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Full text of "Cyclopaedia of the practice of medicine;"

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OF THE 



z 

CYCLOPEDIA 

PRACTICE OF MEDICINE. 

Edited by Dk. HI^von ZIEMSSEN, 

PBOFESSOB OF CXINICAI. H££)ICIN£ IM MUNICH, BAYAfilA. 

VOL. XIIL 

DISEASES OF THE SPINAL CORD 

AND 

MEDULLA OBLONGATA. 

BY 

Prop. WILHELM HEINRICH ERB, of Heidelberg, Baden. 

EDWARD G. GEOGHEGAN, M.D., of London; EDWARD W. SCHATJFFLER, M.D., of Kansas City; 
DAVID F. LINCOLN, M.D., of Boston; and JOHN A. McCREERY, M.D., of New York, 



ALBEET H. BUCK, M.D., New York, 

2DIT0B OF AMEBIOAN '^ITIOM. 



NEW YORK: 
WILLIAM WOOD AND COMPANY, 

' 27 GREAT JONES STREET. 

1878. -a\> 



Entered according to Act of Congress, in the year 187S, by 

WILLIAM WOOD & CO., 

In the Office of the Librarian of Congress, at Washington. 



ATT. RIGHTS EESERVED. 



Trow's Printing and Bookbinding Company, 

205 to 213 East Ttvelftk 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 46 

Inhibition of reflex action 51 

Centres and paths for the innervation of the viscera 53 

General Symptomatology 6G 

Disturbances of sensibility 66 

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 CONTENTS. 



PACE 



Sexual excesses and irregularities 147 

Influence of age and sex 1^0 

General disturbances of nutrition 151 

Propagation of neighboring morbid processes 151 

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 1*^'^ 

Irritation and disease of peripheral organs. 154 

General Diagnosis 155 

General Therapeutics 160 

External remedies 1^2 

Cold 163 

Warmth 163 

Baths 164 

Climate 1'75 

Electricity I'^S 

Blood-letting and derivatives 185 

External frictions 186 

Internal remedies 187 

Symptomatic remedies and methods 193 

General method of life 196 

Diseases of the Membranes of the Spinal Cord 199 

Hyperjemia of the Meninges and the Cord itself. 199 

Bibliography 199 

Etiology and pathogenesis 200 

Pathological anatomy 202 

Symptomatology 203 

Diagnosis 206 

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 317 

Pathological anatomy 218 

Symptomatology , 219 

Diagnosis 220 

Prognosis and treatment 321 



CONTENTS. V 

PAGB 

Pachymeningitis Spinalis Interna 221 

Etiology and pathological anatomy 222 

Symptomatology 223 

Diagnosis, prognosis, and treatment 225 

Inflammation of the Spinal Pia Mater 22G 

Bibliography 220 

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 263 

Bibliography 262 

Pathological anatomy - 264 

Etiology 268 

Symptomatology 208 

Course, duration, termination 273 

Diagnosis 274 

Treatment , 276 

Addendum 277 

Anatomical Changes in the Spinal Membranes, without clinical signifi- 
cance 277 

Diseases op the Spinal Cord 279 

Introduction 279 

Hypera3mia 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 

% 



Yl CONTENTS. 



PAGB 
291 



Spinal Apoplexy 

Bibliography 291 

Pathogenesis and etiology 293 

Pathological anatomy "^'^ 

Symptomatology 297 

Course, duration, termination 301 

Diagnosis 302 

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 

Diagnosis 378 

Prognosis 379 

Treatment 380 

(Translated by David F. Lincoln, M.D.) 



Myelitis 383 

Bibliography 383 

Introduction 383 

History 385 

Myelitis acuta 387 

Etiology and pathogenesis 388 

Pathological anatomy 391 

Symptomatology 403 

Course, duration, termination 414 

Diagnosis 418 

Prognosis 420 

Treatment 423 

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 456 

Treatment 457 

Myelomalacia 467 

Bibliography 467 

Pathogenesis 468 

Pathological anatomy 470 

Symptomatology 470 

Diagnosis, prognosis, treatment 471 

Multiple Sclerosis 473 

Bibliography 473 

History 473 

Etiology and pathogenesis 475 

Pathological anatomy 477 

Symptomatology 483 

(Translated by John A. McCreery, M.D.) 



Course, duration, termination 605 

Diagnosis ^. 507 

Treatment 512 



Viii CONTENTS. 



PAGE 



Tabes Dorsalis • ^^'^ 

Bibliography • Sl'^ 

History • ^^"^ 

Etiology and pathogenesis 523 

Pathological anatomy ^^1 

Symptomatology ^^^ 

Course, duration, termination 596 

Theory of the disease 5^^ 

Diagnosis • ^^^ 

Prognosis ""* 

Treatment 6C8 

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 

PAOB 

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 anatomj* 796 

Symptomatology 800 



X CONTENTS. 



PAGE 



Saltatory Spasm 801 

Bibliography 801 

Symptomatology 801 

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 

Greneral remarks 818 

Paraplegia dependent on Idea , 819 

Bibliography 819 

Etiology 819 

Symptomatology 819 

Diagnosis 821 

Treatment 821 

(Translated by Edward W. Schauffler, M.D.) 



Diseases op 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 centre 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 

PAOX 

Pathological anatomy 867 

Symptomatolojjy 868 

Diagnosis 874 

Prognosis 875 

Treatment 875 

Anaemia 876 

Bibliography 876 

Pathogenesis and etiology 877 

Pathological anatomy 878 

Symptomatology 880 

Diagnosis 884 

Prognosis 886 

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 948 

Treatment 943 

Other Chronic Diseases i 947 

Bibliography 947 

Sclerotic Centres «. 9 17 

Diffuse Sclerosis 949 



Xii CONTENTS. 

PAGB 

Tumors of the Medulla 950 

Bibliography 950 

Pathological anatomy 950 

Etiology 953 

Symptomatology 953 

Diagnosis 956 

Prognosis 957 

Treatment 957 

(Translated by Edward Gr. Geoghegan, M.D.) 



DISEASES 



OP THE 



SPIIAL CORD AND ITS ENVELOPES. 



ERB, 



INTRODUCTION. 

W — 

V ^UR 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 

kupon it are bearing fruit in many ways, 
h 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. 

i 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 SPIjS'AL CORD AND ITS ENVELOPES. 

liension 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 refel- 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. Xor 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. 6 

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 
physiology, 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 tilings 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 repetitions 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. 



L Anatomical Introduction. 

Cf. Longet, Anat. et physiol. du systSme nerveux. German transl. by Hein. 1847.— 
Koelliker, Mikroskop. Anatomic. Handb. der Gewebelehre, 5. Km^.— Stilling, 
Neue Untersuchungen iiber den Bau des Riickenmarks. 1857. — Bidder und 
Kupffer, Untei-such. iiber die Textur des Riickenmarks u. s. w. 1857. — Schroe- 
der van d. Kolk, Bau und Function der Medulla spinalis und oblongata. 
Braunschweig, 1859. — Golly Denkschrift der med.-chir. Gesellsch. des Cantons 
Ziirich. 1860. — Frommann, Untersuch. fiber die normale u. pathol. Anatomic 
des Ruckenmarks. 1864. — Deitera, Untersuch. fiber Gehirn und Rfickenmark 
des Menschen u. s. w, 1865. — M. Schultze in Strieker's Handb. der Gewebelehre. 
— Gerlach, ibidem. — Henley Handb. der Anatomic. HI. Bd. 2. Halfte. — Wundt^ 
Physiologische Psychologic. Leipzig, 1874. — C. Lange^ Ueber chron. Rucken- 
marksentziindung. Kopenhagen, 1874; see Schmidt's Jahrb. Bd. 168. p. 238. 
1875. — Leydeiiy Klinik der Rfickenmarkskrankheiten. I. 1874. — HugueniUy Allg. 
Pathol, der Krankheiten des Nervensystems. 1873. — Boll, Histiologie und His- 
tiogenese der nerv. Centralorgane. Arch. f. Psych, und Nervenkrankheiten. IV. 
p. 1. 1874. — SchiefferdecJcer, Beitr. zur Kenntniss des Faserverlaufs im Rficken- 
mark. Arch. f. Mikroskop. Anatomic. 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 verteora downward, especially 
in the lumbar part. Throughout the greatest part of the dorsal 



8 ERB. — DISEASES OF THE SPInAL CORD AND ITS EN^VELOPES. 

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 cord^ 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- 
tebrae. Fehst ' 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 

' Spinal cord : the term will be thus used henceforward. 
» 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 dae in part to cerebral implication. 

The spinal fluid is not in a state of repose, but, as Quincke ^ 
has recently given exact proof, is constantly undergoing a 

' Zur Physiologie der Cerebrospinalflussigkeit. Reichert's and Du Bois-Reymond's 
Archiv. 1872. Heft 3. 



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 terminal e, 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 tlien smooth, and seldom 
pushes over the edges ; shortly after death it begins to grow soft 



12 ERB. — DISEASES OF THE SPINAL COED 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 running down the whole length of the cord, 
which, sinking into the cord, forms the broad fissura longitudi- 
nalis anterior,^ 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,^ 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. 

• Anterior median fissure of Quain. 
' Posterior median fijssure 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- 
luedius '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 intermedins 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-sJiaped column of Goll^ ov funiculus gracilis 
(zarter Strang) ; while the lateral portion, which adjoins the 
posterior lateral fissure, is cBlledfuniculus 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 intervertebi-al foramina ; the posterior root of 
each spinal nerve enlarges to a ganglion {ganglion spindle) 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 Krause ^ — 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 

' Centralbl. f. d. med. Wiss. 1874. No. 48. 



ANATOMICAL INTRODUCTION. 



15 




^KfX 




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 Pig. 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 chieHy, 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 







Fio. 1. 

Sections of the human ppl- 
nal cord taken at different 
heights. Magrnified '/a' 

1. Upper cervical portion. 

2,y. Cervical enlargement. 

4, 5. Dorsal portion. 

6,7. Lumbar enlan?ement. 

8. Conus termlnalia. 



■ 



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 tradus 
inter medio-later alls (Fig. 2, o). 




Fio. 2. 
Semidiagrammatic section of the cord about the lower part of the cervical enlargement. Magnified «/,. 
a. Anterior median fissure. 6. Posterior median fissure, c. Anterior column, rf. Lateral column, e. Pos- 
terior column. /. GoU's wedge-.shaped column (Zarter Strang), g. Funiculus cuneatus. h. Anterior roots. 
i. Posterior roots. *. Central canal. I. Sulcus intermedins posterior, m. Anterior pillar (cornu). n. 
Posterior pillar (cornu). o. Tractus intermedio-lateralis. p. Processus reticulares. q. Anterior or 
white commissure, r. Posterior or gray commissure. «. 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 sepia 
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 mew 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 prolections and knobs upon 
the pillar ; in parts they are wholly filled up, and here and there 
a longitudinal ridge comes out into them. 

VOL. XIIL— 2 



18 ERB. — DISEASES OF THE SPINAL CORD A1!TD ITS ETTVELOPES. 

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. 

Bloo&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 tliey 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 lympliatic 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-fihres^ 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 luniculi 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 erery 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 consider 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, I^anvier, C. Lange, and others) 
are still divided, as the difficulty of investigating this tissue is 
very great. All observers agree that the neuroglia consists 



23 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 and 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, Kanvier), 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.' 

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.' 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 

* See Virchow-HLrsch'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. 



M 



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 
cord, for which reason they almost 
always present their well-known 
cross-section, in transverse sections 
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, ^r only a little off from it. 
They pass more or less directly from the cortex to the gray 



W?oPo 



^1^^ 



Fio. 3. 

A piece of the transverfse section of the 
white substance of a lateral column. Neu- 
roglia, with Deiters' rells ombedde<l in it, 
embraces the nerve-fibres, which are cut 
across, and are seen with distinct axis-cylin- 
ders. Maguihed '^^, 



24 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 Clarice'' 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- 



L 



ANATOMICAL INTRODUCTION. 25 

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 Grerlach'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 cor^jcal layer. From this it would 
follow that this remarkable and important network is universally distributed 
through the cord. 



26 ERB. — DISEASES OF THE SPIITAL CORD AND ITS ENVELOPES. 

Schieiferdecker lias 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. 



y 



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, J., a l)\ and containing a great many cells ; 




Pro. 4. 

Seml-diagramatic transverse sections of the gray substance of the cervical (4) and lumbar enlargemenc 
(/?), to show the situation of the ganglion-cells. Magnified 'Vj* Aa, medial group; <>, antero-lateral ; 
c, postero- lateral group : <f, columna vesicularis. /?a, medial group : a', group first appearing in the lumbar 
region, perhaps belonging to the medial ; 6, 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 ii-regularly 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 tisane 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 INTRODUCTIOX. 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 wJiite 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 cj^lindrical 
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 beenlhe results ; hardly any- 
thing is established with certainty, and the liveliest controversies 



30 ERB. — DISEASES OF THE SPIl^AL 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 they 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 INTRODUCTIOX. 



81 



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 EKB. — DISEASES OF THE SPHSTAL CORD AXD 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 tlie 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 accessorius^ 
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 posterolateral 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. 



11. Physiological Introduction. 

Cf. Longet, Anatomic ct physiologic du systSme nerveux ; German transl. by Hcin, 
1847. — Scliiff, Lehrb. der Physiol, des Nervensystems. Lahr, 1858-59. — 
Ccntralbl. f. d. mod. 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, Groningcn, 
iSQQ.— Wundt, Physiologic, 1873. 3. Aufl. ; Physiol. Psychologic. Leipzig, 1874. 
-^Hermann, Grundriss der Physiologic. 2. Aufl. 1874. — Ley den, Klinik dcr 
Ruckenmarkskrankheiten. I. 1874. — Also innumerable articles in Reichert and 
du Bois-Reymond's Archiv, Virchow's Archiv, Pfluger's Archiv der Physiologic, 
Zeitschr. f. wissensch. Zoologie, Zeitlschr. f. rationelle Medicin, Moleschott's 
Unters. z. Naturlehre, the Monatsberichte of the Saxon Academy, Brown - 
S6quard's Journal de la physiol. dc Thomm^, etc. , the Archives de la physiol. 
norm, ct pathol., etc. 

VOL. XIII.— 3 



34 ERB. — DISEASES OF THE SPINAL COKD 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 being- 
used by the pathology of our day. 



PHYSIOLOGICAL INTRODUCTION. 95 



Sensory Conduction in the Spinal Cord, 

All the impressions received by peripheral sensitive nerves ^ 
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 
anniliilate 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-S6quard 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. Psychologic, 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 tlic 
reaction occure, its intensity is all the greater, and produces pain. If, therefore, tlic 
gray substance alone remains for the purposes of conduction, more powerful irrita- 
— ■ _ — _____ « ' — - 

' According to Brown-Sequard, the paths for the ''muscular sense" lie in the ante- 
rior roots. 



36 ERB. — DISEASES OF THE SPINAL CORD AT^D 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-Sequard, 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- 



PnYSIOLOGICAL INTRODUCTION. 37 

sioii 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 interior 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 functioD 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 both 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 V) 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 latei-al 
columns of the upper cervical portion contain those for the 
muscles of respiration, and that cutting them destroys jp^ma- 
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 latei-al 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 tlie innervation of a large number of 
muscles simultaneously^ each with a different but appi'opriate 
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 qiiite complex, 
and involve a large number of muscles ; still more is this the case in the more com- 
l)licated 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 COKD 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- 



I 



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 he 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-motoT 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 INTRODUOTIOX. 



