horns or nerve roots of the cervical region are diseased, the same condition
occurs in the muscles of the arms. Bed sores over the buttocks or heels
develop as a result of trophic disorders and the skin becomes dry and hard
and the nails brittle.
Vasomotor changes result in mottling of the skin, oedema and hyperi-
drosis; the surface temperature of the paralyzed limbs is often subnormal.
The electric reaction of the muscles, when these are atrophied, is changed
and the reaction of degeneration is present.
Cervical myelitis is characterized by paralysis of greater or less extent in
the arms and complete paralysis of the legs; atrophy of all or only certain
738 DISEASES OF THE NERVOUS SYSTEM.
groups of the muscles of the arms while the muscles of the legs remain of
normal size may be noted; these latter, however, may become flaccid from
disuse. The deep reflexes of both sets of limbs, or only of the legs, are
exaggerated and vesical and rectal disturbances occur.
In dorsal myelitis, while the upper limbs retain their normal state, the legs
are paralyzed and may be the seat of sensory disorders. If the anterior
cornua are involved there may be muscular atrophy and reaction of degener-
ation; vesical and rectal disturbances develop and, whi\e the cutaneous reflexes
usually remain normal, the knee jerk is increased and ankle clonus is present.
In lumbar myelitis the arms are not affected; the legs are paralyzed and
atrophied and the reaction of degeneration is observed; rectal and vesical
disturbances are present and both cutaneous and deep reflexes are absent.
The prognosis. Rarely cases of very rapid development, causing death
in a week or ten days, may occur. The usual course of the disease is chronic
after a more or less acute onset and continues for months and often years.
The chances for improvement remain good up to about a year and a half
after the beginning of the symptoms; they are less favorable when motor
disturbances are marked than in cases evidenced chiefly by sensory disorders;
they are worst in cervical and best in dorsal lesions. Death may result from
exhaustion or concurrent disease.
Treatment. During the acute stage the patient must be kept in bed,
the bowels are kept regularly open by means of laxatives and the pain and local
congestion may be relieved by the application of leeches or wet or dry cups
to the spine. If cardiac excitement or hypertension of the arterial system
is present aconite or glyceryl nitrate should be given. After the acute symp-
toms have subsided, moderate doses â€” gr. viii to x (0.52-0.66) â€” of potassium
iodide should be administered and if there is the least suspicion of syphilis
as a causative factor the patient should be immediately put upon a course of
mercurial inunctions and increasing doses of potassium iodide. The tonics,
iron, strychnine and quinine are useful as adjuvants. If there is no response
to the antisvDhilitic treatment, sodium arsenate gr. yV (0.006) three times a day,
elixir of phosphorus i drachm (4.0) three times a day or silver nitrate gr. \
to ^ (0.016-0.032) three times a day may be tried. A necessary precaution
in the administration of these drugs is a period of intermission every two
to four weeks depending upon the tolerance of the patient. Gold chloride
has been recommended but there is doubt if this or any of the other sub-
stances mentioned above can ^materially influence the course of the disease.
Very important considerations are the prevention of cystitis and bed-sores.
The disturbances of the bladder may be mitigated by the internal adminis-
tration of tincture of hyoscyamus 15 to 20 minims (i.o to 1.33), oleum santali,
hexamethylenamine and the various balsams; when catheterization becomes
necessary the utmost attention must be given to the asepsis of the procedure.
Bed-sores may be guarded against by means of attention to the cleanliness
of the back and limbs and of the bed, by powdering the parts with talcTim,
tannic acid or lycopodiimi, by bathing with alcohol and astringent solutions
and by the use of the water bed when necessar}'. In the later stages of the
disease it is preferable to empty the bowel by irrigation rather than by purga-
tives. Electricity in the form of galvanism should be employed, the electrodes
being applied to the vertebral column over the seat of the lesion. Both
faradism and the continuous current should be administered to the affected
nerves and muscles of the limbs and electric treatment of the bladder may
accomplish good. Massage is an excellent means of exercising the paralyzed
muscles and preventing wasting, it also improves the circulation and the
general condition of the patient.
