ment of certain hyperaesthesias. Vaso-motor disturbances evidenced by oedema
and h}^eridrosis may be present. There is no mental impairment and seldom
any febrile movement. Rarely cases have been observed in which the paral-
ysis has been of the descending type, the upper part of the body being involved
first. Death may supervene here from involvement of the medulla before
the paresis reaches the lower limbs.

The course of the disease may last but a few days before the fatal outcome
or it may continue for several weeks, depending upon whether or not the vital
centers are affected.

The prognosis is generally very unfavorable but in rare cases the symp-
toms have gradually ameliorated and recovery has ensued.

Treatment. The patient should be confined to his bed and counterirri-
tation applied to the spine by means of dry cupping, mustard pastes or the
thermo-cautery. The bowels should be opened by repeated small doses of
calomel foUowed by a saline and the activity of the skin and kidneys stimu-
lated by diaphoretics, the warm bath, and the potassium salts (potassium



SYRINGOMYELIA. 755

citrate or acetate, gr. X to XX — 0.66-1.33 — three times a day) in order to assist
in the elimination of the toxin causative of the disease. If there is suspicion
of syphilis mercury biniodide, gr. -^^"-g-V (°-°°^2"~°-°°2) three times a day
should be given. The use of ergotine is recommended by Gowers, he having
administered gr. xx (1.33) in divided doses hourly with improvement of the
symptoms, followed by recovery. The salicylates also are advocated and iron
perchloride may be employed although it is probable that these drugs will
influence the progress of the disease but little. The symptoms of respiratory
or cardiac failure should be combated by the application of the electric
current to the muscles of the chest and to the phrenic nerve and in the cases
which survive the acuity of the disease this means should be employed to aid
muscular and nerve regeneration.

The patient should lie upon the side rather than upon the back since the
latter position tends to augment the congestion of the spinal cord. When
swallowing becomes difficult the use of the stomach tube may be necessary
in order to maintain the patient's nutrition and to prevent the lodgment of
food particles in the respiratory tract.

SYRINGOMYELIA.

Definition. A condition of the spinal cord characterized by the existence
in its substance of abnormal cavities which usually contain liquid and are
surrounded by an increase of neuroglia tissue.

.Etiology. This disease may exist as the result of a congenital anomaly,
of the degeneration of embryonal or gliomatous tissue in the cord or of a
hasmorrhage, traumatic or due to arterial disease, into the cord substance.

Pathology. The spinal membranes remain normal but the surface of the
cord is irregular, protuberances being seen in certain places, retractions in
others. Over the prominences fluctuation may be obtained and puncture
may reveal the presence of serous fluid. The cavities may be multiple,
extending considerable distances up or down the cord, being usually largest
in the upper dorsal and cervical regions and may involve nearly the whole
diameter of the structure even to the pons, converting it into a tube. The
cavity may appear to be a dilatation of the central canal or it may be situated
in the posterior portion displacing the central canal forward. The cavity
is lined with neuroglia which may, before it degenerates and becomes softened,
interfere with the function of the normal tissue of the cord. Upon the out-
skirts of this neuroglia the blood-vessels are more numerous than normal,
they may be dilated and their walls may be the seat of sclerotic change.

Symptoms. While mild types of the disease may be evidenced by no symp-
toms, the onset usually occurs at from twelve to twenty vears of age and is



756 DISEASES OF THE NERVOUS SYSTEM.

of gradual development. The symptoms depend upon the situation of the
lesion and consequently the neck, arms and upper thorax are most affected.
The characteristic symptoms are disorders of sensation, particularly of the
pain and temperature senses; touch is seldom affected but may be rendered
less acute than normal. These distiirbances chiefly involve the upper part
of the body, but areas of pain sense disturbance may be observed in any
part. "Muscular weakness may occux and trophic changes in the skin
and nails as evidenced by thickening, eruptions, or superficial gangrene of
the former and corrugation, Assuring or even loss of the latter. The absence
of pain sense may result in neglect of injuries and consequent superficial
infectious processes and ulceration. Sweating, blueness, coldness, oedema
and other vaso-motor distiurbances may be observed. The joints of the upper
extremities may become swollen, their cavities filled with fluid and their
articular surfaces absorbed, a change analogous to that occurring in locomotor
ataxia. The bones become brittle and are easily fractured and spinal curva-
tures may appear as a result of the atrophy of the muscles or involvement
of the vertebrae. Secondary contractures of the hands may develop.