48 



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 xaso-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.' They refer the symp- 



' Pflueger's Archiv. Bd. IX. S. 174. 

• 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. 



TropJiic 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 



I 



PHYSIOLOGICAL INTRODUCTION. 45 

of nutrition. That tlie 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.^ 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, Yulpian, 
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- 

' 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. 



Reflex Action of the Spinal Cord. 

The production of reflex movements — ^. 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 — L 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- 

' Arch. f. experiment. Path. u. Pharmak. II. p. 343. 



PHYSIOLOGICAL INTRODUCTION. 47 

tion with each other ; but these conductors may be supposed to 
be connected by means of tlie 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 Goltz ' 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- 

% 

' 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. 

Keflex 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 Westphal ^ and 
myself,^ 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 

' XJeber einige Bewegungserscheinungen an gelahmten Gliedern. Arch, fiir Psych, 
u. Nervenkrankh. V. p. 803. 1875. 

^ Ueb, Sehnenreflexe bei Gesunden und bei R .-M. -Kranken. Ibid. V. p. 793. 



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, appeared after I had written the above. 
He gives the name of '* lower leg phenomena" to that which I denominated the 
tendo-patellce 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. Westjjhal, 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 liand, 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 reasofls, 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 ulnoe was lightly 
tapped, and one in the triceps brachii 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 mechai^cal shock, transferred to tlie dis- 
tant muscle, could have been the cause. In hcmiplegic patients, when the patellar 
tendon of one side is tapped, we often see twitching of the adductors of the other 
VOL. XIIL— 4 



50 ERB. — DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

side. In a case of compression of the lumbar cord the tendo-patella) 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-patellae 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 doulit. 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-patellse 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 expossd 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 
he due to a direct action through the tendon, hut 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, t?uit a reflex act originating in the sJcin can- 
not possibly he the cause. 

The last statement leads by anticipation to the observation of Joffroy ' 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 ths muscles of the calf, to be described below. I have repeatedly 
seen 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 sufl[ices 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.' 

We may therefore with propriety introduce the name of "tendinous reflexion" 
for this plienomenon. 

Our view is decidedly supported l)y C. Sachs' very recent demonstration of 
nerves in the tendons, which can hardly have any other than a sensitive function.* 

It is also known, and has lately been confirmed by Freus- 
berg's data, that numerous reflex actions may originate from the 

' CentralbL f. d. med. Wiss. 1875. No. LIV. 

' De la trepidation epileptoide du membra infer,, etc. Gaz. med. de Paris. 1875. 
No. 33 et 35. 

3 Schles. Gesellsch. f. vat. Cult. Medic. Sect. Sitzg. v. 23. Juli, 1875. 
* Die Nerven der Sehnen. Reichert und Du Bois' Archiv. 1875. p. 403. 



w 



PHYSIOLOGICAL INTRODUCTION. 51 

riscera, 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 faeces 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. 

Inliihition 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 hrain 
(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 COED AND ITS ENVELOPES. 

years have shown that the spinal reflexions can be arrested and 
completely suppressed by irritation of sensitive nerves (Lewis- 
son, Setchenow, JS'othnagel, 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 



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. Rokitansky ' 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 Goltz'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 
flrst 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, 



' Untersuch, iib. d. Athemnervencentra. 
« Pfliiger's Archiv. VL 1873. 



Wien. med. Jahrb. 1874. L S. 30. 



54 ERB. — DISEASES OF THE SPIRAL CORD AXD 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 fsecal 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,' 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 vesicae, 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 flrst 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 



' Pfluger's Archiv. VIII. 1873. 

* 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 A:N-D ITS EiS'VELOPES. 

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. 

Yery 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. c). 

The erection of the penis is brought about, according to 
Eckhard's investigations,^ 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), 

' Beitr. z. Anatomie und Physiologie. Giessen. Bd. III. IV. und VII. 



PHYSIOLOGICAL INTRODUCTION. 67 

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 centrts may be demonstrated in 

' 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/ 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-libres 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 Eckhard ' in regard to the secretion of urine, who 
says that section of the cervical cord produces a complete and 



1 Pfliiger's Archiv. Bd. IX. p. 553. 

2 Untersuchungen iiber Hydrurie. Beitr. zur Anatomie und Physiologie. Bd. V. p. 
147. 1870. 



PHYSIOLOGICAL INTRODUCTION. 69 

permanent arrest of tliis 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 excitahil' 
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 J;)ladder and rectum is cer- 
tainly of a reflex character, and principally depends on the 
lumbar cord. 



60 ERB. — DISEASES OF THE SPINAL COPwD AT^D 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. 



Gl 



made to a direct transference of pliysiological 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. 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 (Physiologic, p. 
292), and Brmcn-Seguard'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, hypersemia, 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 hypersesthesia occur in the parts situated posteriorly. 

9. A lesion producing paralysis^ affecting the posterior 
columns in the same w^ay, 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 w^hicli 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 SPIXAL COPwD AND ITS ENVELOPES. 

26. In limited destruction of the dorsal medulla, tlie 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 Schiif, 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. Scliiff ' 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, 

J Centralbl. f. d. med. Wiss. 1873. 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 ' 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.^ 

\^M ' Centralbl. f. d. med. Wiss. 1869. No. 39 ; and Arch, de Physiol, norm, et path. 
IV. p. 268. * 

2 Arch, f . experim. Pathol, und Pharmacol. Bd. II. p. 225. 1874. 
» Pflueger's Arch. Bd. IX. p. 390. 
VOL. XIIL— 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. 



m. 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 ^^rj 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 



lis, compare Vol. XL of this Cyclopoedia, p. 212 [American ed.]. The qualities of 

jrception which are classed together under the name of muscular sensation, or 

mse, should also be tested. Besides the methods given in the same volume, p. 

54, there is a good method given by Leyden ' for the exact testing of the sensation 
>f passive motions. No extensive apparatus is required for this ; the same exact 

jsults are obtained when the leg is suspended in a broad cloth, and by means of tho 
Bloth is made to move in various directions, upwards, downwards, outwards, or 

iwards — 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 

le movements. In testing the passive movements of the ankle-joint, the front 
)art of the foot is grasped carefully with the hand, and is moved passively. This 

lethod is quite sufficient, as the cutaneous sensibility of the i^atient is usually 

ipaired. 



a. Diminution of Sensory Action— AncBstliesia, 

All the sensations which originate in the skin, the mnscles, 
i,nd other more deeply-seated parts may be diminished in dis- 
Lses of the spinal cord ; and the diminution may increase, even 

the extent of total loss of sensation. They may be extin- 
;aished all at once, or some may be lost and the rest retained. 

The disturbance of sensibility usuallj'- appears first in the 
lower extremities, ascending by degrees until it reaches the 
ipper extremities. But often the latter are the first attacked, 
md the anaesthesia extends downwards. 

Anaesthesia is very commonly attended by various subjective 
msations, as the furry sensation (Pelzigsein) or numbness, un- 
jertainty in feeling the ground, sensation of walking on cotton 
'^adding, 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 
jection of the posterior columns and the gray substance is de- 
itroyed ; that is, chiefly in affections which are diffused over the 
mtire section, extending to a variable distance in the longitudi- 
lal direction. It also accompanies a complete severance, crush- 
ing, or compression of the cord at any ppint ; in which case the 



' Ueber Muskelsinn und Ataxic. Viroh. Arch. Bd. 47. 1869. 



63 EUB. — DISEASES OF THE SPINAL COKD AND ITS ENVELOPES. 

anfBsthesia occupies all portions of the body wliicli 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 ancBstJiesia^ 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 tlie spinal lesion, owing to the 
decussation of the sensory paths in the cord. Tlie muscular 
sense, however, usually remains unimpaired, because the fibres 
for it cross at a higher point. 

As ancBsthesia 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 ancestJiesia, 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- 



II _„._, . 
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 (Schift*). 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 

I and imcertain facts. If disturbances of sensation are present, 
|he physician will have to put to himself the questions — whether 
there is an affection of the posterior roots within or without the 
pord, 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 
pata which are given here and in the physiological introduction 
pill 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 sensibility* 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 tlie 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 tliey 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 Ley den and Goltz. ' 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. Remak^ has 
published a case in which pricking with a needle provoked in 
every instance an immediate sensation of touch, which was fol- 

' Anatom. pathol. Livrais. XXXVIII. p. 9. 

' Leyden^ Klinik der Riickenmarkskrankheiten. I. p. 146. 

3 Arch. f. Psych, u. Nervenkr. Bd. IV. p. 763. 1874. 



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 journal^ seems on some accounts to belong here ; 
it included retardation of the sensation of pain, associated with 
hypersesthesia, while the sensation of touch remained normal. 
Yulpian ^ 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.^ 

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.^ Schiff has even been enabled by his experience to 

J Archiv f. Psych, u. Nrevenkr. Bd. IV. p. 760. 

^ Arch, de Physiol, norm, et path. I. p. 405. 

^ llertzberg (Beitr. zur Kenntniss der Sensibilitiitsstorungen bei Tabes. Diss. Jena. 
.1875) 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. 

"* See Schiff'8 Physiologie. p. 245. 



72 ERB. — DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

predict the existence of double sensation in man, whicli has 
lately been confirmed by the beautiful observation of E. Remak ; 
he looks for the appearance of this symptom in every case where 
the transverse dimensions of the gray substance have been di- 
minished by pathological processes, while the posterior columns 
have remained intact.^ 

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,'^ 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 
tinder 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). 



' See Physiol p. 294. CoroU. 3. c. 

* Physiolog. Diagaostik der Nervenkrankheiten. Leipzig. 1 875. 



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. 

h. Exaggeration of Sensory Action. 

This is one of the commonest symptoms in diseases of the 
XJord, and may appear in various forms, viz. : 

1. As simple Tiypercestliesia ; more or less increase of sensi- 
tiveness to all possible kinds of sensory impressions, which di- 
rectly increase to pain. This hypersesthesia not seldom resembles 
anfesthesia 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. Hyperaesthesia may also be confined to single 
denominations of sensibility (pain, sen^e of temperature, espe- 
cially sense of cold), and may occur in connection with partial 
paralysis of sensation. 



74 EKB. — DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

It is known from physiological experiments that section of 
the posterior columns is followed by a hypersesthesia of tlie pos- 
terior half of the body, which at first increases rapidly and con- 
siderably, and afterwards very gradually diminishes and disap- 
pears ; ^ and that when only one posterior column is cut, the 
hypersesthesia remains confined to the same side. The hyperses- 
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 hyper^fisthesisB 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. K'evertheless, it is not 
unlikely that there are other processes capable of occasioning 
hypersesthesia, e. g,, implications of the nerve-roots in meningi- 
tis, etc. 

2. As parcBstliesia. 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, tinghng, 
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 

' See Scldff, 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 hypersesthetic 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 SPIl^AL COED 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 llesh, 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 hypersesthesia. 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 excentric^ pains, 
under pathological conditions ; though usually the gray sub- 
stance is only sesthesodic. 

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. 77 

oftener in diseases which directly irritate the sensitive roots, as 
especially in inflammation, caries, carcinoma of the vertebra?, 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 sesthesodic 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- 
siderably alter the excitability of the sesthesodic substance, and 
it is possible that pathological irritations act differently from 
our coarse mechanical or electrical stimulations. Hypersesthesia, 
when- present, may also assist in the production of such pains. 

Special notice is due to the 'pain in the hacJc, 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 moveifients, 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 cBstJietic 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 hyperjBsthesia 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., prodiice 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- 
tree ; 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 
hypersesthetic portions may also be very well ascertained by 
passing over them a sponge dipped in cold or hot water, or b}'' 
electrical examination. 

A brief notice of headache is necessary, which, not including 
accidental complications (fever, cerebral disease), is not a rare 

^ Compare also A. Mayer, Die Bedeutunj^ des Riickenschmerzes bei Erkrankungen 
des Ruckenraarks und der umgebenden Theile. Arch, der Heilk. I. p. 349. 18G0. 



GENERAL SYMPTOMATOLOGY. 79 

accompaniment of spinal diseases. A direct involvement of tlio 
sensitive fibres of the cervical plexus in the lesion of tlie 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. (/. 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 examming 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 oftsn be repeated, that the examination of these points 
should be as thorough and general as possible in all cases ; in many cases of difR- 
fcult 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- 
iquency. 

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- 
fing 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 AT^D 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 XL p. 436. 
VOL. XIII.— 6 



^2 ERB.— DISEASES OF THE SPIXAL CORD AXD 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, i)alsy 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 jxaraplegia 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 cervical is; 
a rather rare form. It oc<:urs 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. 83 

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 Jiemiparaplegla 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. 

h. 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 Ms 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 difiiculty 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. Sb 

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 ; t/ie case can- 
not, therefore, he 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 disturh- 
ances of innervation (under &), as proposed by Cyon,' 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 caus^. 

' Zur Lehre von der Tabes dorsualis. Berlin. 1867. 



86 ERB. — DISEASES OF THE SPINAL COKD 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 patlis 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, 

^ Central ataxia, caused by disease of the centres of co-ordination, may be placed in 
a class distinct from these forms. 



/ 



GENERAL SYMPTOMATOLOGY. 87 



I 

^^Bataxia, others, as Axenfeld, Landry, Leyden, Ruelile, Clifford 
^^Allbutfc, 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,' and has gained a very large 
number of supporters. We will briefi}^ 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. 
P 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 lirst 
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,'' 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 



> Die graue Degeneration der Hinterstriinge des R-M. 1863.— Zur grauen Degenera- 
tion der hinteren Ruckenmarksstrange. Virch. Arch. ^d. 40. 18G7.— Ueber Muakelsinn 
und Ataxie. Virch. Arch. Bd. 47. p. 321. 1809. 

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. Ley den does not fully admit 
their existence. I mj^self, 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 anesthesia 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 ancBS- 
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.' 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 TJeber einen Fall von allgemeiner Anasthesie. Arch. d. Heilk. XV. 1874. p. 44. 



GENERAL SY3IPT0MAT0L0GT. 89 

Remigius Leins, aged forty-two, in the year 1862, has suffered for twenty years 
with ansesthesia 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 powetful and per- 
fectly coirect ; 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 limls. 
In spite of this the patient can walk icithout support, quite fast and securely, foi' a 
good distance. If lie is ashed 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 tlic 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,' 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 Ley den'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 ig-ace of ataxia. 

^ This fact is also very decisive against the reflex theory of Brown-Sequard and Cyon. 



90 EKB. — ^DISEASES OF THE SPII^'AL CORD AND ITS ENVELOPES. 

It results without question from this, that the retention of 
sensibility is not necessary, in order that 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 indispensahle in perform- 
ing co-ordinate movements whicli Jiave 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 
rigid 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 suflacient 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. 

I 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 
I 



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, hut they are correctly carried out, while in 
ataxia proper tJte 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- 
niina, 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 will certainly conduce to clearness in the 
question of ataxia. The discovery by Goltz 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 

t 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 when 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 
I is, corresponding with the existing disturbance of sensibility. 
In fact, this symptom also is found chiefly or exclusively in 
cases of marked disturbance of sensibiliQr of the lower limbs ; in 
complete ansesthesia 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 hy 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 force. 