Hydrotherapeutic measures should be employed with care, and while
benefit may attend the use of warm (85Â°-9oÂ° F. â€” 29.5Â°-32. 5Â° C.) full baths
or cooler (75Â°-8oÂ° F. â€” 24Â°-27Â° C.) half baths, both with thorough frictions,
cold baths and applications are not advisable. The baths may be more
stimulating if salt is added and sojourns at the various hot springs of this
countr}' or Europe, when the patient is able to travel, are often beneficial.
In the chronic stage of the disease mechanical appliances or tenotomy,
employed ^nth a view of straightening the contracted limbs, may be advised.
Compression myelitis should be treated with proper orthopaedic apparatus
with the object of reKeving the pressure upon the cord and, when the lesion
is the result of vertebral fracture, such surgical operations as laminectomy, etc.,
may be indicated.
The diet of the patient should be sustaining and easily digestible and assi-
milable, and he should lead a quiet restful life, as much in the open air as his
condition and the weather permit. Sea voyages, when possible, are especi-
ally to be recommended.
This is a condition of the spinal cord resulting from an insufficient blood
supply due to embolism or thrombosis of its nutrient blood-vessels and charac-
terized by a degeneration of the cord substance. The initial change consists
in a necrosis accompanied by the extravasation of red blood cells andleucoc}i:es;
upon microscopical examination degenerated nerve fibres and fatty cells may
be seen together with red and white blood discs; later the degenerative nerve
substance is replaced by neuroglia tissue.
ACUTE ANTERIOR POLIOMYELITIS.
Synonyms. Infantile Spinal Paralysis; Infantile Palsy; Acute Atrophic
Definition. An acute febrile disease characterized by paralysis of rapid
740 DISEASES OE THE NERVOUS SYSTEM.
development, followed by wasting of the muscles and without disturbance
-Etiology. This disease occurs, in by far the majority of cases, in infancy
and childhood. It may be met at all ages but is rare after the age of ten years.
It appears most commonly in the warm months â€” June to September â€” and
a number of epidemics have been reported. Over-exertion and chilling of
the body may be contributory causes and the condition may appear as a sequela
of the infectious diseases, especially measles, typhoid fever and diphtheria.
The specific cause of anterior poliomyelitis is probably an infectious bac-
Pathology. The disease is one of the anterior horns of the spinal cord^
particularly in the region of the cervical and lumbar enlargements. It is
characterized by an acute exudative inflammation, and consequent degenera-
tion with replacement by connective tissue, of certain groups of cells. As a
result of this process there occur an atrophy of one or both cornua, slight
sclerotic changes in the lateral columns, atrophy of the anterior nerve roots
and of the muscles which they supply.
Symptoms. The onset of the disease is usually sudden, although such
prodromal symptoms as slight malaise and rise of temperature are sometimes
observed. The sudden onset is characterized by a moderate but rapid rise
in temperature â€” ioiÂ° to 102.5Â° F. (38.5Â°-39.2Â° C), rarely as high as 105Â° F.
(40.5Â° C.) â€” headache, pains in the back, limbs and joints, vomiting and,,
perhaps, stupor. Slight convulsions may occur, but are rare, as is delirium
or coma. The paralysis may set in at once or not vintil the constitutional
symptoms, which seldom last longer than two or three days, have abated.
This involves both legs equally in the majority of cases, next in frequency
one leg, next an arm and a leg. Various other combinations may occiu: but
are less common than the foregoing. The muscles of the eye, the larynx
and those of respiration are unaffected but in adults the facial nerve may be
involved. The paralysis reaches its height in from one to four days after the
invasion, remains stationary for from two to six weeks and then gradually im-
proves; seldom does it wholly disappear. It usually remains in a certain group
of muscles. In the legs the extensor muscles are most commonly involved,
in the arm the deltoid. The affected limb atrophies, the atrophy being most
marked in the permanently paralyzed muscles. The nutrition of the whole
limb suffers and its growth is impaired, the skin temperature is subnormal,
the cutaneous sensibility is unaffected, the sphincters of the bladder and
rectum remain normal; the reflexes at the level of the lesion are lost, elsewhere
they are imchanged.
The reaction of degeneration is present, faradic irritability being lost within,
a week or two; galvanic irritability persists but is diminished.
