Chapter M: M——, was a stout Irish woman about forty years of age. She had (26)

The best studied form of secondary degeneration is that of the voluntary motor conduit known as the pyramid tract. Beginning in the so-called motor area of each cerebral hemisphere, the Rolandic loop passes into the anterior part of the posterior half of the internal capsule, to be thence continued through the crus, pons, and the pyramids of the oblongata to the decussation or crossing-point of the pyramids. Here the greater part of the tract crosses into the opposite lateral column, occupying the position described in the section on Spastic Paralysis. A smaller part remains on the same side of the continuous interpyramidal and ventro-spinal fissure, constituting the direct fasciculus of Türck.

The crossed-pyramid tract diminishes as it passes caudad in the cord, giving off its fibres to the lateral reticular processes of the cord, {895} whence—whether interrupted by cells (Von Monakow) or not—they probably reach the great cells in the gray substance from which the anterior rootlets spring. The direct fasciculus probably terminates in a similar way, and perhaps makes good, as it were, its failure to participate in the gross decussation at the level of the foramen magnum by decussating in detail along its entire length. It is usually exhausted before the lumbar cord is reached, whereas the crossed tract in the lateral column continues down as low as the origin of the sacral nerves. A destructive lesion anywhere in the course of the pyramid tract, whether it be in the motor area of the cortex, in the loop of Rolando, in the internal capsule, the pons, or the cord itself, will provoke descending degeneration; that is, sclerosis of so much of the tract as lies below the lesion. Thus such degeneration is found with porencephalic defect of the motor area. I found it in a paretic dement who had extensive cortical destruction following a submeningeal hemorrhage. It has been observed after focal lesion of the pons (Homén, Schrader), and after transverse lesions of the cord, either myelitic, traumatic, or as the result of compression by vertebral disease. As a rule, the cells in the anterior horn are not involved, and some observers question whether this ever occurs. I have never found such involvement, although in its gross dimensions the anterior horn as a whole appears atrophied. This atrophy I have been able to account for satisfactorily by the disappearance of many of the fibres which run into the gray substance from the reticular processes.

While the distribution of degeneration in the cord is rather uniform, varying only in harmony with the ascertained individual variations in the relative preponderance of the crossed and uncrossed parts of the pyramid tract, there is much more variation in the cerebral distribution of the degeneration according to the extent of the original lesion. Thus, if the entire capsule be destroyed, the greater part of the crus is involved. If only the posterior division in its anterior part be destroyed, the degeneration is in the crus, limited to that part which runs a subpial course on the crural demi-cylinder, occupying from a fifth to a third of its surface-area. Still more limited degenerations are described, but as yet are too few in number to base other than tentative conclusions on them. Among these is one occupying a thin strip on the inner side of the crus, which degenerates after lesions near the genu of the capsule, and probably represents the tract which governs the cranial nerve-nuclei. An excellent observation by Von Mannkopf shows that the course of the motor fasciculus is subject to some individual variation even within the capsule.

A number of forms of secondary degeneration are described, involving intracerebral tracts, such as those connecting the cerebrum and cerebellum. The degeneration of the visual tract, from the optic nerve to the occipital lobe, observed by Richter and Von Monakow, with some conflict of opinion between these observers, is often as perfectly demonstrative of the course of the optic fasciculi as degeneration of the pyramid tract is demonstrative of the course of the voluntary innervation of the muscles moving the limbs.

The secondary degenerations following lesion of the pons varolii are acquiring special interest in view of their relation to special nerve-tracts of the spinal cord of hitherto unknown function. The purest instance {896} of an isolated degeneration of other than the pyramid tract is the case illustrated in the accompanying diagrams. It involved the interolivary layer, was both ascending and descending, being traced above into the subthalamic region, and below decussating into the opposite side of the oblongata, to terminate in the nuclei of the columns of Burdach and Goll. The leading symptom manifested by the patient was a hemiplegia of the muscular sense.[156]

[Footnote 156: Besides my case, others have been recorded by Homén, Meyer (Strassburg), and Schrader, which are impure. In the former and latter degeneration of the pyramid tract, in the second degeneration of the olivary fasciculus, coexisted. It is not generally known that Westphal, in one of the first volumes of the _Archives_ now edited by him, found an ascending degeneration of the same tract for a short distance.]

Ascending degeneration is found in a very distinct form after compression of the cauda equina. It is limited to the posterior columns, occupying nearly the entire area of the latter in the lumbar cord, particularly the triangular field of Burdach's column mentioned in the article on Tabes. In the dorsal and cervical cord it is limited to the columns of Goll, and terminates in the clava of the oblongata at the nuclei of those columns.

Higher lesions produce the same ascending degeneration of the column of Goll, and in addition involve other, probably centripetal, tracts which happen to be injured at their origin or in their course. For example, a transverse lesion of the dorsal cord would produce ascending degeneration for its whole length of the column of Goll and of the direct cerebellar tract. In addition, it would, in obedience to the law previously stated, produce descending degeneration of the pyramid tract. This combination is almost a typical sequence of compression myelitis of the cord, as {897} well as of ordinary transverse sclerosis. Recently, Gowers[157] has described a secondary degeneration in such a case of transverse lesion not previously noticed. It is found in cases showing gross disturbance of cutaneous sensibility, and occupies a narrow belt encircling the anterior quarter of the circumference of the crossed-pyramid tract. It is continuous, in my opinion, with a tract which in the upper cervical cord is situated in a corresponding situation, and which degenerated a short distance caudad in a case of secondary degeneration of the olivary fasciculus described by Meyer, and in which similar sensory symptoms were noted.