This may be the reason why atactic patients, without disturb- 
ance of sensibility, occasionally totter a little when 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- 



I 



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 aft'ections 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 we to look for th%se 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 CJiaracteristic 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 Sind 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 

^ Charcotj Lejons 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 EKB. — 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-fiuid 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,' 
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 

> Vol. XL 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.^ 

> 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.^ 

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 oi 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-Sequard^ and Charcot, most probably originates in the 
reflex manner, through irritation of the tendo Achillis.** In se- 

1 Volume XI. p. 368. 

' Journ. de la Physiol, de rhomme et des anim. I. 1858. p. 473. 
3 TJeb^r Sehnenreflexe bei Gesunden und Ruckenmarkskranken. 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 
reliexly, 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,' 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,' 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 ' 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 attackmay.be 
produced at any moment by irritating an epileptogenic zone, 

' Clinical Lectures on Diseases of the Nervous System. 1872-3. p. 216. 

' Erb^ Ueber einen wenig bekannten spinalen Symptomencomplex. Berl. klin. 
Wochenschr. 1875. No. 26. 

sCompt. rend, de la Soc. de Biolog. 1850. Vol. 11.; Arch, de Medic. Fevr. 185G; 
Researches on Epilepsy. Boston, 1856-57; Lectures 4>n the Physiol, and Pathol, of the 
Central Nervous System. Phila. 1860. p. 178 ; Arch, de Physiol, norm, et path. I, 1868. 
p. 317; 11. 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 conlirmation 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, Westphal ^ 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 Ley den ^ 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. Charcot^ 
mentions periodic epileptic attacks among the symptoms of com- 

* Ueber kiinstl. Erregung von Epilepsie bei Meerschweinchen. BerL klin. Wochen- 
schr. 1871. No. 38. 

' Virchow'a Archiv. Bd. 55. 

^ Lemons 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 Dumenil ^ seems especially convincing; andOppler-* 
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- 
merits, 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 ; tlms 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 



^ Gaz. des hopit. 1862. p. 470. ^ 

^ Riickenmarksepilepsie ? Archiv fiir 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 refiex 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 Ley den and von Wittich,* 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. Burckhardt ' 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 

' Virch. Arch. Bd. 46. p. 476, and Bd. 55. p. 1. 

* Die physiol. Diagnostik der Nervenkrankheiten. Leipzig. 1875. 



I 



f 



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. Eetardation 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 scarcel}^ need be said that these theories are greatly in 
need of more exact establishment and elaboration. 



/. 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. XI., 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 shown ^ the method which should be observed in seeking 

^ Erby Zur Lehre von der Tetanie, nebst Bemerknngfen iiber die Priifiing der elektr. 
Erregbarkeifc 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 degeneration ' 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- 

» See Volume XI. p. 427. 



I 



GENERAL SYMPTOMATOLOGY. 1()7 

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.^ 

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 
•esults. 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. 
I 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 
I 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 
i 



' Compare the observations of BurckJiardt in Physiolc^. Diagnostik der Nerven- 
krankheiten. pp. 3G4 and 270. 



108 ERB. — DISEASES OF THE SPINAL COED 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. 

cZ. Finally, it is permissible to entertain the case of reflex 
arrest^ in accordance with known physiological facts (see above, 
p. 51) ; but w^e 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 ; ^ 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 sMn ; 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 

* Vircliow^ GrBsammte 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 fseces 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, Yulpian, Dubois, 
and others) — namely, the reflex clonus which appears in the foot 
and lower leg when the foot is rapidly brought into dorsal flexion 
hy 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 sufliicient to set in motion the clonus ; the action may 
extend to the whole leg, and even to the other leg ; in its most 

I violent forms, tetanic rigidity of the legs alternates with convul- 
sive shaking, and we have the phenomenon described by Browii- 
I 



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 Actions ' 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 
Joff roy ' 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 hrain^ which 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 



' Arch. f. Psych, u. Nervenkr. Bd. V. p. 793. 
« Gaz. m4d. 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 (hypersesthesia), 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. Yaso-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 hypercemia and fluxion^ increased rea- 
\ness^ and elenation 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 
tor 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 sj^mptoms of palsy appear, there is a striking 
coldness^ great paleness^ and ancemia 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 limdity^ 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 hypersemia — we should recall 
the hundreds of experiments that have been made upon section 
of the cord ; every such section produces paralytic hypersemia 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, hsematomyeli- 
tis, etc.) will the fluxion and elevation of temperature be more 
permanent, and finally result in atony of the vessels. 

For the second group — ischsemic 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 hypersemia 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 hypersemia 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- 

( elusions respecting its exact locality. 
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 
I must necessarily speak of the different tissues separately, in our 
enumeration of these symptoms. 
The trophic disturbances of nerves aifd muscles have received 
great attention, especially in spinal diseases ; it has very lately 
VOL. XIII.— 8 



5. Trophic Disturbances. 



114 ERB. — DISEASES OF THE SPINAL COKD 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 tolemble 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 XI., 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 (atrophie muscul. progress, protopathique of Charcot) ; 
it appears to occur also in the sclerose laterale amyotrophique 
described by Charcot,^ 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 
ft 

' LeQons sur les maladies du systeme nerveux. 11. S6:. 3. fascic. p. 313 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 Ai'chives de physiol. norm, et patliol., by 
Charcot, Joffroy, Hayem, Duchenne, Vulpian, Pierret, Gombault, 
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 primar}^, 
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 
grsuy 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.' 

' Physiol. Dla^uosoik der Nervsnkuankli. p. 234. BeoL. 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-patlis ; 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- 
haidt " 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 Schultze ' 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- 

' Ein Fall von Bleilahmung. Arch. f. Psych, u. Nervenkrankh, Bd. V. 1875. 
p. 445. • 

■^ Log. cit. p. 271. 
2 Strieker's Handb, der Gewebelehre. p. 130. 



118 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 purel}^ 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.'' 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 tropJiic 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- 



^ Legons 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 

genei-ation, 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 
seen 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.^ 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 (Friedreich '). 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.^ 

Trophic disturbances in the structures of the sJcin 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 hair * 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 slcin itself 
are more important." First, and not infrequently, erythematoits 



' Arch. f. Psych, u. Nervenkrankh. Bd. V. Heft 8. p. 782. 

^ Ueber process. Muskelatrophie, ueber wahre und falsche Muskelhypertrophie. 
Berlin. 1873. Cap. VL 

3 Loo. cit. Bd. V. p. 780. 

* Jelly, Brit. Med. Jour. 1873. June 14. % 

^ Compare in particular the beautiful account given by Charcot in his CUnical Lec- 
tures. 



120 EKB. — DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

Spots and eruptions, wliicli 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. XL, 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 ia 
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 io\ greater and greater ex- 
tent, the gangrenous destruction goes deeper and deeper, laying 



122 ERB. — DISEASES OF THE SPINAL COKD AND ITS ENVELOPES. 

bare and including in its destructive operations tendons, fascise, 
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 hsematuria 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 septicsemic 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 chroniG 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 iappear 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 



I 

ft 

I 



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 tropliic. 
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 Trias se 
by fractures of the vertebrae, etc.), in acute myelitis, hsematomy- 
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 tlieir 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 thej'' 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. 



i 



GENERAL SYMPTOMATOLOGY. 125 

The conchisions 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 honefi often undergo trophic disturbances in spinal dis- 
ease. One of the commonest symptoms in the spinal paralysis 
of children is arrest of growth of hones. 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 pai^alysis 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 cpntrary, a swelling^ thickening^ hy- 
pertrophy of the hones 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 hrittleness of the hones 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 comua, 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 ii^ partly, no doubt, of ner- 




126 ERB. — DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

Charcot' s admirable researches ' have very recently placed 
before us an extremely characteristic affection of the joints, of 
manifestly nervous origin, chiefly associated v^ith 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 tahes. 

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- 



' Cf. Charcot, Arch, de Physiol. I. 1868; IL 1869; III. 1870 (with Joffroy)\ and 
Clinical Lectures on Diseases of the Nervous System. I. and II. Berxes.—BaU, Gaz. des 
Hop. 1868 and \m% .—Buzzard, Lancet. 1874. A.ug.22.— Wdr Mitcliell, kmer. Joum. 
Med. Sci. April. 1875. p. 339.— See also below, section on Tabes Dorsalis. 



I 

I 



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 cliildren, 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 %taU of the general bodily temperature, and the fever of spinal diseases, may 
here be mentioned. The local changes of temperatwe, limited to single extremities 
or parts of bodies, are accounted for by the vaso-motor disturbances 



128 EKB. — DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

Inflammations of the cord are accompanied by ferer, 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 ascendent 
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.* 

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- 
spinaUs (Erb), etc. Very lately, J. W. Teale^ 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. 



* For further information see the following : Wunderlich, Archiv der Heilkunde. II. 
p. 547; and III. p. 11^.— Brodie, Med. Chir. Trans. 1837. p. 416.— BillrotJi, Beo- 
bachtungsstudien iiber Wundfieber. 1862. p. 158. — Erb, Deutsches Archiv f . klin. Med. 
I. p. 175. 18Q5.—Tsc7iesc7iic7iin, Reichert und Du Bois' Archiv. 1866. p. 110.— Naunyn 
and Quincke, Reichert und Du Bois' Archiv. 1869. pp. 174 and ^21.— Quincke, Berl. 
klin. Wochenschr. 1869. No. 20.— IL Fischer, Cenbralbl. f. d. med. Wissensch. 1869. 
No. 17.— i^. Heidenhain, Pflueger's Archiv. 1870. p. 578.—Riegel, Ibid. Bd. V. 1872. 
p. 629. — Naunyn and Duhczanski, 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 Avell as in those of a 
pathological nature, there is a paralysis of certain paths which serve to restrict tlic 
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 tlie 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 
collai)se, but at other times they are doubtless due to excessive loss of heat from 
vaso-motor paralysis. 

6. Disturbances in tlie 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 



VOL. 



' Med. Times and Gazette. 1873. No. 1180. 
XIIL— 9 



130 EBB. — DISEASES OF THE SPINAL COIiD AND ITS ENVELOPES. 

tlie 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 
kidnej^s, secondary to the cystitis. Rosenstein ^ believes that he 
has obtained certain proof of this. .But Charcot," 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 spina] 
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. 

' Pathol, u. Ther. der Nierenkrankheiten. 2. Aufl. p. 287. 
' Lemons sur les maladies du systeme nerveux. 1872-3. p. 117. 



J 



GENERAL SYMPTOMATOLOGY. 131 



h. 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 hsematuria, 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 th^ 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 cTironic cases, which 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 symptom ; 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 Tieight 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 
tlie 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.' 



' 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, ftom the brain as well as from the 
centres in the lumbar cord, are close together, and therefore, as a rule, are affected 



136 EEB. — DISEASES OF THE SPIXAL 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 w^eakness 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 weaJcness of the 
sexual organs^ w^hich 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, anil 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,' 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 

* Lemons sur les maladies du syst. nerv. II. Ser. I. fasc, 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 
cliaracter. 

Of much more importance are the disturbances of evacuation^ 
which accompany many diseases of the cord, and are analogous 
to a certain extent with tlie disturbances of tlie 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 EBB. — DISEASES OF THE SPINAL COED AND ITS ENVELOPES. 



8. Disturbances of Respiration and Circulation. 

Our knowledge of tliis branch of the subject is confined to 
isolated points, and is applicable only in a slight degree to tlie 
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, while 
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. 

Tlie 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. Charcot^ notes a permanent 
acceleration of the pulse as a frequent symptom in ataxia ; he 
also speaks of a permanent retardation ' 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 



' Lemons, etc. 2. Ser. 1. fasc? p. 56. 
2 Loc. cit. 3. fasc. p. 137. 



142 ERB. — DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

and spinal diseases is very clear. The fibres destined for tlie 
dilatator pupillse 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 liypoglossus 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. ^., 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. 

HhQ 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. 

' Virchow-Hirsch's Jahresbericht f iir 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- 
bro-spinal 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 {anartliria). 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 train 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 ensenible. 

(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. XIIL— 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 nerv^ous 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.^ 

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.^ 



1 Virch. Arch. Vols. 26 and 37. 

^ KlLalk der Kuckenmarkskrankheiten. I. p. 170. 



148 ERB. — DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

My own opinion, based upon observations whicli 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.' 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 
symptoms 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 

^ Wundt^ Physiologie. 2d edition, p. 690. 



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. 

In 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 would 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 eocceaa — 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 Tiahitual 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 %mdue 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 ^Q 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 otlier 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 neigJiboring 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 EKB. — DISEASES OF THE SPINAL COED 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. 163 

jases in which paralyses and other disturbances of a probably 

jpinal 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. Hine ' saw an acute and fatal myelitis in a pregnant 

f woman, caused by violent emotion. Leyden reports a ease of 

[paraplegia caused by fear at the breaking out of a conflagration, 

md Kohts" tells of similar occurrences at the bombardment of 

;Strasburg. It is quite uncertain how we ought to interpret these 

[acts, and whether the psychical emotions act through the vaso- 

[inotor paths,* or whether they may directly produce a disturb- 

Lnce of the finer processes of nutrition in the central nervous 

elements. 

Certain intoxications present well-known spinal symptoms ; 
juch are poisoning with strychnia, arsenic, phosphorus, lead, 
ttc. Some of these poisons seem to have the power, when long 
;on tinned, to produce marked spinal diseases ; for example, 
lead. 

The local development of various infectious diseases^ acute or 
jhronic, 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 
Lttacks the cord and its membranes ; and of the acute infectious 
liseases there is one (meningitis cerebro-spinalis) of which the 
[chief seat is the pia mater cerebro-spinalis. To these must be 
idded the cases, not few in number, of spinal affections follow- 
big acute diseases (typhoid, acute exanthemata, intermittent, 
tintiuenza, 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 
local predisposition established by the acute disease. 
A very frequent source of spinal disease is found, lastly, in 



^ Remarks on Paralysis, etc., Dependent on Idea. Brit. Med. Jour. No. 6. 1869. 
p. 4^. 

^ Med. Times. 1865. Aug. 5. % 

3 Berl. klin. Wochenschrift. 1873. Nos. 24-26. 

^ In the third case of KohU 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 kidnej^s 
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, wiiich 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.' AVe have discussed this point in another place;* 
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. 
Eegarding 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 



^ For more minute information we refer the reader to the following : Leyden^ TJeber 
Reflexljihmung. Volkmann's Sammlung klin. Vortr. No. 2. 1870.— Lewisson, Hemmung 
der Thatigkeit der motorischen Nervencentren, etc. Reichert u. Du Bois' Archiv. 1869. 
—Feinherg, Ueber Reflexlahmung. Berl. klin. Wochenschrift. l^ll.—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,ljes paraplegies et Tataxie du mouTement. 1864. — W. G lUl, Med.-chir, 
Transact. Vol. 39. 1856. p. 195. 

2 See Vol. XI. p. 399. 



GENERAL DIAGNOSIS. 



155 



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 Roessingli ' 
^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's' laborious studies leave room for many questions 

tnd doubts. They by no means prove that a direct propagation 
[of the inflammation takes place along the nerve to the central 

►rgan : an extension hy 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 

>ody, without demonstrable affection of the central organs, the 
[only explanation is that which assumes a sort of reflex transmis- 

jion. The process may be essentially like that in which ex- 

)osure 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 

Loubt, and is in great need of further clinical and experimental 

itudy. 