Various deformities result, not so much from the paralysis as from the unop-
ACUTE ANTERIOR POLIOMYELITIS. 74I
posed action of the healthy muscles; of these the most frequent are talipes
equinus and talipes varus and valgus. The lack of development in the affected
leg, when only one is involved, results in tilting of the pelvis and spinal curva-
The patient's general health remains unaffected. The prognosis as to life
is good but as to final recovery is less favorable. The use of the faradic
current is an excellent means of ascertaining which muscles will be perman-
ently affected. After two weeks the muscles in which faradic irritability persists
will recover entirely. After three months the muscles in which it has retiuned
will recover to some extent; after six months the muscles which do not react
will remain permanently involved.
Treatment. During the acuity of the disease the patient should be kept
in bed, at the onset the bowels should be opened by fractional doses of calomel
followed by a saline, and diaphoresis should be induced by hot mustard baths
or the hot pack. For the febrile movement tincture of aconite, i to 2 minims
(0.065-0.130) every half to one hour, should be administered; small doses of
antipyrine or spiritus stheris nitrosi, J to i drachm (2.0-4.0) every four hours
may be given. The administration of the salicylates and of ergot has been
suggested, the former particularly in patients of rheumatic heredity, but it is
doubtful if they or any other drug of which we now have cognizance can influ-
ence the progress of the lesion. Counter -irritation to the spine by means of
leeches, dry cups, the Paquelin cautery, mustard, iodine or ice bags is indicated,
but we should never blister. A weak mustard paste applied at intervals
of two hours and sufficiently long to redden the skin is as effectual as anything.
The dry cups should be of small size and may be applied to the skin along both
sides of the spinal column. The child should be encouraged to lie on its stom-
ach. In the chronic stage, drugs are of little value but nerve and general tonics
such as strychnine, phosphorus, iron, arsenic and codliver oil, may be prescribed.
At the end of two or three weeks the use of electricity may be cautiously in-
stituted, first applying the electrodes without the current in order to gain the
little patient's confidence. The galvanic current should be used on the par-
alyzed muscles, the faradic on those unaffected. Treatment by this means
may be given two or three times a week for the first month or so and for the
following four weeks, daily, each limb receiving the current for two or three min-
utes only; after an intermission of two or three weeks another month's treat-
ment should be started and so on at intervals until a year has elapsed. After
this little benefit will be obtained in most cases, but rarely those occur in
which electricity may produce good results even later in the disease. It must
be remembered that electricity should never be used until after the acute
stage has passed, and then never for a sufficiently long time to tire the muscles.
In lessening the tendency to muscular wasting, systematic massage and fric-
tions, given for from five to ten minutes daily to each affected limb, are even
742 DISEASES OF THE NERVOUS SYSTEM.
more important than electricity. The patient should be dressed warmly and
the paralyzed limb especially, should be kept warm and to this end may be
wrapped in cotton at night or surrounded by hot water bags. An excellent
idea is to allow the child to play in a full bath of salt water at 98Â°-99Â° F.
(36.9Â°-37.4Â° C.) for a half hour each day.
Exercise and life in the open air should be advised and the moderate use
of light gymnastic apparatus may in proper cases be encom^aged.
Contractures and deformities may be prevented by the application of splints,
braces and other orthopaedic appliances, and may be radically corrected often-
times by surgical intervention, tenotomies, tendon transplantations and the like.
CHRONIC ANTERIOR POLIOMYELITIS.
Synonym. Progressive Spinal Muscular Atrophy.
This is a rare disease, is most often seen in adult males, and, while its
direct causation is unknown, exposure to cold and wet, chronic plumbism
and syphilis, are thought to contribute to its incidence.
Pathology. The morbid anatomy of this condition consists in an atrophy
of the fibres and cells of the anterior cornua of the cord. There is no acute
inflammation, but merely wasting of the involved nerve tissues; the anterior
lateral columns and the anterior nerve roots are also affected and the degen-
erative process extends both along these tracts and also down the motor nerve
fibres even to their termination in the muscles; these latter, too, are involved
in turn, their striae becoming indistinct and fatty degeneration developing.
Symptoms. These vary with the portion of the cord diseased. There is
usually a gradually increasing paralysis of the extremities, one or all, followed
by atrophy and wasting; the reaction of degeneration is present, the bladder
and rectum are undisturbed; the reflexes in the affected muscles are lost;
the circulation of the affected limbs is poor and the skin cold. There is no
acute stage of onset. The disease steadily progresses with greater or less
rapidity and death ensues within a few months or the course of the affection
may be prolonged for a year or two.