[Footnote 157: _Diseases of the Spinal Cord_, and _Neurologisches Centralblatt_, 1886.]

CLINICAL HISTORY.—Secondary degenerations are passive results of other more active processes, and few clinical signs are attributable to them. The most important of these is the contracture which is found in old hemiplegias, and attributed, like the secondary exaggeration of deep reflexes in such, to the descending degeneration of the pyramid tract. Bouchard believed that it was the retraction of the sclerotic strand which acted as an irritant on the neighboring fibres. The development of spastic symptoms in amyotrophic lateral sclerosis and in focal lesions of the crossed-pyramid tract is in favor of this view. On the other hand, the occurrence of flaccid hemiplegia, and its conservation for years after the most extensive lesions, is against it, as it is in these very cases that the secondary degeneration is most intense. That the retraction of a {898} longitudinal strand exercises any serious effect on neighboring and parallel fasciculi is questionable, as the process is slow. There is, however, one situation where such influence is very likely to occur—the decussations of the oblongata. In the case already referred to, the retracting sclerosing bundles undoubtedly must have exercised a damaging effect on their fellows of the opposite side, which, interdigitating with them, were compelled to pass through the sclerosing tissue. It has occurred to me that the slight sclerosis which is sometimes observed in the crossed-pyramid tract of the same side of a cerebral lesion, even where that lesion is strictly unilateral, is due to a similar influence. I think it can be shown that such sclerosis cannot be traced to the primary lesion; it begins at the decussation, and it is more than probable that the firm constriction to which the healthy fibres are subjected in crossing through their shrinking fellows of the opposite side is not alone the cause of the symmetrical yet slighter lesion, but also accounts for the observation by Pitrés and Charcot of a slight motor weakness observed on the same side as the hemiplegia, producing lesion in ordinary cases of capsular hemorrhage.[158]

[Footnote 158: Some of the French observers claim that this occurs only in the early period, but a careful study of the matter by R. Friedländer shows that the weakness of the side not usually regarded as involved is found in the later periods, and well marked then (_Neurologisches Centralblatt_, June 1, 1886).]

The PROGNOSIS and TREATMENT of secondary degenerations are practically involved in the primary lesion which gave rise to them. The contractures attributed to secondary sclerosis of the motor tracts is to be treated on the principles mentioned in the following section.

The Treatment of Spinal Sclerosis.

As the histological character of the different forms of sclerosis is similar—at least in the terminal period—the causes producing them identical even in name, and the indications furnished by leading symptoms analogous if not identical, the treatment of these various disorders is naturally based on the same leading principles. There are two objects to be aimed at in dealing with these chronic disorders: The first is the cure or arrest of the morbid process itself; the second is the amelioration of distressing and disabling symptoms.

It is generally recognized that a perfect cure of a sclerosis is a consummation never to be realized by any plan of treatment now at our disposal. The experiments of Kahler and others have shown that spinal tissue, once destroyed, is not regenerated. The post-mortem examination of cases of tabes which were considered as cured during life (Schultze) has shown that the sclerosis had not been removed; the process had merely become quiescent, and the apparent recovery had been due to the vicarization of other nerve-elements than those destroyed for the latter.

But if attempts at the regeneration of destroyed fibres and cells are to be regarded as futile, the arrest of the destructive process is to be considered as an object which offers better chances of realization, and which is worth attempting for other than merely conservative reasons. In a number of the forms of sclerosis described, notably in tabes and the disseminated form, it is remarked that the axis-cylinders lying within the {899} morbid district are in part intact and in part but slightly affected. Here and there groups of nerve-tubes may be found which retain even their myelin. While subject to the vicissitudes inseparable from their position in the midst of active pathological changes, these channels of nerve-force, though anatomically patent, may have their function perverted or destroyed, just as a nerve outside of the cord may be paralyzed by pressure or anæmia though its structure be intact. Should the active phase of the sclerotic process be arrested, these intact or nearly intact fibres will resume their function, and thus an apparent improvement will be effected. The spontaneous ameliorations in the course of tabes dorsalis and the less marked ones of diffuse sclerosis, coupled with temporarily improved sensation in the former and improved motion in the latter disease, show that retrogressions of this character are possible and do occur. How is the physician to imitate the action of nature? how to intensify it so as to secure the permanent improvement which nature unaided does not grant? The first factor to be considered is the removal of the cause of the disease. A number of cases are due to exposure to wet and cold and to over-exertion. Such exposure and over-exertion, if not already rendered impossible by the disease, is to be discontinued. A large number of cases of tabes—according to many authors, a majority—a considerable number of cases of diffuse sclerosis, and not a few of other forms, are connected with the syphilitic dyscrasia. Here, at the very outset, we have a definite indication for treatment, and while we may be disappointed in the results of such treatment in a large proportion of cases, yet enough of well-assured and substantial success has been and is obtained to render it almost a matter of duty for the physician to try antisyphilitic measures in every such instance.