C. General Diagnosis of Diseases of the Spinal Cord. 

When we encounter a complicated nervous affection, the first 
itep to be taken is a careful enumeration of the existing disturb- 
inces. The first and most important point is, to test all the de- 
)artments of the nervous system, and thus to ascertain the 
existence, the grouping, the succession, and the history of each 
jymptom. The diagnosis is made from the total of all these. 

The next question is always that of the location of the dis- 
',ase ; the organ affected; in nervous diseases, the choice lies 



' Bijdrage tot de Theorie der Reflexparalyse. Nederl.%Tijdschr. vor Geneesk. 1873. 
Bd. I. No. 53. See Virchow-Hirsch's Jahresb. for 1873. Bd. II. p. 44. 
* Ueber Neuritis migrans. Diss. Strassb. 1874. 



156 ERB. — DISEASES OF THE SPIRAL CORD A:N'D ITS ENVELOPES. 

between the brain, tlie medulla oblongata, tlie 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. 

When, 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 2^ 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 manj^ others. 

Experience goes still further ; it often gives us notice by a few 



GENERAL DIAGNOSIS. 



167 



symptoms, often by a single one, of a threatening or actually 

►resent disease of the cord, because the constant or almost con- 

jtant, coincidence between the symptom and the disease has be- 

jome 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 
lay 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. 
e must, however, here confine ourselves to naming a few points 
'liicli will assist diagnosis in given cases. 

In favor of a peripheral localization, the following circum- 
jtances may be mentioned : Limitation of the disturbances to 
lingle nerves or branches of nerves ; exact coincidence of the 
lotor, sensory, vaso-motor, and trophic disturbances with the 
[istribution of a peripheral nerve ; absence of retarded conduc- 
tion of sensation ; absence of all reflex action ; absence of weak- 
less of the bladder and the sexual functions, etc., in case the 
jacral nerve itself is not the seat of disease ; presence of great 
listurbance of the trophic function ; certain results of electrical 
lamination ; ^ 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 



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 parses thesise, retardation of 
the conduction of sensory impressions ; disturbance of certain 
automatic movements ; tlie 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 liard 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 (probabl}^ 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 thq^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. 

patliological 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. ICl 

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 ; &, alteration of disturbances of circulation (hyperemia 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 tjie very important group of 
external or pliysical remedies^ then speak of the very scanty list 

^ VOL. XIII.— 11 



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 by ischfemia ; 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, hypersemias, 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," 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,^ 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 ischaemia of the cord, lessening the retiex 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. 

' 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, 18G3. 



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. 

WarmtL 



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 



» Berliner klin. Wochenschr. 1870. No. 48. 



164 EEB. — 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, Chapm^'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. ISIB.—Seegen, Heilquellenlehre. 3. Aufl. 1862.— Helff't-TMleyiius, 
Handb. der Balneotherapie. 8. Aufl. 1874. — Durand-Fardel, De la valeur des 
eaux min6rales dans le traitement des paraplegics. Bull, de Thgrap. Mai 30. 
1857. — Gotth. Scholz, Ueber Ruckenmarkslahmung und ihre Behandlung 
durch Cudowa. Liegnitz. 1872. — Runge, Die Bedeutung der Wassercuren in 
chronischen Krankheiten. Arch. f. klin. Med. XH. 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- 
thermse ; 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 w^m 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, mucli sweating, increase of tissue-changes. 
Lukewarm baths (28°-82° 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. TMb 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 ma}^ 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- 



X 



GENERAL THERAPEUTICS. 1G7 

cises (by virtue of increasing the metamorphosis of tissue and 
changing the direction of the blood-current) upon coarse and line 
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' ; a5.0° [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 (048' ; 37.5-42.5° [99° to 108° Fahr.] ) ; 
Leuk (3,309' ; 39.0-50.0° [102° to 122° Fahr.] ) ; Baden-Baden (016' ; 
46.0-68.0° [115° to 154° Fahr.]); Plombieres (1,310'; 19.0-62.0° 
16Q° 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-haths, hot sand hatlis^ 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 hrine-'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. 



I 



GENERAL THERAPEUTICS. 1G9 

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 
rfuch 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 C02 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 SPIN"AL CORD AT^D ITS ENVELOPES. 

for clironic congestion of tlie cord, especially in ansemic persons 
and tlie subjects of nervous exhaustion ; only by exception in 
spinal meningitis, limiting tlieir 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 
ansemia 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'), Briickenau 
(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 ansemic 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, Bruckenaii, Meinberg, Elster, Eilsen, ISTenndorf, 
Liebwerda, Pyrniont, 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 



The 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 d,irect action upon the nervous system^ of an exciting or a depressing nature, can 
be produced by the application of cold 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 efEect 
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 ischaemia, 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 disti'ihv.tion 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, hypersemia of internal 
parts (F. Kichter) ; 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 hj^per- 
a^mia of the cord (washing and affusion of the back, stimulant 
sitz-baths, and long-continued moist cold wraps applied to the 
body), for fluxionary hypersemia (sogthing 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 
hatlis 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. 
Yery 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 bodilj'' 
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. Irritable, 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. 



* Zur Lehre von der Differenz der Wirkung dft 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 tJie 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-thermse 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-thermse, 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. HypercBmic states of the cord and its membranes. For 
passive hypersemia (so-called hsemorrhoidal tabes, etc.) the 
stimulant methods of cold-water treatment, steel-baths, and 
thermal brine baths are the best. The thermse are contra-indi- 
cated. For active hypersemia, 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 vf\t\\ 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 clianges 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 hypersemia, 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. XIIL— 12 

L 



178 ERB. — DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

cal tact and skill liave here a wide field for displaying them- 
selves. 



Electricity. 

Memah, Galvanotherapie. 1858. p. 443 et seq. Application du courant constant au 
traitement des n6vroses. Paris. 1865. — Rarike, Ueber krampfstillende Wirkung 
des constanten elektrischen Stroms. Zeitschrift f. Biologie. II. 1866. — Flies, 
Galvanotherap. Mittheilungen. Deutsche Kliuik. 1868. — Erh, Galvanotheraj). 
Mittheilungen. Arch. f. klin. Med. IIL 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. — UspensJcy, Einfluss des const. Stroms auf 
das R.-M. Centralbl. f. d. med. Wiss. 1869. No. d7.—BurcMardt, Ueber die 
polare Methode. Arch. f. klin. Med. VIIL p. 100. lS70.—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 was 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, ansesthesi^e, 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, Engelkeu, 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 ol)scure, 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 spigms, contractures, tremor, lanci- 
nating pains, anaesthesia, paralysis, etc. But these facts are not always beyond a 



ISO ERB. — DISEASES OF THE SPINAL COED 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,' 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 (hypersemia, stasis, exuda- 
tion) the explanation may be deduced from the powerful action 
of electricit}^ 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 tliat 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 
sufiicient 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 he 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 tlie cord. We shall see further on, 
however, that they are possible to a certain extent. 

As regards the special methods of applying the galvanic cur- 
rent ' 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 Stiihrer 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. 

' IlelmJioltz^ Verhandl. des naturhistor. med. Vereins zu Heidelberg. Bd. V. p. 14. 
1869. 

' The same principles apply for the most part to the use of faradism. 



182 ERB. — DISEASES OF THE SPINAL COPwD AND ITS ENVELOPES. 

The greatest density of current is found immediately under 
the electrodes ; the portions of tissue lying between them are 
not readied by any great quantity of the current, probably not 
enough to have any therapeutic effect ; hence it follows that the 
diseased regions should he 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 TIIEKAPEUTIC3. 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- 
emia. 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 sympatJietic. 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 
through 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 sMn. 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,* 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,^ probably acts like peripheral faradization. It consists of a stimulation 
of the skin and the muscles, extending over the whole body. 

Beard ' lias 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 * 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 

J Allg. med. Gentralzeitung. I860. No. 69. 

' Med. and Surg. Uses of Electricity. 1871. p. 186, etc. 

3 See Virchow-HirscJi's Jahreabericht fur 1871. I. p. 376, and 1873. I. p. 404. 

4 Berl. klin. Wochenschr. 1875. No. 51. 



I 



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 

may be indicated, under certain circumstances, just as in dis- 
eases of other organs ; thus, in severe acute inflammations, hy- 
persemias and stases, with the consequent irritation or paralysis. 
' General Mood-letting is seldom indicated, and is to be gov- 
erned entirely by general therapeutic principles. 

Local hlood-letting is best practised on the back, at both 
sides of the vertebral column, owing to the connection between 

I 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. 
f Derivatives. 

These formerly played a very prominent part ; scarcely a 
patient with disease of the cord escaped, even from the severest 

nof 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 tise 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, moxse, 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. 

' 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 eifect 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 
lore soothing frictions (with warm oil, infused oil of hyoscya- 
Lus, opium or belladonna ointment, etc.), and the more stimu- 
,ting and invigorating frictions (with French brandy, spirit of 
mts, of wild thyme or of camphor, liniment of ammonia or of 
imphor, etc.). 

2. Chemical Remedies — Internal Remedies. 

Cf. Nothnagel^ Handbuch der Arzneimittellehre. 1870. — Husemann, Handbuch der 
gesammten Arzneimittellehre. II. 1875. — Schueller, Ueber die Einwirkung eini- 

Iger Arzneimittel auf die Hirngefasse. Berl. klin. Wochenschrift. 1874. Nos. 
25 and 26. — Brown- Sequardy 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- 

ies 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, liow they act upon the cord and its 






188 ERB. — DISEASES OP 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,' 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 sucli 
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- 

» 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 hypersemia and paraplegia ; in 

I the latter disease it is especially useful (according to Brown- 
Sequard) when there is hyperaemia or chronic inflammation of 
the cord and its membranes, while it is contra-indicated in the 
absence of symptoms of irritation or hyperjemia. (Dose of 
aqueous extract of ergot, from one and a half to seven and a 
half grains (0.1-0.5) internally, from oi^-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. 

Atropi7ie (or helladonna) lias also a powerful action upon tlie 
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 silmr. 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 
freqiiently used. 

J Arch, der Heilkunde. II. 1861. p. 193, and IV. 1863. 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. Tlie 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, we 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 ^ect. 

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 ATs^D ITS ENVELOPES. 

doubtful. The dose is from one-sixtli (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. 
!N"othing 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 propliylactic 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 day, l?ut 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 COKD 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, ' 
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 R-obin ' 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, Yichy, Selters, 
etc.), seems to have a good effect in light cases. Clemens ' 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 a 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. 



' Berl. kUn. Wochenschr. 1875. No. 19. ZurWirkungder Salicylsaure. Jena, ISTo. 
p. 02. 

• Traitem. de la cystite ammoniac, par Tacide benzoique. Arch. gen. Nov. 1874. 
2 Deutsche Klinik. 1865. No. 27. 



GENERAL THERAPEUTICS. 185 

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. 



lOa 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.' 

It is often 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 OhserT^ations— 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 

» Hammond (Diseases of the Nervous System. 3d edition. 1873), foUowing Crassel 
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 l{fe^ tlie 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. Hypercemia of the Meninges of the Cord, and of the Cord 

itself 

J. P. Frarik, De vertebralis columnse in morbis dignitate. Select, opuscul. med. 
Ticin. 1793. p. 1.— OZ?tt)ier, Traits desmalad. de la mo6lle ^pin. IIL 6d. 1837. 
Tom. II. pp. 1-137. — Hasse^ Krankh. des Nervensystems. 1855; 2. Aufl. 1869. 
p. C56. — 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 
Riickenmarkskrankheiten. I. 1874. p. 362. — M. Rosenthal, Klinik der Nerven- 
krankheiten. 2. Aufl. 1875. p. 270. — Oaune, Epid6mie de congestion rhachid. 
Arch. g6n. Janv. 1858. p. 1. — A. Mayer^ Die Bedeutung des Riickenschmerzes 
u. s. w. Arch. d. Heilk. I. 1860. p. Zn.—Leudet, Arch. g6n6r. Mars. 1863. 
p. 257. — Desnos, Observat. de congestion m6ningo-spinale, etc. Gaz. m6d. de 
Paris. 1870. No. 14. p. 187. — Steiner, Fall von Ruckenmarkshyperamie. Arch, 
der Heilk. XI. 1870. p. 233. 

It is impossible to treat of hj^persemia of the spinal meninges 
without including that of the spinal cord. And it is hardly con- 
ceivable that any considerable hypersemia 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 hypersemia 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 hypersemia 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 



I. 

I 



200 ERB.— DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

may be due either to an increased ^ow of Mood, wlien it is usu- 
ally of an arterial character (active, arterial hyper CBmia, fluxion), 
or to arrest of the return current of blood, when it is usually of 
a venous character {passive hypercemia, mnous stasis). In 
practice, these two sorts cannot always be clearly separated. 

The frequency and importance of spinal hypersemia have certainly been over- 
estimated hitherto. This results chiefly from the fact, that in many fatal cases 
those who examined tlie body have been content with the mere macroscopic ap- 
pearance of hypersemia 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 hyperaemias 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 hypersemia. 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's^ 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 hypersemia. 

Active hypersemia has certainly some relations to hypersemia 
of the brain ; this follows from the fact that *he spinal arteries 
originate from the vertebrals. But hypersemia of the cord usu- 
ally recedes into the background, as compared with hypersemia 
of the brain, if the latter is present. 

Hypersemia of the cord and its membranes is produced — 

a. By functional stimulation of the cord. In this case, as 



Des h^morrhagies intrarhachidiennes. Paris. 1873. 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. 

1). By nutritive stimulation. Active hyperemia 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 hyper^emia. 

d. By collateral fluxion^ as in sudden suppression of the 
menses, in dysmenorrhoea, 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 
hypersemia. 

e. By the effects of cold. This is thought by Hammond to be 
the most common cause of spinal hypersemia ; 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 hyperfemia, and th^ latter has appeared epi- 
demically in a girls' boarding-school (Gaune). 

Of passive hyper cemia^ the most prominent cause is to be 



202 ERB.— DISEASES OP 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- 
ino- the death-agony ; also, in local venous stasis^ especially sucli 
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 hyperseraia 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 hyperse- 
mia; the arteries are emptied, the veins over-filled; we may 
find, on the one hand, a deceptive disappearance of hypersemia, 
which existed during life, and, on the other, a deceptive appear- 
ance of hypersemia, 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 hypersemia, in marked cases, 
can generally be detected with certainty. 

Active hypercemia 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- 
aUy increased, is muddy, and of a reddish color. 



HYPERiEMIA OF THE SPINAL MENINGES. 203 

In passive hypercemia 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 hypersemia the pia and arach- 
noid are thickened and opaque, and highly pigmented. 

These hypersemias do not always extend over the entire spi- 
nal canal, but often are confined to the cervical, or lumbar, or 
other portions. 