When the disease aft'ects the medulla there may be partial laryngeal paral-
ysis, dysphagia, lingual and facial paresis and disturbances of the heart
action and respiration. The pupils may react sluggishly or be unequal.

Involvement of the lumbar cord may produce paralyses of the rectum and
bladder.

The prognosis. The course of the disease is chronic, extending over from
ten to twenty years; its development is slow but as it nears its termination it
progresses more rapidly. The ultimate result is invariably fatal, death super-
vening from exhaustion or involvement of the medulla.

Treatment. This is entirely without avail as far as checking the disease
is concerned. The patient's strength should be maintained by nourishing
food, tonics may be given and the administration of arsenic and silver has
been recommended. The patient should be warned of the danger of trau-
matism and fracture and he should be protected against possible injur}-.
Otherwise the treatment consists in the relief of the symptoms as they appear.

MORVAN'S DISEASE.

This is a condition analogous to s}T:ingomyelia and characterized by prac-
tically identical symptoms; necrotic infections due to trophic disorders are
likely to be more severe. The bacillus leprce has been found in the degener-
ated tissue in the cavity of the cord in certain cases. It is probable that
further study will show that the so-called Morvan's disease is identical with
syringomyelia.



HuEMOKRHAGE INTO THE SPINAL CORD. 757

HEMORRHAGE INTO THE SPINAL CORD.

This is of rare incidence; it is met most frequently between the ages of twenty
and forty although it has been observed during infancy. The condition may
result from traumatism, it may occiir in haemophilic subjects, in conditions
of asphyxia, illuminating gas poisoning, for instance, in the severe convul-
sions of epilepsy, eclampsia, tetanus, etc., after excessive coitus and as the
result of aneurysmal rupture or arterial disease. The haemorrhages may
be single or multiple, are usually in the gray matter and may be sufl&ciently
large in quantity to burst through the white substance to the pia. After the
extravasation of the blood the tissues of the cord become soft, degenerated
red blood cells and leucocytes and small round cells are seen and the
cord substance is tinged with the coloring-matter of the blood. Later the
involved area may develop into a connective tissue cicatrix, become the
seat of fatty degeneration, or the clot may be absorbed, leaving a cavity
behind.

Symptoms. The onset of this condition is usually sudden with feelings
of numbness quickly followed by paralysis of the lower limbs, with loss of
sensation and, perhaps, ataxia; there is loss of vesical and rectal control,
the reflexes are lost but soon return and become increased; there may be
severe pain referred to the spine or to the abdomen, chest or limbs. If the
upper dorsal or the cervical region is involved the arms and chest are affected.
The acuity of the symptoms lessens after about a week and the condition
then resembles that present in chronic myelitis. Spasmodic contractions
may' appear and muscular atrophy may ensue resulting from injury of the
anterior horn cells. If the extravasation of blood is large improvement may
not take place and the affection may result in death with symptoms of acute
myelitis.

The characteristic symptoms of spinal haemorrhage are the very sudden
onset and the pain.

The prognosis is dependent upon the situation and volume of the hem-
orrhage. It is least serious in the dorsal region, most in the cervical.

Treatment. The patient should be put to bed and kept absolutely at rest,
cold applications should be made to the spine in the form of ice bags and
the circulatory irritability should be lessened by the administration of aconite;
restlessness may be controlled by the bromides. Otherwise the treatment
is entirely symptomatic. Ergot has been recommended and may be
tried.

The treatment of the chronic stage consists in the exhibition of the iodides
in the hope of lessening the tendency to the production of connective tissue
growth at the site of the lesion, together with the employment of the other
means discussed under the treatment of chronic myelitis (p. 738).