Treatment. This is practically identical with that of the chronic stage of
acute anterior poliomyelitis. Rest is essential, massage and electricity should
be employed, a course of mercury and potassium should be instituted and
strychnine and arsenic in moderate dosage may cause some improvement.
Attention should be given to the general hygiene of the patient in the way of
nourishing food, plenty of fresh air, etc.
Synonyms. Spastic Spinal Paralysis; Spastic Paraplegia; Spasmodic
LATERAL SCLEROSIS. 743
Definition. A chronic sclerosing inflammation of the lateral p>Tamidal
tracts of the spinal cord.
etiology. This is a disease of adult life, akhough it has been observed m
children; heredit>^ seems to exert an influence in some cases. The condition
seems sometimes to occur as a result of syphilis, trauma, exposure, excessive
muscular exertion, chronic plumbism and the infectious diseases. The
so-caUed Little's disease is akin to lateral sclerosis, but is a congenital affection
and the result of a lack of development of the lateral tracts or due to prema-
ture or instrumental delivery.
Pathology. The sclerotic change in the lateral pyramidal tracts usuaUy
begins in the lumbar cord and involves the crossed pyramidal tracts as well.
The degeneration extends upward and the myelin is graduaUy replaced by
connecttve tissue. Other lesions such as myelitis, meningomyelitis and
multiple sclerosis often co-exist and when the process reaches the cervical
cord the anterior median columns may be affected.
Symptoms. The patient's attention is first caUed to the existence of this
disease by a feeling of fatigue in the legs, this progressively increases until
walking becomes difficult owing to the increased spasticity and paralysis.
The gait is characteristicaUy "spastic," that is the toes drag, the knees are but
little flexed and overlap one another, the feet are hardly lifted and the motion
is stiff. Contraction of the muscles of the calf may compel the patient to
walk on his toes. Motor paresis is a characteristic symptom but at times is
absent, yet the spastic condition is sufficient to disorder the gait, even though
the patient may be able to walk considerable distances. In marked degrees
of paresis the muscles are firm and tense and the legs are held permanently
extended, the feet being in a position of plantar flexion. Sudden attempts
to flex the knees or the feet upon the legs are resisted but, if force is exerted
gradually, the effort will be successful. The patellar reflex is markedly
exaggerated, ankle clonus and the Babinski reflex (upturning of the toes,
especiaUy the great, when the sole is stroked) are present. The reaction of
degeneration is absent, the bladder and rectal functions are normal, ^ there
are no sensory disorders nor does atrophy appear until late in the disease.
The disease progresses but slowly, the patient, in the later stages being unable
to walk or stand. The muscles of the arms are seldom affected, but when
this does occur, the extensors are first and chiefly involved, the paresis and
exaggeration of the tendon reflexes being analogous to that found in the
Hysteria may exactly reproduce the symptoms above described (hysteric
spastic paraplegia) but the differential diagnosis, while not easy, may be made
upon finding other hysterical manifestations.
The prognosis. The progress of this disease is slow and prolonged and re-
coverv is not to be expected. The general health and the mind are not disturbed.
744 DISEASES OF THE NERVOUS SYSTEM.
Treatment. If syphilis is suspected the patient should be put upon mer-
curial inunctions and potassium iodide; the spastic condition of the limbs
may be lessened in certain cases by conium extract, gr. ^ to i (0.032-0.065), the
bromides or hydrated chloral; the latter drug, however, should be given with
the greatest caution lest the habit become established. Galvanism and farad-
ism ma^ be employed and while they are likely to accomplish little in the
ordinary type of the disease, in hysterical spastic paraplegia they are very
useful on account of the impression made upon the patient. Massage and
passive movements, when not too vigorous, may lessen the spasticity and the
patient should be encouraged to do a moderate amount of walking so as to
keep the legs as limber as possible. Warm baths lasting from twenty to forty
minutes at a temperature of 92Â°-98Â° F. (33. 3Â°-36. 7Â° C), during which passive
movements are practiced, are often of benefit.
Braces and other appliances are useful in special cases and tenotomies
may become necessary in order to straighten the limbs.
AMYOTROPHIC LATERAL SCLEROSIS.
Synonym. Charcot's Disease.