The cerebral hypersemia, and the diseases of other organs 
which cause spinal hypersemia, 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 parcesthesia (tingling, formication, etc.) 
and tearing pain in the extremities (especially the lower) are 
soon perceived. A slight hypercesthesia 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 ot the muscles, 
trembling 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 ATfD ITS EITVELOPES. 

the nervous apparatus, and doubtless belong principally to the 
condition of active hypersemia ; 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 Jieamness is perceived in the lower 
extremities ; slight ancesthesia 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 hypersemia 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 hypersemia 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 hypersemia 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 feoer in simple hypersemia of the cord. The pulse 
may be accelerated, or retarded, if the hypersemia 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 hypersemia 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 hyperemia ; 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 hyperfemia 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 developcji, 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 hyperemia 
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. 

Deathy as resulting from hypersemia 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 EBB.— DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

Diagnosis, 

A demonstration of the fact that hypersemia 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 hypersemia ; 
and if nothing is discovered af the autopsy of such patients, the 
cause, doubtless, lies in defective methods of observation. It 
certainly seems to us improper to interpret as simple hypersemia 
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 hypersemia 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 hypersemia. 

The diagnosis of hypersemia of the structures within the 
spinal canal is chiefly based upon the sUgJitness 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 nonfebrile^ usually short 
and favorable course^ and upon the success of treatment suited 
to relieve hypersemia. 

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 hypersemia 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 ancemia^ 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 hypersemia 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 hypersemia, 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 hyperjemia 
by derivation to the skin. A great variety of remedies may be 



208 EKB.— 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 hypergemias, 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, b}^ 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-hags 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 hypersemia (espe- 
cially coitus) must be avoided. 

2. Hemorrhages of the Membranes of the Cord—HcBmator- 
rhachis — Meningeal Apoplexy. 

Ollivier, \. c. 3« €d. L p. 465; H. pp. Q0-U7.—Ha8se, 1. c. 2. Aufl. p. 664.— 
Hammond^ 1. c. 3d edition, p. 440. — Leyden^ Klinik der Ruckenmarkskrank- 
heiten. L p. 367.— 3f. Rosenthal, 1. c. 2. Aufl. p. 274. 

Fallot, Hgmorrhag. mgningge spinale sousarachn. Arch. gCn. 1830. T. XXIV. p. 
438. — Boscredon, De I'apoplexie m6ning6e spinale. Tli^se. Paris, 1855. — Ch. 
Bernard, Observ. d'li^morrh. rhachid. Union m6d. 1856. No. G2,~Jaccoud, 
Les paraplegics et Tataxie. Paris, 1864. p. 232.— Z^/<!t, Beitrage zur Path- 



MENINGEAL HEMORRHAGE. 209 

ologie der Ruckenmaiksapoplexie. Diss. Bern. 1864. (Contains a copious list 
of authorities). — Roh Jachaon, Case of Spinal Apoplexy. Lancet. July 3. 18G9. 
— Hayem, Des h^morrhag. intrarhacliidiennes. Th^se. Paris, 1872.— i?a6M/>, 
Fall von Meningealapoplexie in Folge von iibermassiger Korperanstrengung. 
Berliner klin. Wochens. 1874. No. 52. 

Definition. — Hsematorrliachis implies any effusion of hlood 
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 PatJiogenesis. 

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 mrtehrce 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 EKB.— DISEASES OF THE SPINAL CORD AISTD ITS ENVELOPES 

apoplexies which so often occur during the molent spasms of 
epilepsy, eclampsia, tetanus, trismus neonatorum, etc. 

The bursting of hlood-mssels 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 hypersemia 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 sufllused 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 
fiuid 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- 



I 



MENINGEAL HEMORRHAGE. 211 

ducing hsematoma 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) hypersemic. 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 heglns suddenly and molently — 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 af^r a few hours or days. 

The characteristic symptoms are first those of excitement^ 
caused by physical irritation of the meninges with thek 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 tlie 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 ; hypersesthesia 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 mrtebral 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 cermcal 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 ;^af ter two or three weeks 
these symptoms usually disappear. 

In the majority of cases the disease runs a favorable course, 



214 EEB.— DISEASES OF THE SPINAL COKD 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 weeks or months a tolerably satisfactory cure 
may be completed. 

Death is not rare— of ten 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 th-Q 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 medullce 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 ansesfchesia ; the pain and tendency to spasm are less 
marked ; the latter is said by Brown- Sequard to be always ab- 
sent in hsematomyelia. 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 always 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 lirst 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 mouths, may be predicted. 

Treatment. 

Much can be done by way of prevention ; by treating hyper- 
semia of the cord, or spasms, by regulating the menses, the hem- 
orrhoidal bleeding, etc. 



216 ERB.— DISEASES OF THE SPINAL CORD Al^D 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 mrtehral column^ repeated powerful 
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. 

OlUvier, 1. c. II. pp. 272, 280. 3d ed.—Hasse, 1. c. 2. Aufl. p. 6S9.— Leyden, I. c. 
pp. 385-406.— if. Rosenthal, 1. c. 2. Aufl. p. 279. 

H. Koehler, Mouographie der Meningitis spin. 18Q1. —Ruehle, Klin. Mittheilungen. 
I. Bd. Zur Compress, des R.-M. Greifsw. med. Beitr. I. p. 5. 186d.—Trauhe, 
Deutsche Klinik. 1863. No. 20; Gesamm. Abhandl. ll.—MannTcopf, Berlin, 
klin. Wochenschr. 1864. Nos. 4-7.—^. Meyer, De pachymeningitide cerebro- 
spin. interna. Diss. Bonn. 1861.-7%. Simon, Ueber den Zustand des R.-M. 
in der Dementia paralytica. Archiv f. Psych, u. Nervenkrankh. II. 1869. p. 
137, 143, Ml.—R. E. Mueller, Ueber Peripachymeningitis. Diss. Konigsberg. 
1868.—^. Wagmr, Arch, der Heilkunde. XI. 1870. p. Z22.— Charcot, Pachy- 
mgningite cervicale hypertrophique. Soc. de Biol. 1871. p. 35 ; Gaz. m6d. de 



INFLAMMATION OF THE SPINAL DURA MATER. 217 

Paris, 1872. No. 9 ; Le<?ons, etc. 2« sCrie. 3« fasc. p. 246. I^IL—Joffroy, De la 
pachymen. cervic. hypertroph. Paris, 1873. 

The mtiammations 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 — Perip achy meningitis. 

Definition. — TJiis disease consists of inflammation of the 
Older surface and layers of the dnra 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 hed-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 cellu]^r tissue (H. Mueller), and 
all possible forms of chronic inflammation of the abdomen and 



I 



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 sujipuration 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 
OUivier ' seems to us of still more importance. In Mannkopf's case the secondary 
nature of the peripachymeningitic lesion could only be made extremely probable. 
c 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 Leyden ^ 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 Anatomy. 

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 vertebrse, 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 (Euehle). This consists either of pus, either 

' 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, 
anemic ; 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 in^)ortant are as follows : 

Pain in the hack^ various in seat and extent, according to the 



220 EKB. — DISEASES OF THE SPINAL CORD A]^D ITS ENVELOPES. 

location of tlie disease. Stiffness of the vertebral column^ which 
renders it difficult and painful to sit up. Tension andjerJcing 
in various groups of muscles. Excentric pains ^ in the form of 
a girdle or sliooting into the extremities ; sensation of a cord tied 
around ; formication and slight hyperesthesia 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 DUKA MATER. 221 

cora. The most difficult thing will always be to distinguish it 
irom 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 inliamed. 

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 we 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. 

h. Pacliymeningitis Interna {HypertropMca et Hcemorrhagica). 

Definition. — Inflammation^ cliiefly 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 tissTie ; 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 durse 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, Ley den 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 DUBA 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 hsematoma 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 hj pains. 
These are very violent in the back of the neck and head, the 



224 EKB.— 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 fi-ee. 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 ancBsthesia 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 vdth the 
affection in these parts, or not until a very late period. In severe 
cases complete ^ara^Ze^m with marked anaesthesia, _2?araZ2/5^^ 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 slow 



INFLAMMATION OF THE SPINAL DURA MATER. 225 

meningitis^ with periods of exacerhation, 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. XIIL-16 



226 EKB.— 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.— OUivier, I c. 3d ed. XL p. 233.— 5aa««, L c. 2. Aufl. p. 690.— 
Hammond, I. c. 3d ed. p. iU.—Leyden,!. c. pp. 406-443.— Jf. Rosenthal, 1. c. 
2. Aufl. p. 283. — Koehler, Monographie der Meningitis spinalis. Leipzig. 1861. 
(Contains a great deal of valuable matter and very full references.) 

Klohss, Diss, de myelitide. Halis. 1820. Huf eland's Journ. XVL 1%2^.— Funic, 
Die Ruckenmarksentzundung. Bamberg. 1825. — Henoch, Schmidt's Jahrb. Bd. 
28. 1846. — Evans Reeves, Diseases of the Spinal Cord and its Membranes. 
Monthly Joum. of Med. 1855. p. 506; Edinb. Med. Journ. 1855-56. pp. 120 
and 302. — Noetel, De meningitide spinali. Diss. Berlin. 1861. — BeaumeU, 
M6niDg. spinale, suivie de roideur des extr6m. inf^r. Gaz. des Hop, 1861. No. 
129. — Brown- Sequard, Lectures on the Principal Forms of Paralysis of the 
Lower Extremities. London. 1861. p. 66, etc. — Gamerer, Ueber Meningitis 
spin, chron. und deren Differentialdiagnose. Wiirtemb. Correspondenzblatt. 
XXXII. l^Q2.—Jaccoud, Le9ons de clinique medicale. 1867. pp. 372-420. — 
Vulpian, Note sur un cas de mining, spinale et de sclerose corticale annulaire 
de la moelle 6p. Arch, de Physiol. IL p. 279. 1869.— Liouville, Etude anato- 
mo-pathologique de la m^ningite c6r^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. LVL p. 62. 1873.— Brulerger, Fall 
von Meningitis syphil., etc. Virch. Arch. 1874. Bd. 60. 

Compare also von Ziemssen, Meningit. cerebrospin. epidemica, in Vol II. of this 
Cyclopa;dia, 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 tlie 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 Yulpian 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- 

' Berl, klin. Wochenschrift, 1876. No. 1. Dr. Schultze has permitted me to view 
his microscopical preparations bearing on this poiijt, and it is my agreeable dnty 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 sw^ollen 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 oedematoas 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 w^hat 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- 
fects 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, tlie 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 2i febrile inflammation of the soft 
membranes (pia and arachnoid) of the cord^ beginning with mo- 
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, 

^\iQ 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 neigJiboring 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 tlie spinal 
cavity, and there setting up an inflammatory irritation ; and Anally, 
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 Weber ' and Bierbaum ' are of comparatively little force as 
evidence. The most important cases are three by Koehler/ 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.^* 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,^ also, gives a 
case of this kind, without making any exact statements legarding the frequency 
of its occurrence. It is certainly much more frequent than has been supposed. 

' Deutsche Klinik. 18o2. No. 34. p. 380. 

« Journ. f. Kinderkrankh. Bd. 26. p. 355. 1856. ■* Loo. cit. p. 127. 

. » Ibidem, Bd. 32. 1859. p. 409. » Loc. cit. p. 438. 



INFLAMMATION OF THE SPINAL PIA MATER. 231 

Among the somewhat doubtful 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. 

Gaun6 ' 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 hypercemia and commencing exuda- 
tion. 2. A stage ot serous or purulent fibriiious exudation, and. 
3. A stage of resorption or termination in some other way. The 
one most commonly observed is the second ; the lirst 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 
— ^ — — % 

» 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 hypersemia 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 PI A 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 intil- 
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 
hypersGmic, often opaque to a considerable extent, and covered 
with thin, librino-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 oedema- 
tous, at other times more hyperfemic, 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. SchultzG 
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. SchuUze 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 
^K 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- 
iuf were found at all parts of the transverse section. In the vessels of the cord ko 
essential chano-es 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 often 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.— XGutQ 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 hack, 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 b}^ muscular tension and contracture, may extend 
to the entire column, and produce a^^ery close resemblance to 
tetanic spasm. 



236 ERB.— DISEASES OF THE SPIIfAL COllB Al^^D 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 skm 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 hypercBsthesia, so that every 
touch, every movement of the patient, calls out expressions of 
pain, even in cases where the consciousness is quite impaired. 
Hyper (Bsthesia of the muscles seems to be equally demonstrable 
in many cases. 

The reflex actimty 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 fceces 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 wutli 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 Huctuations. 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 hack. 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 ET^^VELOPES. 

irritation of the nerves of the pia and dura, to inflammation of 
the posterior roots, and the consequent hypersesthesia, 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 
necTc, 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 'ooluntary 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 MATEPw. 239 

an interesting manner by two cases in wliicli Le3'^den' 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 Jiypercesthesia, 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 ancBsthesia 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- 



Klinik, etc. L 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- 
natmg 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 dj^spnoea, 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.* 

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 
% 

» Cf. Erb, Arch. f. klin. Med. L p. 185. \%^.-^Leydeji, Klinik, etc. I. p. 431. 
VOL. XIII.— 16 



242 ERB.— DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

for liimself 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 t?ie impll 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. 
XIL). 

The fe^er 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 sMn (herpes, roseola, petechise, 
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- 



I 



INFLAMMATION OF THE SPINAL PI A 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, 
Anally, 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 
And 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, prsecordial 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 [^. 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 disetse 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/<^er, pain and stiffness 
in the hack,, stiffness of the hack of the neck,, muscular spasms^ 
hyper (Bsthesia and par (Bsthesia of the skin,, pains in the limhs^ 
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, hj^peraesthesia 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 ; hyperesthesia 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 hypersesthesia 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 rlieumaUsm of the 
muscles of the lack, which is characterized by its light and 
favorable course, the local painfulness of the muscles, absence of 
pain in the limbs, of hypersesthesia 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 tuherciilous 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, anjfimia, 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 paraiysis, signs of general loss 
of strength, high fever, continually rising temperature and in- 



248 ERB.— DISEASES OF THE SPINAL COIID 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 favor able 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, 

1^0 effective propJiylactic 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 



I 



ITTFLAMMATION OF THE SPINAL PIA MATER. 240 

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 w.hen 
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 sJcin. 
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 iudividual 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 recommeijded 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 tlie back or extremities, in tlie 
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, hypersesthesia. 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 uot 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 



I 



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 paclcing of the whole body often 
soothes and brings sleep. 

For liyper^esthesia 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 thQfeoer^ 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. 
jH 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 
Ion Chronic Meningitis and Myelitis. 
■ 



252 ERB.— DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

h. Leptomeningitis Spinalis Chronica. 

By this term we understand a non-febrile inflammation of 
the soft membranes of the cord, slow 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. 

Miologij, 

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. 263 

caries of the vertebrae, chronic periostitis of the same, carCiiioma, 
and other new formations of the vertebrae or the spinal mem- 

i 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 tlie 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 

tof 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 hypersemia of blocked circulation, with 
H 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 hypersemia, 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 ^n abundance of spinal 
fluid. 



254 ERB.— DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

The hypersemia 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 kiteral columns, 
and reaching to a great distance. Tlie 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 



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 ^y special importance. 