The mixed treatment in chronic spinal disorders should be followed out for long periods and faithfully. Most tabic and other sclerotic subjects affected with constitutional syphilis are in what is called the tertiary period of that disease, when iodide of potassium is less useful than mercury. I have never gained anything by pushing either drug to the extreme point in advanced cases, and it should be borne in mind that mercurialization carried too far may itself prove directly injurious to the nerve-centres.[159] In cases where gastric crises, gross ataxia, muscular atrophy, and bladder disturbance have been of long duration this treatment is rarely successful.[160] But in the initial and early periods of tabes and in diffuse sclerosis of slight intensity the effect is sometimes gratifying, and of such a nature that it cannot be attributed to a coincidence with spontaneous remissions of the disease. In one case both knee-jerks and the pupillary reflexes returned, to disappear on premature discontinuance of the treatment; and on resumption one knee-jerk again returned, and has remained demonstrable now over half a year. In a second case the fulminating pains and the bladder disturbance disappeared, a slight indication of the pupillary reflex developed, and the patient has remained stationary with this gain for a period of three {900} years.[161] In a third case, one of established ataxia, with which luetic osseous lesions occurred, the pupillary reflex has returned twice, disappearing after the first reappearance. In one case of combined sclerosis in which no syphilitic antecedents could be found the paresis of the arms has disappeared, and the ataxic paresis of the lower extremities has improved to such an extent that the patient can stand with his eyes closed and his feet together, and on one leg with the eyes open—feats which a year ago he was unable to perform. None of the changes in symptoms taking place in these cases occur spontaneously in sclerotic spinal disorders, and they must be attributed to the treatment. Such treatment is best carried out in conjunction with warm bathing. The Hot Springs of Arkansas, those at Las Vegas, New Mexico, and the baths of Aix-la-Chapelle in Europe enjoy a special reputation in this field. The springs of Arkansas, as regards the intrinsic character of the water, possess advantages which are probably not excelled by any European baths, but the therapeutical management[162] is far from that ideal point of development attained, for example, at Aix-la-Chapelle.

[Footnote 159: Mendel thus found in his experiments made on dogs, developing cerebral disease from rotation with the head directed toward the axis of rotation, that dogs who had previously received subcutaneous injections of corrosive sublimate showed an increased vulnerability to the action of the rotary apparatus.]

[Footnote 160: A remarkable exception is related in the section on Chronic Myelitis.]

[Footnote 161: There was concentric limitation of all color-fields, and only central perception of green; to-day, if anything, the color-fields of this patient are a little greater than in the physiological average. The case was undoubtedly one of initial tabes.]

[Footnote 162: Mercurial ointment is used by the hundredweight, to quote the expression of a patient, and in certain establishments the sufferers from the common taint plaster each other from head to foot, as with mud, with this panacea for most of those ills which flock to the springs. Still, there seems to be no doubt that enormous quantities of mercury are borne well by those who use the baths, and who under other circumstances are susceptible to its most undesirable effects.]

Optic-nerve atrophy, according to the best authorities, constitutes a contraindication to the use of mercury in any form. It may be laid down as a general rule that the more rapidly the symptoms indicating a sclerotic process are developed, and the more recent its advent, the more energetically should the treatment be pushed. Mercurial inunctions and the so-called heroic doses of iodide are to be employed. But in cases progressing slowly and of long antecedent history what may be called a dilute plan is more apt to yield good results. Small doses of mercury,[163] given steadily for years, and iodide of potassium, administered in well-tolerated doses for periods of ten days, alternating with corresponding periods of intermission, have, in my opinion, delayed or arrested the progress of tabes and other forms of sclerosis for the long periods referred to in the preceding sections.[164] Although the antisyphilitic measures adopted in sclerosis of syphilitic origin are the most important, and the prognosis of no such case can be regarded as hopeless as to recovery or duration until they have been tried, other procedures, detailed under the head of Peripheral Treatment, should not be neglected. While some very severe cases improve rapidly on antisyphilitic treatment, other much less severe and more recent cases, in which the same cause is assigned with equal reason, are not affected by it in the slightest visible degree. The reason for this difference is unknown, but it necessitates the bearing in mind that by {901} limiting the treatment to the etiological indication valuable time may be wasted in which the symptomatic indications could be profitably followed.

[Footnote 163: The tablet triturates of biniodide of mercury or corrosive sublimate furnished by Fraser & Co. of New York I have found peculiarly useful; one one-hundredth or more of a grain may be thus administered every two to four hours.]

[Footnote 164: I am now employing the same treatment in some cases showing no syphilitic history. If any medicinal measures can act upon connective-tissue proliferation, it is these very ones.]

In cases of sclerosis due to other causes than syphilis a number of medicinal agents have been recommended as calculated to affect the central disease directly. Ergot is recommended in sclerotic troubles, particularly tabes, by a large number of writers. It is admitted that this substance can produce tabes itself, so that its administration in the large doses recommended by some is not without its possible dangers. I have seen a patient well advanced in the disease who had received the drug for three weeks consecutively in such quantities[165] that on estimates made I came to the conclusion that he had received more than some of the persons in whom Tuczek discovered the development of ergotin tabes. Favorable results are reported ensuing after its use in the early stages, particularly where signs of irritation preponderated, such as lightning-like pains, hyperæsthesia, and frequent erections; and it has been suggested that the beneficial action is due to an effect on the blood-vessels, which are supposed to be congested in the beginning of the disease. Proof of such congestion has not been furnished: the vessels are usually sclerosed and their lumen narrowed. In view of the undeniable danger which attends the administration of ergot in tabes, it may be properly insisted that its indications be more precisely formulated than has yet been done. It is commonly noticed in the natural progress of tabes that the lightning-like pains disappear, usually about the time the anæsthesia becomes greater. The anatomical parallel is supposed to be the destruction of the nerve-tubes whose previous irritation caused these pains. If, as is claimed—and it seems to be substantiated—ergotin does produce amelioration of the lightning-like pains, it would prove a damaging revelation which showed that it did so in imitation of the natural process; that is, by increasing the sclerosis.