Definition. A chronic disease characterized by degeneration of the lateral
columns of the spinal cord, associated with atrophy of the motor cells in
the anterior horns and medulla, and a consequent progressive atrophy of the
^Etiology. This disease is most frequently met in males from twenty-
five to fifty years of age. Its actual cause is unknown but it is probably
the result of an imperfectly developed nervous system. Contributory causes
are said to be exposure, over-exertion, the abuse of alcohol, chronic metallic
poisoning and injury.
Pathology. The essential lesions are a sclerotic degeneration of the crossed
pyramidal tracts of the lateral columns, a like change in the anterior median
columns of the spinal cord and an atrophy of the motor cells in the anterior
horns; the changes are most frequently found in the cervical cord but may,
in old cases, involve the lumbar region as well. The sclerosis in the motor
columns may extend to the motor cells of the cerebrum, through the medulla,
pons, crura cerebri, capsule and corona radiata, involving on its way the
cranial nerve nuclei in the floor of the fourth ventricle. The sclerosis consists,
first, of a wasting of the normal nervous substance and secondly in a re-
placement by connective tissue.
Symptoms. These depend upon the portion of the nervous system first
affected by the disease. When the disorder begins in the cervical cord and
the anterior horn cells, the muscles of the arms become stiff and their reflex
irritability is exaggerated, this is accompanied by a certain amount of paresis.
LOCOMOTOR ATAXIA. 745
followed by atrophy of the muscles of the hands, the extensors being involved
before the flexors; as the paresis extends further up the arm the atrophy also
progresses and is especially marked in the deltoid. Fibrillary contractions
appear early, and the fingers are often held in a position of mid-flexion, and
the muscles being rigid, it may be difficult for the observer to straighten them.
The symptoms later involve the legs, but in rare cases the lower limbs may
be first affected. The symptoms referable to these extremities are fatigue,
a stiff gait, difficulty in rising from a sitting posture, tremor, paresis and atrophy;
one limb, either upper or lower, may be much more seriously affected than
The electric excitability of the muscles is diminished and the reaction of
degeneration may be present. The knee jerk is exaggerated, and ankle
clonus and the Babinski symptom are frequently to be obtained. Sensation
remains unaffected and there is no disturbance of bladder or rectum except
that, in lumbar involvement, there may be nocturnal incontinence of urine.
The sexual power may be lost.
Late in the course of the disease bulbar symptoms may appear, speech
becoming disordered, swallowing difficult and there may be dripping of the
saliva. Atrophy of the tongue and lips may occur and, the patient being
unable to properly masticate and swallow his food, nutrition becomes impaired.
The pupils may be unequal and while there is usually no loss of mental power,
dementia of mild type may develop.
The prognosis is not favorable, although the patient's life may be pro-
longed and much may be done to make him comfortable. Death occurs from
exhaustion, intercurrent disease and not seldom from foreign body pneu-
monia due to the disturbance of swallowing.
Treatment should be carried out along the same lines as in lateral sclerosis.
Feeding by means of the stomach or nasal tube may be necessary if advanced
bulbar symptoms are present.
Synonyms. Tabes Dorsalis; Posterior Spinal Sclerosis; Duchenne's
Definition. A chronic disease of the posterior columns and nerve roots
of the spinal cord, characterized by sensory and trophic symptoms and dis-
turbances of coordination.
.etiology. This affection is most often seen in middle life but may occur
as early as the tenth or as late as the sixty-fifth year. Heredity is a negligible
factor save as regards inherited syphilis. Exposure, excessive exertion, both
physical and mental, and sexual excesses have been considered to have a place
in the causation of locomotor ataxia, but the most important factor in its
746 DISEASES OF THE NERVOUS SYSTEM.
aetiology is syphilitic disease. Various observers state that syphilis is an
element in the causation of from 60 to 90 percent, of all cases. It seldom occurs
within five years of the primary lesion and often not until a much later period
and seems to appear more frequently in individuals whose secondary period
has been characterized by mild symptoms. The disease seems to be rather a
result o| luetic infection than a syphilitic affection of the spinal cord.
Pathology. On microscopical inspection the cord is found to be dimin-
ished in calibre and the posterior columns may be noticeable as a grayish band^
the pia mater is usually thickened and less transparent than normal and its
vessels are sclerosed. Section of the cord reveals an atrophy of the posterior