The commencement is marked by occasional abnormal sensa- 



256 ERB.— DISEASES OF THE SPINAL COED AND ITS ENVELOPES. 

tions in the lower limbs, gradually increasing pain, and some 
stiffness of the hack. 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 necTc 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 parcBsthesice, 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 hyper cesthesia, 
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 hack, 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 fuW 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 parsesthesiae, not seldom mixed with liyper- 
sesthesia ; 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. XIIL— 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 anses- 
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 ansemia and hydrsemia, 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 diflficulty 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 tlie 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 
has 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 tke chronic inflammation of 
the spinal membranes need not be a continuous and limitless 



260 ERB.— DISEASES OF THE SPINAL CORD AT^^D 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 sMn 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 jastly 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 sj'-philis exists. Nothing remarkable is to be expected 
from ergotin and belladonna. If we have cause to suspect the 
existence of an abundant serous exudation, we may emplo}'- 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 cures 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-haths^ and hot safkl-haths. 

Of the effect of the galvanic current in chronic spinal menin- 



262 ERB. — DISEASES OV 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 hksten 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. 

OUivier, loc. cit. 3d ed. p. 517.— Cruveilhier, Anatomie pathol. livraison. XXXIL 
pi. 1. XXXV. pi. YI.—Hasse, loc. cit. 3. Aufl. p. 731.— Rosenthal, loc. cit. 3. 
Aufl. p. 34:Q.—IIa7n7nond, loc. cit. 3d edition, p. 517.— Leyde7i, loc. cit. I. p. 
Ud.— Virchow, Geschwiilste. I. pp. 386, 433, 514; II. pp. 93, 130, 345, 354, 
^Ql.— Charcot, Le9ons sur les mal. du syst. nerv. II. Ser. II. fasc. Paris. 1873. 
—Jaccoud, Les parapldgies et I'ataxie du mouv. Paris. 1864. p. 2d6.—Brown- 
Sequard, Lectures on Paralysis of the Lower Extremities, etc. 1861. p. 93. 

Athol Johnson, Fatty Tumour Connected with the Interior, etc. Brit. Med. Journ. 
lS57.— Virchow. Bosartige, zum Theil in der Form des Neuroms aiiftretende 
Fettgeschwiilste. Virch. Arch. 1857. XI. p. 281.— Trauhe, Flinf FiiUe von 



Virchow's Archiv. 1867. Bd. XL. 



TUMORS OF THE SPINAL MEMBRANES. 263 

Ruckenmarkskrankheiten. Charitg-Annalen. IX. 1861. (Gesamm. Abhandl. 
n. b. p. 994.) — Wliipham, Tumour of the Spinal Dura Mater, Resembling 
Psaramoma, etc. Trans. Path. Soc. XXIV. 1873. p. l^.—Benj. Bell, Tumour 
of the Pia Mater, etc. (fibro-nucleated growth). Edinb. Med. Journ. Oct., 1857. 
p. 331. — Loewenfeld, Fascrig. Sarkom an d. Wurz. der zwei ersten Sacralnerven 
links. Wiener med. Presse. 1873. No. 31. — L, Benjamin, Neurom innerhalb der 
Riickenmarkshiiute. Virch. Arcii. 1857. XL p. 87. — Seitz, Pseudoplasma 
medull. spin. Deutsche Klinik. 1853. No. 37. — Charcot, Hemiparai)lCgie d6ter- 
min^e par une tumeur, etc. Arch, de Phys. 18G9. II. p. 291. — Baierlacher, Zur 
Symptomatologie der Geschwillste am R,-M. Deutsche Klinik. 1860. No. 31. — 
Meschede, Sarkom am R.-M. Ibid. 1873. No. 32. — 2'h. Simon, Tumor im Sack 
der Dura spinal., die Cauda comprim., etc. Arch. f. Psych, u. Nervenkr. V. 
p. 114. 1874. — Simon, Paraplegia dolorosa. Berl. kiln. Wochenschr.- 1870. Nos. 
35 and 36. — Davaine, Traite des entozoaires, etc. Paris. 1860. p. 666. — Bar- 
tels, Echinoc. innerhalb des Sacks der Dura spin. Deutschcs Archiv. f. klin. 
Med. V. p. 108. 1869. — Behier, Compress, de la moglle Cpin. par un kyste hy- 
datique. Arch. g6n. Mars. 1875. p. 340. — TF^^^p/ia/, 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, Ley den, 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 Yirchow, 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. 

.^ See Virclu)w, Geschwiilste. II. 



TUMORS OF THE SPINAL MEMBRANES. 205 

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.' 

Carcinom,a 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 wliicli originate in 

' See Vol. XL p. 599 et eeq. 



266 ERB.— DISEASES OF THE SPINAL CORD AND ITS ENVELOPES, 

inflammatory, liemorrTiagic, and other processes in the spinal 
membranes or the neigliboring 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 
hematoma of the dura mater, originating in pachymeningitis 
interna hsemorrhagica. 

The sypMlomata which are occasionally found in the spinal 
membranes are of a somewhat similar nature (Wilks, Yirchow). 
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 cellulosce 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. 

EcMnococcus 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 clmical 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, fiat, grayish and translucent, atroj)hied and degenerated, 
according to the duration and extent of the process. 

The cord itself always experiences some degree of compres- 
sion, which may cliange it to a Hat, 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- 
perfemia, etc.) of various extent. In correspondence with this, 
an increase of tlie 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 foun?l on the bodies of those 
dead of meningeal tumors— bed-sores, cystitis, extreme maras- 



268 EKB.— DISEASES OF THE SPINAL COllD AXD ITS ENVELOPES. 

mus, changes of internal organs, etc. — will be described here- 
after 

Etiology. 

The causes of meningeal tumors are usually obscure. Ifc 
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 /r/^^^, may give the impulse 
to the formation of meningeal tumors. 

Finally, xertehral 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-woim. 

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, parcesthesice, ancesthesice, 
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 



TUMOIZS OF THE SPINAL MEMBRANES. 2G9 

follows, and increases ; it begins as a progressive paresis, often 
unilateral, like Brown-Sequard's palsy, but usually making 
rapid progress across tlie 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, Avhen 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 titmor, 

2. Symptoms of irritation and compression of the cord itself^ 
and of consecutive myelitis (myelitis hy 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 EPwB. — DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

Bymptoms 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. 

FarczsthesicB 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 twUcMngs, spasms, may appear at the be- 
ginning. 

These symptoms of irritation are almost always accompanied 
by distinct, sometimes very active pain in the hack, 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, parse sthesise, 
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 



TUMOPwS 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 tlie 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 variousl}'' 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, Ley den, Brown- Sequard) show that violent 



272 ETIB.— DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

pain of that kind in tlie 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 tlie 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 hed-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 
/6?)er— 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 pio- 
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, paralysis 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 OUivier, 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. 

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. XIIL— 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 difficult}^. 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 chiefly 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. 

AVhen 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 tills 
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, in most cases, to define the precise seat of the ticmor, 
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 
wliich 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 : ths 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 tlie 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 anaBsthesia, 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 tlie 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 ansesthesia 
occurred. 



276 EliB. DISEASES OF THE SPINAL COKD AND ITS ENVELOPES. 

Prognosis, 

It follows from wliat was said of tlie course, that tlie 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. AVe 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 patienfs 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 directl}^ Cystitis and bed-sores are to 
be treated upon general principles. 



Addendum. 

Anatomical Changes in the Spinal Membranes^ without Clint' 

cat 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. Tliesc 
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, Virchow * 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 iriitation. Tlie 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 osteophytic elevations are also seen in the same 
membrane ; the deposition of brain sand [corpp. arenosa] in the exudations with 
thickening of the dura (pachymeningitis arenosa ^) 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.^ 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 externa ^) 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- 



' Loc. cit. 3. Aufl. II. p. 466 seqq. » Virchow, ibidem. II. p. 117. 

2 Gesehwiilste. II. p. 92. •» Ibidem. II. p. 120. 

^ VirclioiD, Gesehwiilste. I. p. 175. 



IIYPERJEMIA OF THE CORD. 279 

corpuscles, etc., its iacrease 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 sj^inal 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 w^ould 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 i\\Q 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 JS'o. 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. Hyper cBmia of the Cord, 

We have already spoken of this, as indistinguishable from 
the same condition of the membranes, either by anatomical or 



ANJEMIA OF THE CORD. 281 

clinical tests ; and would refer the reader to the complete account 
given on page 199 et seq. 



2. AncBmia of the Cord, 

Basse, loc. cit. 2. Aufl. p. 652. — Hammond, loc. cit. 3d edition, p. 396. — K. Rosen- 
thal, 1. c. 2. Aufl. p. 290. — Leyden, 1. c. II. p. 21.—Jaccoud, Les paraplCgies 
et I'ataxie du mouvement. Paris, 1864. p. 293 et seq. 

N, Stenon, Element, myologiae specimen. Flor. 1667. — Kussmaul and Tenner, Un- 
ters. iiber Ursprung und Wesen der f allsuchtartigen 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, Lehrbucli der Nervenkrankh. 2. Aufl. I. 3. p. 2. — Earth, Oblitfirat. 
complete de Taorte. Arch. g6n. 1835. VIII. p. 26. — Oull, Paraplegia from 
Obstruction of the Abdom. Aorta. Guy's Hosp. Rep. 3d series. III. p. 311. 
1858. — Gumings, Paraplegia from Arteritis. Dubl. Quart. Joum. May, 1856.— 
Panum, Zur Lehre von der Embolic. Virch. Arch. XXV. 1%Q2.— Brown- 
Sequard, Lectures on the Diagnosis and Treatment of the Principal Forms of 
Paralysis of the Lower Extremities. London, 1861. — Sandras, Traitfi des mala- 
dies nerveuses. Paris, 1851. — Service of Orisolle : Paraplegic apr^s une m6tror- 
rhagie considerable. Gaz. des hop. 1852. No. 108. — Moutard-Martin, Para- 
pl(ig. caus6es par les h6morrh. ut6rines ou rectales. Soc. m6d. des hop. 1852. 
Union m6d. 1852. — Abeille, Etudes sur la paraplegic indCp. de la myelite. 
Paris, 1854. — Van Bervliet, Observ. de parapl6g. chlorotique. Annal. de la soc. 
med. de Gand. 1861. — Mordret, Traite prat, des afEect. nerveuses et chloro- 
anemiques. 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 — ischcemia ; or, 

&. Deficiency of blood in the cord, owing to the diminution of 
the total amount of bloody and had crasis (oligsemia, hydrsemia, 
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 acd otherwise, originating in 
the anaemia, and obscuring the spinal symptoms. 



282 EKB. 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 
nutriiioii 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 which 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 weaJcness of 
the heart ; and finally, an undue excitability of the xaso-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- 
plegics 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 



ANEMIA OF TJIE CORD. 283 

referred by a^x the earlier observers to a peripheral disturbance of the nutrition of 
nerves and muscles. Kussmaul and Tenner liave, however, shown that anaemia of 
the cord leads to i)alsy much more rapidly than anaemia of the nerves and muscles. 
Scliiffer has tested the question again, and has decided that ansemia of the cord 
itself is certainly the immediate cause of the j)alsy, 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 ischajmic paraplegia} 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, 

TJiromhosis and embolism of gwen spinal arteries can only 
lead to quite circumscribed isclisemia, owing to the numerous 
arterial supplies wliicli 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 ansemia 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 ischsemia ; 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-S6quard 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-SC'quard'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 day«,' *nd 
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 ischsemia 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- 
minisJi the total amount of hlood^ or cause a decided change in 
its composition, with a tendency to oligocythsemia, 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 anemia 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 shows, 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 GrisoUe, Moutard-Martin, Abeille, Landry, and others. 

A similar effect is produced by great loss of hlood, 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- 

. — _ — _ — . , 

' See Nothnagel, Vasomotorische Neurosen. Deutsches Arch, f . kUn. Med. II. 



ANEMIA 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 semiHuent, 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 dilferent 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 ischsemic form, furnish us abun- 
dant information. 

When the dorta is compressed^ motor and sensory palsy of 
the legs imniediately 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, Ley den, 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 



ANEMIA 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 ischsemia of the cervical part. Clo- 
sure of both vertebral arteries might be followed by ischa^mia 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 isclicBmia of the cord must be 
the same, but they can hardl}^ 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 tlirorribosis 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 weaJcness — 
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 AKD ITS ENVELOPES. 

The sensibility/ is usually intact ; but parsestliesia of every 
sort, pain, and hypersesthesia or slight ana3sthesia occur. Tlie 
re/lex actions are often exaggerated ; only in the severest cases 
are they depressed. The sphincters do not seem to be usually 
affected, unless the severest ansemia with full paraplegia has 
been developed. 

At the same time, the most marked symptoms of general 
ansemia 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 hypersemia 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. 



ANiEMIA 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 ischsemic 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 cmtsal indication. If we succeed 
in removing the causes of spinal ansemia, 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 hlood 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, [^V to -J- of a grain], three times a day), or, still better, in 
combination with phosphorus (extract of nux vomica 0.02 [J of a 
grain], phosphide of zinc 0.006 [tV 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 — Hai- 
matomyelia {Hcematomyelitis) — Hwmorrhagia Medullce 
Spinalis — Spinal Apoplexy. 

Compare the repeatedly quoted works of Ollivier (II. p. 167), Jaccoud ( p. 251), 
Hasse (p. 667), Hammond (p. 440), if. JRosenthal (p. 392), and Leyden (11. p, 
64). Also 

E. Levier, Beitr. zur Pathologic der Ruckenmarksapoplexie. Diss. Bern, 1864 (con- 
taining all the older cases). — Hayem, Des hgmorrhag. intra-rhachidiennes. Paris, 
1872 (list of cases complete to that date). — Breschet, H6matomy61ie. Arch, de 
m€d. XXV. 1831.— OrisoUe, Rev. hebdom. des progr. des sci. mCd. 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. — Oendriuy De 
I'apoplexie rhachidienne. Gaz. des h6p. 1850. No. 48. — M. Trier j Hosp. Med- 
delelser. Bd. IV. 1852 (quoted in Levier. Schmidt\s Jahib. Bd. 78. p. 293). 
— Lebeau, Cas d'hSmatomy^lite. Arch. belg. de m6d. milit. Janv. 1855. — 
Barat-Dulaurier^ Sur les h^morrh. de la moBlle. Th^se. Paris, 1859. — Duriau, 
De I'apoplexie de la moelle 6pin. Union m6d. 1859. Nos. 20-25. — Broton- 
Sequard, Paralysis of the Lower Extrem. p. 86. 1861. — Colin, Hfimorrh. de la 
moelle. Soc. m6d. des hop. 1862. — Mouton, Consid. sur ThSmorrh. rhachid. 
Th^e. Strasb. 1867. — Schuetzenbet'ger, Apoplexie spinale. Gaz. med. de Strasb. 
1868. No. 5. — Koster, De pathogenic der apoplex. medull. spin. Nederl. Arch. 
voor Geneesk. IV. p. 426. 1870. — Gorsse, De Th^morrh. intramCdull. etc. 
Thfese. Strasb. 1870. — C. 0. Joerg, Fall von Spinalapoplexie. Arch. d. Heilk. 
XI. p. 526. 1870. — Bourneville, H6morrh. de la mocJlle 6p. Gaz. m6d. de Paris. 
1871. No. 40. — Lioumlle, H6matomy61ie avec angvrysmes. Soc. de Biolog. 
1872. — Erh, Ueber acute Spinallahmung. Arch, fiir Psychiatric u. Nerven- 
krankh. V. 1875. Beob.5. p. 779.— R Eichhorst, Beitr. zur Lehre von der Apo- 
plexie in die Riickenmarkssubstanz. Charitg-Annalcn I. (1874) p. 192. Berlin, 
1876. — E. Ooltdammer, Zur Lehre von der Spinalapoplexie. Virch. Arch. Bd. 
66. 1876. 