[Footnote 165: An expert ophthalmoscopist found that the retinal vessels, which were somewhat dilated in this patient, were not influenced by the treatment.]

The first drug to which an influence was assigned upon the sclerotic processes, and which has maintained its reputation longest, is nitrate of silver.[166] Its claim to being regarded as a remedy may be best characterized by the fact that an author who is far from being prejudiced against it, and who recognizes the claims of Wunderlich, its advocate, speaks of it as a valuable placebo.[167] I have never obtained any effects from this drug in the scleroses, or from the chloride of gold, which has been also recommended for these affections, nor have I seen any in cases where either or both had been faithfully tried by others for years. The same is to be said of the chloride of barium, which has been warmly extolled on the basis of a very limited trial in disseminated and diffuse sclerosis.

[Footnote 166: One of the first patients on whom Wunderlich tried this drug died while I studied at Leipzig. He had extensive argyria and sclerosis of the posterior columns.]

[Footnote 167: Leyden, _op. cit._, vol. ii. p. 359.]

The direct application of the galvanic current to the spine is recommended, more particularly by Erb and Neftel.[168] I am unable to state {902} anything regarding currents derived from as many as twenty of Siemens cells and applied in the ascending direction, as the latter recommends beyond an experience which occurred in the practice of a colleague, who, alarmed by the event to be related, referred the patient subjected to this treatment to me. The patient suffered from tabes dorsalis, the symptoms being limited to the lower extremities, the ulnar distribution, and the pupils. The belt was in the lower thoracic region; the ataxia and lightning-like pains were not great. After a single application of an ascending current from twenty-two cells, continued for ten minutes, the patient suddenly felt a severe dull pain in the occiput and terrible lancinating pains in the distribution of the occipital nerves. With this there occurred scintillation before the eyes, and at the subsequent examination I found that the belt sensation had moved into the neck. The coincidence was so close, and sudden changes in the distributional area of tabic symptoms are otherwise so uncommon, that I attributed the observed change to the treatment.

[Footnote 168: In describing a case in which this measure not only ameliorated lancinating pains and vesical symptoms, but also, applied to the head, relieved the diplopia—usually a spontaneous occurrence, according to both American and European writers—this writer takes occasion to state that in the year 1869 tabes dorsalis was practically unknown to American physicians (_Archiv für Psychiatrie_, xii. p. 619). Duchenne described progressive locomotor ataxia in that and the preceding year; the necessity of referring to the unfamiliarity of American physicians with a disease not at the time recognized on either side of the Atlantic is hence not apparent. Leyden (_op. cit._, vol. ii. p. 325) candidly admits that the German medical profession was at first averse to recognizing Duchenne's limitation: this reproach cannot be laid at the door of American physicians, as I can distinctly recollect the demonstration of several well-marked cases exhibiting the characteristic symptoms then known, in the year 1870. The disease obtained recognition in American textbooks and journals as early as in those of any other land.]

Erb does not recommend such powerful applications. But the most sanguine electro-therapeutist must admit that the action of galvanic currents on the spinal cord is an exceedingly uncertain one. It is questionable whether weak ones deflect sufficient current-loops to reach the cord and to exert any material effect. As to currents powerful enough to produce an effect, it is not known, except in the loosest and most empirical way, what that effect is. The procedure followed by Erb is to use large electrodes, the cathodal one being a little smaller than the anodal, the former being placed stabile, over the upper cervical sympathetic ganglion of one side, the latter labile, on the opposite side of the vertebral spines, moving gradually downward, the session not exceeding three minutes. This is repeated daily or every alternate day.[169] It would prove a strong proof that this treatment really affected the morbid process in a remedial direction if any of the exact signs of the disease were to be modified by it, be it ever so slightly. If, after galvanization of the cervical cord and the sympathetic nerve, the initial myosis of tabes were temporarily lessened or the reflex contraction to light restored for ever so short a time, a brighter future would dawn for electro-therapeutics than seems now to be in store for it.[170]

[Footnote 169: Why, if the procedure be really remedial or efficiently palliative and devoid of evil consequences, it is not recommended to be repeated oftener I am at a loss to explain or understand. There are some factors involved in practical electro-therapeutic which it is scarcely possible to discuss without encroaching on delicate ground.]

[Footnote 170: In healthy persons the extent of the knee-jerk is increased by the spinal ascending galvanic current, and possibly this observation may lead to the establishment of a rational basis for its use in cases where the reflex is abolished or diminished.]

