokes phe- nomenon is frequently observed; the respiratory process then grows more and more encumbered and paralytic, till at last death results from asphyxia. It is only in comparatively mild cases that the respiration can recover, or is not at all affected. But even in cases which commence as hemiplegia, the hemorrhage generally extends and causes further mischief. Alterations in the action of the heart are generally less prominent. But in every severe case we unfailingly meet with an enormously rapid pulse, which is frequently irregular and intermittent, and the paralysis of the cardiac action runs a paral- 872 ERB.—DISEASES OF THE MEDULLA OBLONGATA. lei course with the increasing asphyxia. In the cases that have hitherto been described, very little is noted of vasomotor changes, unilateral or bilateral rise of temperature in the skin, such as we might expect with certainty, especially in the period immediately succeeding the hemorrhage. Great importance attaches to the epileptiform convulsions which accompany hemorrhage in the pons and medulla. They are often among the earliest symptoms, but they may be repeated in the first few days, and even later, assuming the most violent character. A tonic rigor has been often described in the ex- tremities, of variable duration and frequent recurrence. Disturbances of speech and deglutition, and unilateral and bilateral paralysis of the soft palate result naturally from the participation of the bulbar nerves in the paralysis. The same may be said of aural troubles, such as deafness and buzzing in the ears, which will probably be more frequently detected now that our attention has been directed to them. Vomiting of frequent recurrence, and a continuous troublesome singultus, which have often been observed, may be explained in the same natural way by an irritation of their centres in the medulla. Potain, in a case recorded several years ago, describes the occurrence of polyuria. Dutrait found both sugar and albumen in the urine, but his case proves nothing, as both these sub- stances were found before the hemorrhage as well as after. Both Mader and Desnos confirmed the presence of albumen in the urine in the case of an acute hemorrhage, where the kidneys were found quite intact at the autopsy. In a case where hemorrhage occurred 'in the pons portion of the medulla, I observed a considerable rise in the temperature of the body during the agony. Leyden and others record similar instances, and further it agrees with well known experimental facts. In cases where life lasts long enough, we can test the electric reaction of the paralyzed nerves and muscles. It probably re- mains quite normal for some time in the extremities, though it is stated that the irritability of the paralyzed nerves which come directly from the bulbus soon disappears. Leyden has con- firmed the latter point, at least as regards the faradic current. HYPEREMIA AND HEMORRHAGE. ^> 3NOia3w jo Aavaan ivnouvn pff\/ NATIONAL LIBRARY OF MEDICINE 3NiDia3w jo Aavaan ivnouvn NATIONAL LIBRARY OF MEDICINE W t ^ \ y\ \Al^y 3NiDiaaw do xavaan ivnouvn ,v Q fk. 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