Definition. — The above titles include any Jcind 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 hsematomyelia 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 hsematomyelia there 
is simply a myelitis complicated with hemorrhage (myelitis cen- 
tralis hsemorrhagica) ; 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 jpr mar?/ 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 hlood-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 tlte 
resistance of the walls of the Uood-xessels, 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 
•fever, 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 wliite 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 oi 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 hsematoidin, 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 neui^glia. 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 hypersemia, 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, 
hypersesthesia 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 Al^D 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 (Boiirne- 
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 ancestliesia 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 xaso-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 hack 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. Parsesthe- 
sise 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 hed-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 sequelse. 

It follows, of course, that these severe disturbances are always 
accompanied by marked fever. Chills occur, pysemic and septi- 
c^emic 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. 

ill 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 large effusion, but must undergo various 
modifications according to the seat, size, and cause of the hemor- 
rhage. It seems supei-fluous 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, pyaemia, 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 l^ast 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, hypersesthesia 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 hgematomyelia 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 y 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 hsematomyelia 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 hsematomyelia, 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 ischcBmic 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 EPwB.— DISEASES OF THE SPINAL COKD AND ITS ENVELOPES. 

Prognosis, 

Although we by no means agree with Charcot's view of the 
nsually fatal character of hsematomyelia, yet the prognosis is 
almost always very serions. 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. Ketained 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 seo 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 hatJis, warm 
springs, and hrine haths, 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, Crusliing or Tearing of the Cord {Acute Trau- 
matic Lesions). 

Ollivier, loc. cit. I. p. 246. — J. Hahn, Paraplegics par cause exteme ou traumatique. 
Th^se. Strasb. im^.—Leyderiy loc. cit. I. pp. 310 and 321 ; II. pp. 84 and 
139. — M. Rosenthal^ 1. c. p. 331. — E. Gurltj Handbuch der Lehre von den 
Knochenbriichen. II. 1. ISGi.—Lente, Recovery from Fracture of the Spine. 
Amer. Journ. Med. Sci. 1857. Oct. p. 3Q\.—Riiehle, Greifsw. med. Beitr. 18G3. 
I. p. 12. — Vogt, Liihinung der vasoniotorischen Unterleibsnerven nacliRiicken- 
marksverletzung. Wflrzb. med. Zeitschr. VIT. p. 248. lS(i(^.—Qu^7lcl^e, Einigc 
Falle excessiv hoher Todestemperatur. Berl. klin. Wochenschr. 1869. No. 
29. — Fronmueller, sen., Die Ruckenmarkszerreissung. 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. Lei^jzig, 



306 ERB.— DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

1871. Beob. l.—Meder, Lowered Temperature in Injury of Spinal Cord. Med. 
Times. 1873. I. p. 154.— Steudene?; Zur Casuistik der Herzwunden (Schuss 
auch durclis R.-M.). Berl. klin. Woclienschr. 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 
7)ertebrcB. 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 vertebra. 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 
Gurlt. 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, ^he 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, senere 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, Yogt). 

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 hypersemic, 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 
fibro-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 yet certain how 
far the nerve-elements are restored. 

2. Crushing of the cord produces a softening 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 sof^^ning 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. 
Actiial 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- sub stance 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. HemorrJiagic 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 
(5) 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 hy cutting^ 
or stahhing^ in the nelglihorhood of the splne^ 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, 
hyper (Bsthesia (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 rejiex 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, hypersesthesia 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. 813 

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 
l)reside 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 involuntaiily, and usually 
unperceived; thus, Steudencr 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- 
bra} 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 downwards. 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 tiie 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 THE SPmAL COED AND ITS ENVELOPES. 

io-norant of the jji-ecise 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 be<^inninw 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 sliould 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 
mj^elitis 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 tlie 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.' 

' Cf. Erb, Ueber acute Spinallahmung bei Erwachsenen. Arch, f . Psych, u. Ner- 
venkraukh. V. p. 785. Beob. VI. 



316 EBB.— 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 lirst 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 absolutel}^ 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 hsemato- 
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 J;earing of the cord, death 
is almost absolutely certain, sooner or later. But there are excep- 



318 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 vertebra, 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 



kion of bed-sores and cystitis, which usually destroy life. Two 
jontradictory 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 OUivier (I. p. 387), Basse (p. 735), Jaecovd (Des parapl6gies, 
etc.), Brown-Sequard (Paralysis of the Lower Extremities, etc. 1861), M. Hosen- 
thai (p. 313), Leyden (L pp. 213-311 ; IL p. 147). Also 

Charcot^ De la compress, lente de la moelle 6p. Le9ons sur la mal. du syst. nerv. IL 
SSr. II. fasc. 1873. — Bouchard, Compress, lente de la moelle. Dictionn. ency- 
clop. des sc. medic. II. Ser. Tom. VIIL p. 664. 1874. — C. Hawkins, Cases of 
Cancerous, etc., Disease of the Spinal Column. Med. Chir. Transact. XXIV. p. 
45. l^il.— Vogel und Dittmar, Deutsche Klinik. 1851. Nr. 38.— 7Vaw5«, 5 
Falle von Rilckenmarkskrankheiten. Charit6-Annalen. IX. 2. p. 129. 1861. — 
Buehle, 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.—^. 
Joffroy, Cas de fract. de la colonne vert. Arch, de Phys. I. p. 735. 1868. — 
Leudet, Curability des accid. paralyt. cons4c. au mal vert. M6m. de la Soc. de 
BioL 1862-1863. — Michaud, Sur la mining, et la my61ite dans le mal vert6br. 
Paris, \S>11.— Charcot, Anat. pathol. et trait, de la parapl. liee au mal de Pott, 
Gaz. mSd. 1874. No. 49. — A. Courjon, Parapl6g. dans le mal de Pott. Paris, 
1875.— -E7. 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. XL 3. p. 54. \%m.—M. Rosen- 
thal, Wien^v med. Presse. 1865. Nr. 42-45; Zeitschr. f. prakt. Heilk. 1866. 
Nr. 46-51. Tripier, Du cancer de la colonne vert^br. 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 thi« in common, that a power 
acting from without upon the cord {and the nerm-roots) com- 



320 EPwB. — DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

presses it xery 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 wliether the inira-medallary 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. 
It 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 vertehral 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 Jcyphosis^ which may give rise to a bend- 
ing arid 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 
epace 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 vertebrcB 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 v^rtebr^e 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 ^r^^ 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 w^hether compression may exist alone without 
myelitis, and may of itself produce the paraplegic symptoms, or 
wdiether 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 ischsemia produced by compres- 
sion, an ischsemic softening, but w^ consider it as the direct 
consequence of the irritation of compression acting upon the 



324 ERB. — DISEASES OF THE SPIN-AL CORD ATfD 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 mj^e- 
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. 

Tlie meninges are often hypersemic, 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, hypersemic, 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, tfiese changes usually appear 
confined to clearly defined portions of the transverse section, and 



326 EBB. — DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 






in these may be followed up and down almost tlie 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 






Pig. 5. 
Compresninn of the 
Dorsal Mfdulla. 
Diffuse myelitis at the j . 1.-1 1 . . 

point of compression Qisappearance or the nerve-elements, piffmenta- 

(4); the right half is . ^^ > ^ & 

SieTefr^At^vf se^n" ^^^^^ ^^^' "^^^^ process Is Importaut in explain- 

'Ss?"i3'^^^^ ing many later symptoms. 

SSSndiig ^deJSiemi In severe cases all these processes make prog- 

tion of the lateral col- , , . , . 

unina, to the lumbar ress ; there are consecutive changes m remote 

cord (6—7). After Mi- j. , , , / 

*'**"'*• parts 01 the body (muscular atrophy, degenera- 

tion of peripheral nerves, cystitis, bed-sores, etc.), which hasten 
the fatal result. 



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 SPITS-AL CORD AND ITS ENVELOPES. 

livable 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 hypercBsthesia of tliose 
portions of skin which correspond to the distribution of the pain 
may be added, but often disappears to make room for a corre- 
sponding ancBsthesia, often limited to a few islands of skin — or 
both conditions may subsist together. Severe pain in the hack, 
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 sJcin. 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 
parcesthesia 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 twitcliings, 
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 SPII^AL CORD AI^D 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 ; tlie 
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 ancesthesia 
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 paralj^sis 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 
offaradic 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, ev^i 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 lirst quite unimpaired. 

All this is perfectly intelligible when referred to the gradually 
increasing compression of tlie 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- 
Jialf 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 cermcal 
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 reliex 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 parcBstliesice 
(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^ which 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 
parsesthesia, a peculiar dyscesthesia, which is produced hy 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 ancestJiesia 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 Madder 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 the}' 
'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 fascia? ; 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, hyperfcmia 
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 obseryed 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 patelloe 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 patellae 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 
twitcliings 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 S3^mptoms 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. 

TropJdc 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 attacJcs 
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.), constit4^te decisive proof that this 
is the seat of disease. In this form, also, one or several of the 

VOL. XIIL— 22 



338 EKB. — 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 lurribar 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 vertebrse— 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 hypersesthesia, 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, IN'o. 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 mrtebral 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 



I 



SLOW COMPRESSION OF THE CORD. 339 

the ordinary process of severe paraplegia, bed-sores, py^emic 
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 tlie 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. 

Potfs 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. 
Kosenthal) ; 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 wrtebral 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 hypersesthesia 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, ^yq, 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 y(iung, pretty well-nourished 
persons, in whom the disease of the bone has not assumed con- 



842 EKB. — 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 spondylartJirocace ; 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 tlie 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, moxse are great favorites. The wliite-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 pressitre 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 Myelitis). 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 MedullcB Spi- 
nalis, 

Abero'ombie, Diseases of the Brain and Spinal Cord. German tr. by G. v. d. 
Busch. 1829. p. 520.— OUivier, L. c. I. p. 488.— Leyden, L. c. XL p. 92. — Holmes, 
System of Surgery. Vol. 11. p. 238. — Clemens, Die Erschlitterung des R.-M. und 
deren Behandliing 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 Riickenmarkslahmung 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 TieigM 
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 Mow from a heavy body in motion^ striking the spine or 
trunk, acts in quite the same way. 

A sudden sliock 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 EKB.— 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 liglitning 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. Fischer ' 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 tlie 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. 

' Volkmann's Samml. klin. Vortr. Nos. 10 and 27. 



348 EKB. — 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 vary 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 : 

^ On Concussion, etc. p. 120. 




CONCUSSION OF THE CORD. 



349 



a. General and -eery severe syirvptcmis at tlie 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. 

5. Severe symptoms at the moment of receiving the injury. 
Cure in a short time. Slight shocTc. 

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- 
lyzed and immovable for about a week, when improvement gradually commenced, 
so that the jDatient 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. Si^hincters 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 hy 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 varions 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. Parsesthesia 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 lier seat. She immediately felt a severe pain in the hack of the neck 
and loinSj with gi'cat iceakness, but was able to go into another room. In a quarter 
of an hour she vomited^ the pains increased^ there Tras 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. Vertebraj 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. Urine 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 praecordial 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 tlie 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 i«hort time. No ataxia. Given movements are easily 
executed with the legs, but without force. Arms and head quite free from symp- 
toms. No difllculty 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 vertebras, 
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- 
suit doubtful. 

At the first moment — e. p'., 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, parses thesia of all sorts, anaesthesia 
of various degree and location, and often hypersesthesia. 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 liave acquired a great practical importance in connection 
with the latter {railway-spine of the Englisli). 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 hsematomyelia and hsematorrhachis. 
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 hsematomyelia, 
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 
hsematorrhachis and to concussion ; but the initial symptoms 
are different, being usually more severe in concussion. In hse- 
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 wWiout 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 vertebrse, 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 
tliat 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 severity 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. 
AVe 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 hypersemia 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 sequelcB, 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 Irrita- 

tation, 

Stiehel, Rust's Magazin. XVI. p. 550. 1823.— C7. Brown, On Irritation of the Spinal 
Nerves. Glasg. Med. Journ. No. 2. Mi\y!l828.—T. Pt-idgin 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. 
— Hinterherger, Abhandlung liber die Entziindung des R.-M. u. s. w. Linz, 
1831. — W. and B. Griffin, Observations on Functional Affections of the Spinal 
Cord, etc. London, ISM.— Ollimei\ I.e. IL p. 209.— Stilling, Physiologische und 
pathol. etc., Untersuch. uber die Spinalirritation. Leipzig, lS4:0.—Tuerck, Ab- 
handlung i'lber Spinalirritation. Wien, 1843. — G. Hirsch, Beitr. zur Erkenntniss 
und Heilung der Spinalneurosen. Kouigsberg, 1843. — Eisenmanji, 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. 18Q0.—Bomberg, Nervenkrankheiten. 3. Auflage Bd. L p. 184. 1853.— 
Wunderlich, Handb. der Pathologic und Therapie. 2. Auli. IIL p. 28. 1854.— 
Axenfeld, Des nevroses. Paris, 1863. p. 2SL—RailcUffe, Reynolds' System of 
Medicine. IL p. 640. 1868.— ^^are^ and Rochwell, A Practical Treatise on the 
Uses of Electricity, p. 350. 1871. — Hammond, 1. c. p. 397. ISl^.^Leyden, 1. c. 
IL 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, oq 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 "spinal imtation,'' 
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 occui*s, 
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. 



380 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 
'Miysteria," nor general "nervousness," nor any known ana- 
tomical form of disease, sufficiently accounts. 



Etiology. 

^\q female sex is mry 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, 
Jiereditary 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 oipain 
in the hacJc^ 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 hypersesthetic, 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 vertebra? 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 feft in various parts of the body : 



362 ERB. — ^DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

neuralgiform pains, now in tlie upper extremities, or the occi- 
put, or face ; now in the trunk or viscera, assuming the form of 
various visceral neuralgise ; 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 parcBstlieslce 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 ancestJiesia ; 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. 

Yaso-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 xegetative 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 irritahility 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 Inmhar 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 ?ause, and so does improve- 



364 ERB. — DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

merit ; 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 which 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. 36ff 

in the cord in spinal irritation. Such hypotlieses are numerous, 
but we have not the time to spare for them. The contradictory 
views that are entertained by authors are well illustrated by tlie 
fact that Ollivier and (in part) Stilling also refer spinal irritation 
to hypersemia of the cord, while Hammond affirms with the full- 
est conviction that it is due to ana3mia 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 hypersemia 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 hypersemia and ansemia 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 
ansesthesia ; 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 shouM bear in mind the following : 



366 ERB.— DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

The diagnosis from Tiypercemia 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 hypersemia, 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 paralytic 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 hypersesthesia in the 
vertebral region, but there is the girdld 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 vertebrse 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 
oi 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 fr^uent repose in the horizontal 



368 ERB.— DISEASES OF THE SPINAL COPvD 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 
moxse 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. 



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. — Rassel, Cases of Paraplegia induced by Exhaustion of the Spinal Cord. 
Medical Times. Oct. 31, 1863; May 25, 1867.—^. Bourbon, De I'influence du 
coit et de ronanisme dans la station sur la production de paraplCgies. Paris, 
1859. — Leyden, 1. c. II. p. 22. — Erh, Bericht iibcr die Versammlung mittel- 
rhein. Aerzte am 18. Mai, 1875, in Heidelberg. Betz' MemorabiL 1875. 5. 
Heft. 