Peripheral Treatment.—A number of therapeutical applications are made to the periphery where the symptoms of the sclerotic process are localized. The rationale of such applications is based on the assumption that peripheral conditions are capable of modifying the nutrition and functions of the cord. This is proven not alone by a host of observations made {903} on the normal cord, but is also disastrously illustrated in the part played by surface chilling in the etiology of many acute and chronic diseases of the cord. Notwithstanding this latter, a large and influential body of German neurologists recommend cold baths and cold spinal douches in these affections. I have seen such excellent results from the use of warm baths that I am compelled to plead, in defence of my ignorance of the effect of cold ones, that I have never dared to use them. In numerous cases the beneficial effect of a warm bath is almost instantaneous. Warmth in any shape, whether atmospheric or in the shape of baths, is usually agreeable to patients suffering from the various forms of sclerosis. Cold, on the other hand, is disagreeable, aggravates the symptoms, and in many cases at least hastens the progress of the disease. A winter spent in the latitude of New York or Boston means so much ground lost by the patient, and a sojourn during the colder months in Southern California, New Mexico, Florida, or the West Indies enables the patient to avoid this loss. As regards the choice of climate and baths for sclerotic patients, I should be inclined to roughly formulate the indications as being identical with those of chronic rheumatism. The reaction against the use of warm baths in Germany, where they once were popular,[171] is due to the employment of too high temperatures. Hot baths, in the strict sense of the term, including the various forms of vapor-bath, act badly. They increase instead of calming the irritative symptoms, as moderately warm baths do, and they entail too sudden a change in the bodily state. That, for the present, it is advisable not to adopt unreservedly either the extreme plan once in vogue or the equally extreme one which constitutes the reaction against it, is shown by the observations of Richter of Dalldorf, who records some discouraging results obtained by the use of cold baths in cases of tabes dorsalis. It is but necessary to refer to the fact that the lancinating pains of the latter disease, the rigidity of diffuse myelitis, and the spasms of lateral sclerosis are usually most severe in cold weather, and that the diseases mentioned appear to be rare in warm countries, to show the need of caution in using a therapeutical measure so similar in its action, even if it be but momentary and followed by a reaction, to those which provoke or aggravate the original disease. Eulenburg has seen five recoveries in tabes, and under such different plans of treatment that the latter is not credited by him with the good result. Three were treated with warm baths, one with cold baths, and one with nitrate of silver. It is seen here that the warm baths were used with good results more frequently than the cold.

[Footnote 171: The mud-baths of Cudowa in Gallicia had a very high reputation.]

One of the most singular delusions of modern therapeusis—nerve-stretching—has, following the prediction made by several on both sides of the Atlantic, become obsolete. Introduced by Langenbuch, a surgeon, and attacking the disease at the sciatic nerve—a point where, as well-versed students knew, it was not located—the operation was looked upon with distrust from the beginning. The enthusiasm with which it was taken up by surgeons and by the interested portion of the laity—ever hopeful as tabic patients are of new drugs and methods of treatment—has led to a large number of trials, now numbering several hundred, and from which the useful lesson can be gathered that the good ripens slowly. Nerve-stretching in an organic disease of the spinal cord may take its {904} place among the needless vivisections; it has not influenced the progress of a single case in any essential feature. On the contrary, it has more than once been directly responsible for acute myelitis, spinal hemorrhage,[172] and pyæmia. In a number of cases reported by Langenbuch,[173] Benedict, Erlenmeyer, Schweminger, Debove, and W. J. Morton, the ataxia of the patient has been reported as relieved; in one case, exhibited by the latter operator before the American Neurological Association, this appeared quite evident, but not because the disease proper had been influenced, but for the same reason that prevents the development of marked ataxia in combined sclerosis. Just as the lateral-column lesion inhibits the ataxia which is due to the posterior-column lesion, so the motor paresis produced by stretching the sciatic nerves neutralizes the manifest features of the ataxic gait. As soon as the paresis is recovered from, the ataxia returns in its original form, unless, happily, one of the common spontaneous changes for the better occur. As a therapeutic procedure nerve-stretching is to-day properly limited to affections of the peripheral nerves.

[Footnote 172: Zacher, _Archiv für Psychiatrie_, xv. p. 430.]

[Footnote 173: Westphal showed after the autopsy of Langenbuch's first successful case that there had been no spinal lesion whatever.]

One of the most useful peripheral remedies in the sclerotic processes is the faradic wire brush. It is both an anodyne and remedial for anæsthesia. A number of the tabic patients to whom I referred as not having deteriorated within long periods are provided with a portable faradic battery, and apply the brush to the spots affected by terebrating pains the moment these commence, obtaining instantaneous relief. As has been shown by Rumpf,[174] the cutaneous space-sense becomes more delicate in healthy and improved in tabic patients under its continued use. And while the inco-ordination of tabes is in part independent of the disturbance of cutaneous sensibility, yet if the latter can be refined the ataxic disturbance may be mitigated—a result occasionally obtained through the methodical use of the wire brush.

[Footnote 174: Report of a discussion, _Neurologisches Centralblatt_, 1885, p. 526.]

It is frequently found that sufferers from tabes dorsalis and other forms of sclerosis accompanied by ataxia walk much better in their stocking feet and in slippers than they do in the conventional street shoe or boot. The reason for this is obvious. The patient's gait is impaired by the disease, and, whether the ataxia be a pure co-ordinatory trouble or no, subjective uncertainty regarding contact with the ground which is experienced by most ataxic patients is an aggravating factor. Our modern foot-clothing, with its inflexible soles and raised heels, handicaps the patient as it were, depriving him of the use of what little tactile sensibility may be left him.[175] The use of low-heeled shoes with thin and flexible soles is therefore advantageous.

[Footnote 175: The question whether tabes dorsalis is a disease of civilization has not been raised in any treatise I am acquainted with. Myelitis, both acute and chronic, occurs, however, rarely in the lower animals, as do also central dilatation of the cord and congenital defects of the latter. Posterior sclerosis I can find no record of in veterinary pathology. The influence of the repression of normal aids to locomotion by the foot-gear of civilized life as a possible predisposing factor in the etiology of ataxic troubles is a legitimate subject of inquiry. The lateness of the infant of civilized parents in acquiring the art of skilled locomotion may be in part, as philosophers claim, a penalty of exuberant development of the higher and inhibitive centres. But what part has the artificial obliteration of solar sensibility and pedal flexibility played in this inherited feature? What is its influence in establishing a pathological vulnerability?]

{905} The tremors of sclerotic affections, particularly those accompanying the disseminated forms, are from their distressing character prominent objects of special treatment. The bromides have been given with alleged good effect which I am unable to confirm. Curare has caused the tremor to disappear for two days in one of Erlenmeyer's patients. I have seen good results from the descending galvanic current applied in long sittings to the head and neck, sliding in to the point of tolerance, and sliding out before discontinuing. The mydriatics, atropine, and particularly hyoscyamin, often remove tremor radically for the time being; unfortunately, it is necessary to give them in almost toxic doses to obtain this effect. Recently, Feris recommended veratrum in doses of half a milligram repeated every four to five hours. It acted very well in every case in which I tried it, but, as it became necessary to increase the dose, the same objection was encountered as in the case of hyoscyamin. All these measures should be used as emergency remedies only; they cannot, in the nature of the case, prove curative, while their continued use produces a physiological indifference to their effect, and to that extent decreases their value as the case progresses.

MANAGEMENT OF SPECIAL SYMPTOMS AND COMPLICATIONS.—Among the most distressing features of many sclerotic affections is pain, which is usually associated with sleeplessness. The fulminating variety may be often relieved by the use of the actual cautery applied over the affected level of the cord and along the course of the nerve involved. But in the majority of cases morphine will have to be resorted to. Erb cautions against the use of this anodyne in cases where there is much reflex irritability of the cord, as morphine is said to increase this irritability when administered in small doses, and to reduce it again only when larger ones are administered. It is the latter alone which are serviceable with pain, and I have not yet seen any bad effects in the direction apprehended by Erb from such doses as it is necessary to give. That the physician administering it should be always on guard against the possible formation of a drug habit it is unnecessary to add. But it is also unnecessary to add what alternative he shall adopt when his choice lies between the lesser evil of the opium or morphine habit and the terrible martyrdom which some patients would be compelled to submit to if not allowed to indulge in it.[176] The evil effect of opium and its preparations on the visceral functions is to be neutralized, as far as possible, by the administration of laxatives and bitter tonics.

[Footnote 176: Few sufferers from spinal disease use anodynes habitually; opium and its preparations are not fascinating to the majority of persons. On the other hand, there are two cases of tabes dorsalis now under my observation in which the patients have been compelled to use hypodermic injections of Magendie's solution for two and three years without any materially bad effect.]

The deep-seated diffuse pains, such as are found in disseminated and diffuse sclerosis, are not as markedly relieved by opium as the terebrating and lightning-like variety. Frequently spastic or other signs of increased reflex excitability are associated with them; and as both are favorably influenced by the bromides, the latter are doubly indicated in such conditions.

With pains of a rheumatic character static electricity has been recommended. It undoubtedly relieves such pains, as skilfully-applied {906} galvanism would. Its chief effects, it seemed to me from a six months' trial with it, are on the imagination and hopes of the patient.[177]

[Footnote 177: A large apparatus of the new and improved make was at my disposal at the nervous department of the Metropolitan Throat Hospital. It was very popular with sufferers from rheumatism, who had been allowed to accumulate in the class before I took charge, and with a paretic dement who suffered with the rheumatoid pains often found with diseases such as his.]

The bromides and camphor[178] are recommended for the obstinate priapism found in some cases of early tabes and transverse myelitis. I have seen better results from warm hip-baths and general baths in this condition than from any drug. As a general rule, the exercise of the sexual function, where not already forbidden by the results of the disease, should be limited as much as possible. The frequency of normal seminal emissions in a given case is a guide to the amount of indulgence in this direction which may be permitted. Where there is the slightest indication of irritative or destructive lesions in the upper lumbar cord sexual acts should be entirely prohibited, for under these circumstances no greater injury could be done the weakened centres than to permit them. This is particularly noticed in those cases of tabes dorsalis which are marked by satyriasis in the early period.

[Footnote 178: Particularly the monobromate of camphor.]

The treatment of the bladder trouble and of bed-sores is carried out in the manner described in the section on Acute Myelitis. For bed-sores Hammond recommends the application of a stabile galvanic element consisting of a plate of silver and one of zinc, the two being united by a wire isolated in the usual way. The silver plate is laid on the bed-sore; the zinc plate, covered by a piece of moistened cloth, is laid on the unbroken skin somewhere in the neighborhood. The result is a weak current under whose stimulant effect the healing process takes place very rapidly. I have seen excellent results that had been obtained by this means in indolent ulcers of the leg. It does not, however, seem to have been tested with the malignant variety of bed-sore.

With regard to the management of muscular atrophies by electricity, massage, and strychnia, the same rules are to be followed which are laid down in the section on the Myopathic Atrophies. It is only to be specially remarked that few authorities encourage the administration of strychnia in sclerotic affections, and fewer still in such large doses as could be of any benefit in a wasting process.

Faradization of the affected eye-muscles is often useful in diplopia. The current may be applied by means of a cup-shaped eye-electrode, or, better, by using a finger as an electrode.