Introduction and Definition.— YiY^ry 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 COKD A^"D 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 unquestionahle dis- 
turbances of the fund ions of the cord exists 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. YIII. of this Cyclopaedia. 



' Zur Pathogenese der Hemikranie. Vircli. Arch. Bd. 59. p. 335. 1874. 
' Ueber Ruckenmarkslahmungen 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. ^., great mental and bodily overwork, with disturb- 



372 ERB.— DISEASES OF THE SPINAL COKD 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 onl}^ 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 afEected. 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 ^aiTi in the 
hack^ 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 paraisthesia 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. 

Gold 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- 
We. 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 Madder 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 ansemia, 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 lias 
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— i\i\& 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 symiitoms. — 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 
ansemia. 

He was ordered quinine andiron; 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. — Tlie disease usually begins in 
a very gradual and insidious way, yet 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. Kel apses 
are not uncommon, and are often occasioned by fresh injurious 
exposures of a trilling 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 a functional 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 E KB. —DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

the most would be, perhaps, a disturbance of circulation, liyper- 
gemia, 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 w^ay, and it must remain an open 
question. 

It seems most natural to recur to jine dlsturhances 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 lixed 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 
hetween 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 purel}^ 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 parsesthesise 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 liypercemia of the cord we may distinguish spi- 
nal neurasthenia by the absence of pain, of cutaneous hyper- 
sesthesia, of symptoms of motor irritation, and probably also by 
the long duration of the disease. From passive Jtypercemia^ 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 parsesthesise 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 tlie 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, 
tlie use of a moderate cold-water cure, well graduated to the 
patient's strength and sensitiveness, deserves especial mention. 
Rubbing down wath 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 powder of their lower extremities. 
It is w^ell 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 Tj^rol. 

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 d 

the preparations of iron and quinia ; their forms and combina- vO 
tions ma}^ be very various. It is often useful to combine them, in iv 
the way recommended by Hammond (see the previous section),^ \ 
with small doses of nux vomica or strychnia; but it is welH 
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 EBB. — 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, 

Earless, Diss, inaug. de myelitide. Eilangen, 1814. — Klohss, De myelitide. Halae, 
1820. — Funk, Die Riickenmarksentzundung. Bamberg, 1825. — A/hers, Beob. 
auf d. Gebiete d. Pathol. I. S. 73. imQ.—Ollivier, 1. c. XL S. 302. 3. Aufl.— 
Ahercromhie, Krkh. d. Gehirns u. R.-M. Deutsch von G. v. d. Busch. 1829. S. 
474. — Cruvellhiery Anatom. patholog. 1835. 42. Livr. 32 u. 38. — Marcel, Diag- 
nost. et nature du ramolliss. blanc d. 1. moelle epin, Gaz. m6d. d. Paris. 1854. 
No. 52.— Evan Beeves, Acute Myelitis. Edinb. Med. Jour. L 1855, 1856. p. 305 
and 416. — Oppolzer, Acut. Entzlind. mit part. Erweichung d. R.-M. Spitalszeit. 
1860. No. 1-3. — Brown 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. — Mannkojrf, Fall von acut. Myelit 
Borl. klin. Woch. 1864. No. 1 ; u. Tagebl. d. 40. Vers. Deutsch. Aerzte u. 
Naturf. etc. 1865. — Jaccoud, Des paraplegics et de I'ataxie du mouv. Paris, 
1864. — Armin. Levy,D2 myelit. spinali acuta. Diss. Berolin, 1863. — Frommann, 
Untersuch. iiber 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, Ueber Myelit. etc. Diss. Berlin, 1867. — Fb/«m, Meningo -myelite 
aigue. occas. p. 1. froid. Gaz. d. hop. 1865. Nos. 25-30. — Harley and Loclhart 
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. 123.— flas5d, Krkht. des Nervensyst. 2. Aufl. S. 696.— ^am- 
mond, Diseases of the Nervous Syst. 3d edit. p. 456. — M. Rosenthal, Klinik 
d. Nervenkrkht. 2. Aufl. S. 2^Q.~Leyden, Klinik d. RUckenmarkskrkht. IL S. 
115.— Dujardin-Beaumetz, De la myelite aigue. Paris, 1872. — O. Hayem, Des 
h^morrhag. intrarhachid. Paris, 1872. — Hayem, Deux cas de my61. aigue cen- 
trale et diffuse. Arch, de Phj^siol. VL p. 603 1874.— C. TFesip^a?, Ueber fleck- 
weise oder diseminirte Myelitis. Arch. f. Psych, u. Nerv. IV. S. 338. 1874.— 
Bernheim, Artikel : Myelite im Diet. Encyclop. des Sci. medic. IL s6r. T. VIII. 
p. 674. I^IL—Dudienne (de Boulogne), Electris. localisCe. 3c 6dit. 1872. p. 
459. — ffallopeau, Etudes sur les myelites chron. diffuses. Arch. g^nSr. d. med. 
6. s^r. T. XVIII. u. XIX. 1871, 1872.— a Lange, Fall von Myel. interstit. chron. 
Hosp. Tid. 14. Aarg. S. 35. Virchow-Hirsch, Jahresb. pro 1871. II. S. 77.— 
Frommann, Fall von Wirbelcaries u. Degenerat. des R.-M. Virchow's Arch. 



MYELITIS. 383 

Bd. 54. 1872.— i2<?&. W. TMits, Case of Myelitis. Med. Times. 1871. May 13. 
—JIallopeau, Etude d. 1. scler. diff. periependymaire. Gaz. mCd, 1870. Nos. 
30-35. — Vulpian, Cos d. uiCnm'^. spin, ct d. scK-rose corticale annulaire, etc. 
Arch. d. Physiol. II. p. 279. ISGd.—Martineatt, Inflammat. aiguc gCn6ral. 
de 1. substance grise d. 1. moelle. Union mdd. 1874. Nr. i^O.—Feinberg^ 
Ueber reflect. Gefiissnervenlahmung u. Riickenmarksaffection nach Ueber- 
firnissen der Tiiiere. Virchow's Arch. Bd. 59. 8. 270. 1S7A.—Schuep2)el, Fall 
von allg. Aniisth. Arch. d. Ileilk. XV. S. 44. 1S7^.— Troisier, Deux cas de 
iC'sions sc]6r. de la moello 4p. Arch. d. Physiol. V. p. 709. 1872.— Joffroy, 
Faits experim. pour servir a I'histoirc de la myClitc. Gaz. m6d. de Paris. 1873. 
Nr. 30. — Charcot, Sur la tumCfact. des cellules nerv. motrices et des cylindres 
axiles, etc. Arch. d. Physiol. IV. p. 93. 1872.— C. Zan^e, Bidrag til etc. Hosp. 
Tid. 16. Aarg., Schmidt's Jahrbb. Bd. 1G8. S. 23S.— Raymond, My 41 de la 
rSgiou dorsale. Gaz. mCd. 1874. No. 9. — F. Raymond, MyClite do la rCg. cer- 
vicale. Progrfes m6d. 1875. No. 17. — Gerin-Iioae, My6l. aigue g(iu6rali86e. 
Union mGd. 1875. No. 90. — Langhuns, Myelitis d. grauen Commiss. etc. bei 
Lepra anaesth. Virch. Arch. Bd. 64. 1875. — Hamilton, On Myelitis, etc. Quart. 
Joum. of Microsc. Sci. Oct. 1875. p. 334. — Pierret, Note sur un cas de my€l. 
t rechutes. Arch. d. Physiol. VIII. p. 45. 1876. — Laveran, Obs. d. myCl. centr. 
Bubaigue. Ibid. VII. p. 866. 1875.— P. BaumgarterL,'E\QQni\\. Fall von Paralys. 
ascend, acut. mit Pilzbildung im Blut. Arch. d. Heilk. XVII. S. 245. 1876.— 
Lewin, Paraplegic 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. 



Introdnction. 

Myelitis constitutes unquestionably the most extensxve and 
important chapter in the pathology of the medulla spinalis. 
Any 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 EIIB. DISEASES OF THE SPINAL COED AND ITS ENVELOPES. 

impossible to define accurately the boundaries of inilammation 
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 Inflamma- 
tion. They regard tabes dorsalis, the so-called lateral sclerosis, 
multiple sclerosis, progressive muscular atroph}^, 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. 

We 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, 
Aretseus, 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 



£86 ERB.— DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

nally 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 
Komberg'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 we 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, not 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 
acute 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 acnte 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 studj^ are inju- 
Ties, 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 OUivier, 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 onl}^ 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 Hay em, 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 agens 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/ Here, we will 
only mention the fact that Feinberg ' has recently succeeded, by 
varnishing the skin of rabbits, in exciting an acute affection of 
the spinal cord, which at all events closely resembles intiamma- 
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 tliose 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, tliat softening has 
been generally, but very incorrectly, identified with acute in- 
flammation. That the two processes are not identical, is evident 



' See Vol. XI. and Vol. XII. 

3 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 axia—difuae 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- 
^ersa. 

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 
^i^t^iXiGQ— 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 hyper csmia 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 hypersemia, 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- 
semia. The inflamed spots are alniost 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. Hay em 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 hypersemia and inflammation. 

In preparations hardened in cliromic 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 dift'usion 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 hypersemia. 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. 396 

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 liarden- 
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 co*d, which were previously either 
healthy or very slightly changed, and when it propagates itself 



396 EllB.— 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 wliich 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 hypersemia, 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 yqtj 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, 



398 EPwB.— 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 advaticing 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 frameworlci^ \oos>enQdi 
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. "Yhe^^e 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 cord, 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. .Toffioy 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 Feinbcrg 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 liistological 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 publislied in his " Klinik 
derRiickenmarkskrankheiten," is only fragmentary. He experimented on cats and 
dogs, 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 whicli 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, multiplica- 
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 tins 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 inflamm?ition of the gray sub- 
stance, more or less diffuse hypersemia 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 hcemorrliagica^ which Hayem designates 
by the term TicBmatomyelitis. 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 
exclusivel}^ 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 hemofrhages and in a state of catarrh ; 
in the severest cases it is infiltrated with diphtheritic exudation 

VOL. XIIL— 26 



402 EIIB.-DISEASES OF THE SPII^AL 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 devdopment, 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 : parsesthesise, 
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 pyelonephritis, and extensii^e bed-sores which are often acute, 
set in early. All these complications may, however, be absent. 



404 ERB.-DISEASES OF THE SPIIfAL 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 sloicer and less molent 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 
iriyelitis ; 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 paralj^sis, 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 parses- 
thesise 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 hypersesthesia 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 dysses- 
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 EPwB.— DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

making their appearance, though they too may be permanently 
absent. The anesthesia 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— ansesthesia 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 hypersemic 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 paraesthesise and ansesthe- 
sise 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 
m 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 witliin 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 yef. 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 SPIKAL COKD 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 cliapter. 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 mj^elitis. 



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 cedema 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,* 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 nerms 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 



' 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 excitahility 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 COKD 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 septicsemia or 
ursemia. 

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 vi^ith 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, /(52Jer 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 attain^ 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, 
hsematomyelitis, etc.) the paralysis rapidly ascends, symptoms 
of asphyxia appear, and death takes place in afeio 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, followedby decubitus, fever, cachexia and exhaustion, and 
the patient succumbs after several loeeTcs or Tnonths. 

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 EKB.— DISEASES OF THE SPINAL COED 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 completely 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 w^ith 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 Ticematomyelitis 
(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 tlie 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, parsesthesise, 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 defonuities. (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. XIIL-27 



418 ERB.— DISEASES OF THE SPIXAL CORD AND ITS ENVELOPES. 

Acute myelitis is very frequently complicated with meningitis, 
myelomeningitis acuta. The addition of meningitic changes to 
the mj^elitic 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 hypersesthesia, the diffused pains, etc., 
while the contractures, the severe paralytic symptoms, the paraly- 
sis of the 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 hyperesthesia, etc. (Compare also p. 245.) 

The differentiation of hcernatomyella, 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 TicematorrliacMs, 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 anfesthesia, usually characterize hsematorrhachis 
sufficiently. (See p. 214.) 

It is scarcely possible to confound acute myelitis with liyper- 



420 ERB.— DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

(Bmia of the cord. The absence of fever, tlie 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 
np 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. AVe 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 paralysis, 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 ol favor- 
able portent. 

The nature of the etiological inliuences 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 propliylactic 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, *'Iloob Laf- 
fecteur," etc., when the stage of the disease indicates them. 

As a rule, however, the patients do not come under obseiTa- 
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. Notliwithstanding this, however, in the face of so 
dangerous a disease, the energetic employment of all antiphlo- 
gistic measures is decidedly indicated. Active local hloodletting 
from the spine may be practised by means of leeches or wet cups, 
applied several times in succession ; Chapman's ice-hag, from 
which Tibbits saw very good results, may be employed ; the 
trunk may be enveloped in, or t7ie hack 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 speciflc nature. For the same reason, small doses of 
calomel, frequently repeated, may be tried, and eventually also 
iodide of potassium, in sufiicient doses. Brown- Sequard recom- 
mends, on the ground of physiological experiment, the employ- 
ment of ergot and helladonna (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 Yichy 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 nof the employment of energetic 
derivatives to the skin over the spinal column, is permissible and 



42-i 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 
usino- 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 Lewin' and Hitzig^ 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. 



' Deutsche Klinik. 1875. No. 11. 

' 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, every 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 haths (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 pyelitis. 

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 ever}'' 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 suh finem, and the impending cardiac paralysis, the usual 
irritant remedies are almost powerless. The ansesthesias, para- 
lyses, atrophies, etc., which persist after the cessation of the dis- 
ease, are most satisfactorily treated by electricity. 



E 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 whicli are designated as chronic in- 
liammation in its narrowest soiise, 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 : catcMng cold^ which is one of the most im- 
portant, and certainly one of the most frequent causes ; often- 
repeated exposure, long sojourn in Samp, 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 comjpression 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 
myeUtis, is still doubtful. The question whether the myelitis, 
which develops in persons Buffering 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 
myelitis. 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. Langlians 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 ofperi- 
plieral 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, chropic 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 AT^D 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 correctl}^ 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 nnfrequently 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 u'sually 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 hand-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 varjdng 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 tlie 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, periplieral sclerosis, 
or the sclerose corticale annulaire of Yulpian. 

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 iind 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 fibrillse are developed within the old, enlarged neuroglia 
fibres and cells. They form finally a dense tissue, composed of 
delicate, fibrillated fibres, usually <irranged in long wavy bun- 
dles. The neuroglia- cells enlarge, and their nuclei undergo 

VOL. XIIL-28 



434 ERB. — DISEASES OF THE SPINAL CORD AND ITS ENVELOPES. 

proliferation; they become more mimerous 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 statib 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 j 
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 distributian 
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 Jissue in general, of greater 
density. 

3. Last stage. — Almost exclusively connective tissue ; a dense 



436 EKB.— 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. Yery 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. Joff roy 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 ofE from their nutritive centres. 
(Compare our description and explanation of this in Vol. XL, p. 412.) It is true 



MYELITIS. 437 

that tliis 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 
sijinal 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 this 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 i