The moral management of sufferers from sclerotic spinal affections is very important. The popular notion about spinal disease generally is such that the announcement made to a patient that he is suffering from any form of it is as alarming as would be the discovery of a tumor in his brain or a cancer in his stomach, and exerts a depressing effect. This it should be sought to avoid. A large number of sufferers from sclerosis live longer and suffer less than a portion of those afflicted with rheumatic and gouty affections; and the physician is justified in obtaining the desirable effect which a hopeful or resigned state of the mind undoubtedly has on the body, by laying great stress on this undeniable fact.

{907}

CONCUSSION OF THE BRAIN AND SPINAL CORD.

BY WILLIAM HUNT, M.D.

The writer was asked to contribute a short article upon Concussion of the Brain and Spinal Cord for this work, as these injuries are apt at first to come under the notice, if not charge, of the general practitioner. The article will therefore not be an exhaustive one, and there will be little but the details of personal experience and less quoting of authorities. Much has been written recently upon the subject both in volume and in pamphlet.

Diverse views of equally competent judges of the matter have been put forth, and the brains and spinal cords of the partisans appear to have received as severe a shaking up as the real recipients of the lesions, if absolute lesions there be.

This, in fact, is the point of controversy, for there are those who seem to deny that there can be a jarring or shaking of the cerebro-spinal mass sufficient to cause positive symptoms without producing positive lesions, whilst others are as firm in their convictions that pronounced symptoms may follow a mere disturbing ripple of the nervous elements. How is the question to be settled? The slightly shocked or injured recover rapidly, whilst some who only appear to be as slightly injured or shocked at first, go on to death, during the progress to which event there is no doubt as to the existence of lesion and no difficulty in finding it at the autopsy. Hence, say the lesionists, the first ones had it, but got well, whilst the non-lesionists affirm that it never existed in them.

The logician would think that these differences in opinion were only differences in degree about the same thing, but, nevertheless, the question is one for serious discussion, and is of much greater importance than would appear to be the case to the average layman.

This importance lies in the medico-legal aspects of the suits arising out of the alleged injuries and their consequences. Judges, lawyers, and doctors know them well. In doubtful cases authorities of equal eminence are quoted, and the results of trials are equally as doubtful as to whether justice or injustice has been done. These remarks, as will be seen, are especially applicable to injuries of the spine, but they also may have place in the consideration of consequences arising from concussion of the brain.

{908} Concussion of the Brain.

Whatever doubts there may be as to concussion of the spine, there are none, I believe, who deny the appropriateness of the expression as to the brain, it being, by its anatomical relations, so much more exposed to shock than the spine.

We understand that pure concussion, uncomplicated with fracture, refers to a condition caused by external violence, direct or indirect, which communicates a jar or shock to the cerebral mass, and which expresses itself by certain well-defined symptoms. The nervous system and the circulation are most manifestly involved, but in a pure case it may be said that all of the symptoms arise from central nervous disturbance. Even could it be shown that they were dependent on temporary congestions, these congestions, I think it will be admitted, would be due to vaso-motor derangements.

The anatomical appearances after early death from concussion of the brain are often insufficient for us to comprehend the fatal result, for we know that the organ will bear, both from disease and other kinds of injury, vastly greater inroads upon its structure and surroundings without causing death. Often there is mere localized cerebral congestion, with no ruptures of vessels; then there are slight extravasations shown as points or dots of blood in the nerve-matter; and, again, there is what is called the bruised brain. Sometimes there is nothing abnormal whatever to be found. Most of these cases, under modern criticism, have been justly shut out from the record as having no value; for it has been shown that the post-mortem examinations of them have been very imperfect, the brain only having been inspected, whereas the chest, the abdomen, or the spine might readily have revealed the cause of death.

It is fair, however, to assume that there must be a capacity for serious results in the vibratory jar, as the discoverable lesions in many well-examined cases have been in themselves insufficient to kill. The rapidity of recovery of those who get well also bears weight on this point.

Of nineteen cases of recovery from concussion of the brain of which I have record, the average stay in hospital was eight days. The range of stay was from one to twenty-five days. Many of these were at first profoundly shocked, some of them apparently hopelessly so when we compared their symptoms with those who died. As they recovered, however, in so short a time, there surely could not have been any gross lesion to account for their symptoms. What else, then, can account for them than vibratory jar? and if this can produce such severe results within the line of recovery, why cannot the degree of it be so extended as to involve, for example, the respiratory centres, and so kill without leaving perceptible sign?

The SYMPTOMS of concussion of the brain range from a mere daze or stunning to those of deep unconsciousness. There is no paralysis of the extremities in pure cases. Often the patient is very restless, and throws his limbs about in all directions. When these are quiet there is response to irritation and electricity. Loud speaking to him may elicit some attention, but the answers are mostly incoherent. There is pallor, often extreme, coldness of surface, and sweating. Vomiting is usual, and may come on immediately or later, and it continues as long {909} as there is anything to discharge; sometimes there is retching. In favorable cases the cessation of vomiting is accompanied by a slow return to consciousness, which may be preceded by delirium. This return is never sudden, and the method of it serves to distinguish the case from that of some forms of epilepsy. The pulse is generally frequent and feeble, often irregular; in extreme cases it may be slow and feeble, very rarely, if ever, strong or bounding. After reaction it becomes more natural, and if recovery follows it will not show much variation. The temperature is depressed at first. In one characteristic case it was 98° on the first day, reached 101° on the third day, and receded to 98½° on the eighth day, when the brain symptoms disappeared.

There may be retention of urine and sluggishness of the bowels, but in bad cases coincident with the vomiting there is sometimes involuntary discharge both of feces and urine. The respiration is irregular, sometimes almost ceasing, and then returning with great rapidity.

Much has been said and written about the condition of the pupils in concussion of the brain. I have made this matter a subject of observation, and am convinced that the state of the pupils is of no diagnostic value whatever as to determining the existence of concussion or compression. Their state is of great value in telling us that the functions of certain brain-centres are partially or wholly impaired. The progress of the case will tell us whether the impairment is due to clot or effusion, congestion or jar.

It is wrong, therefore, to say that the pupils are one way in compression and another in concussion. It is right to say that in either case they are sluggish or wholly irresponsive to light. In one person they may be dilated, in another contracted, and in the same person the eyes may present marked contrasts.

In the light of modern physiology this is what might be expected. The condition of the pupils is dependent on that part of their nerve-connections which is involved in the injury, and also upon the method of that involvement. Clinical experience, I think, amply sustains this view.

The reaction from what may be called pure concussion is generally slow. The patient is apt to be dazed for some time, although the pulse and temperature may be normal. When there is a rebound with fever, and florid complexion, and suddenly or gradually another but deeper unconsciousness supervenes, it is almost certain that positive lesion took place at the time of injury, and that the reaction has brought with it great congestion if not extravasation.

Now, really, compression to be followed by inflammation is the condition demanding attention.

DIAGNOSIS.—The history of the case and the symptoms as detailed will enable us to reach a conclusion in most cases as to the existence of concussion of the brain. There are some conditions, however, from which it is to be carefully distinguished. These are simple fracture, with or without depression, compression from any cause, drunkenness, and epilepsy.

There may be such profound shock with fracture that at first concussion symptoms mask those of the lesion, or even keep them for a time completely in abeyance. The head bruises are often very deceptive to the touch in the search for fracture.

{910} I am in the habit of directing students to feel their own scalps, in order that they may appreciate the fact that the touch gives no sensation whatever of the natural thickness of the cranial covering. It seems as though something like a piece of thin parchment only intervenes between the fingers and the bone. The fact is, the scalp varies from an eighth to a quarter of an inch thick, differing in different places, and where muscles, as the temporal, for example, are beneath it, the bone is much deeper. The importance of this observation lies in the fact that a pulpefied bruised mass of scalp will cause the edges of its healthy surrounding part to feel almost precisely like bone around the borders of a depressed fracture. The accompanying general symptoms will mostly not be in accord with this condition, but in some cases the deception is so complete that it is very difficult to persuade those not familiar with the fact that a fracture does not exist, and to induce them to refrain from rash proceedings.

One case I can call to mind where the opinion of the attending physician was only changed by the ultimate favorable result, which left no sign of permanent injury of any kind. These cases are particularly apt to occur with children.

I remember also another source of deception. A boy was severely injured by a blow upon the forehead. Concussion was marked. There was a lacerated wound reaching to the edge of the orbit; fractured bone could be felt, and at first sight what appeared to be brain-matter was oozing from the wound. A hasty unfavorable prognosis was given to the parents. On closer examination it was found that the fracture was of the external wall of the frontal sinus, and the supposed brain-matter was the delicate fat-lobules of the orbit. The patient recovered rapidly.

There is a marked distinction between the ordinary symptoms of concussion and those of compression, whether from depressed fracture or effusion, as of blood in apoplexy. Here there are flushed, often swollen, countenance, stertorous breathing, slow and it may be strong pulse, deep or absolute insensibility, and fixed pupils. The injury, if there is one, is mostly palpable and explanatory. If it is concealed, the other symptoms point to the true nature of the case.

The diagnosis from drunkenness is not always easy, although deep intoxication is more apt to be accompanied with compression than with concussion signs. Drunkards often have bruises on their heads caused by falls, and some of them are pale and sick after debauch. The smell of liquor is not always reliable, for it is so common after accident for friends to administer stimulants before the patient is seen by a medical man that he might be easily misled into too hasty a judgment. The general appearance of the old stager is well known, but in cases where there is the least doubt the patient, whether in hospital or in private, should be kept a sufficient time under observation for the effects of drink to pass off. Then it will be seen whether this has masked a more serious condition. Too hasty conclusions in this matter have led to most unpleasant occurrences. These are well known in police administration and to hospital men.

The convulsions of the epileptic, the foaming mouth, and the quick return to partial or complete consciousness will generally serve to distinguish the case from one of concussion, but at times there are those who {911} require also to be kept under observation for some hours, and even a day or more, in order to come to a correct conclusion.

The PROGNOSIS in concussion is generally favorable, but if complete unconsciousness is present it is doubtful as to the individual so long as this lasts, for, as before intimated, the cases which recover may present as marked symptoms at first as those which prove fatal.

Recovery is mostly complete, but not suddenly so. The after-effects in any case may prove serious.

There is, however, an unwarranted tendency to attribute any defect in character, and even criminal lapses, to a blow upon the head, especially should the history or marks of one be discovered as having occurred at any time, no matter how long, previous to the inquiry.

The blow may be the cause of subsequent epilepsy, chronic inflammations, and insanity or imbecility. These cases have, however, an almost continuous history of trouble from the date of the injury, the manifestations varying in severity from time to time as pathological changes go on or as exciting causes develop them.