758 DISEASES OF THE NERVOUS SYSTEM.

CAISSON DISEASE.

Synonym. Diver's Paralysis.

Definition. A disease caused by suddenly emerging from air under high
pressure into that of normal pressure and characterized by dizziness, pains
in the head and joints, especially the knees and elbows, and in severer cases
by moto/ and sensory paralyses of the legs of greater or less degree.

.Etiology. This condition is met in artisans who have been working under
heavy atmospheric pressure in caissons such as are employed in the construc-
tion of bridges, piers, foundations of buildings and the like. The disease
seems to depend upon distiurbance of the central nervous system caused by
the sudden change of atmospheric pressure attendent upon emergence from
caissons, in which the pressure may be as high as 60 lbs. to the square inch,
into the ordinary atmosphere. Some persons seem to be more susceptible
to the disorder than others and it is unlikely to occur unless the individual
has been subjected to the pressure for an hour or more. Those unaccustomed
to working under pressure are more likely to be attacked than those regularly
engaged.

Pathogenesis and Pathology. The pathogenesis of this disease is not
definitely known; one theory, however, is that under high pressure the blood
is forced from the peripheral into the internal circulation, particularly that
of the brain and spinal cord, causing a dilatation and a paresis of the blood-
vessels; when the pressure is relieved the blood rushes to the peripherv and
upon this occurrence the circulation of the central nervous system becomes
sluggish and a condition of stasis results. The hypothesis has also been
advanced that the manifestations of the disease are the result of the freeing
of nitrogen into the substance of the cord, this gas ha\ang been forced into the
blood by the high pressiure to which the latter has been subjected. In favor
of this explanation is the fact that gas has been demonstrated in the tissues
upon emergence from high into ordinary air pressure.

The findings in fatal cases have consisted in a diffuse parenchymatous
myelitis with degeneration in the posterior and the adjoining lateral
columns.

Symptoms. The onset of the disease takes place within a half hour of
emergence from the excessive pressure and in the milder cases may consist
merely of dizziness and neuralgic headache with joint pains. In cases of
severer type this pain may be extreme, accompanied by nausea and vomiting,
earache, and abdominal pains, followed by motor and sensory paralysis of
the lower limbs. Temporary mono- or hemiplegia may occur. The sphincters
may be incontinent and unconsciousness followed by coma and death has
been observed. The milder cases usually recover within a day or two, but
the severe types of the disease may continue for weeks or months, recovery



COMPRESSION OF THE SPINAL CORD. 759

ensuing as a rule, although death may supervene or the patient may remain
permanently paralyzed.

Treatment. Prevention of the condition consists in arranging chambers
containing lessening degrees of atmospheric pressure through which the
workmen must slowly pass before returning to the ordinary air. Exertion
in climbing ladders seems to predispose to the affection, consequently an
elevator should be employed whenever possible. The hours of work under
high pressure should be short. Patients are often relieved of the symptoms
by a return to the atmosphere of high pressure and the idea of arranging a
chamber at the surface within which the air pressure can be raised is an
excellent one.

The severe pains often necessitate the administration of morphine h}^o-
dermatically. The joint pains may be relieved by the faradic current, mas-
sage and especially by baking as employed in chronic rheumatic conditions.
The patient should be kept quiet and hot compresses should be a^^pli^d to
the spine and to the extremities. Ergot has been recommended and mtfan?
should be employed to relieve the disordered circulation by bleeding it me
heart is over-worked and the arteries are tense and full. The chronic symp-
toms, paralyses, sensory disorders, etc., should be treated by the means appli-
cable in myelitis.

COMPRESSION OF THE SPINAL CORD.

Synonyms. Compression Myelitis; Pressure Paralysis of the Spinal Cord.

Compression of the spinal cord may be caused by various lesions and results
in paralyses differing in degree and character. Among the causes of cord com-
pression may be mentioned neoplasms, syphilitic and inflammatory thickenings
of the spinal membranes, spondylitis, particularly that due to tuberculous
processes (Pott's disease), malignant new growths and injuries of the verte-
brse, cysts of the spinal canal due to the echinococcus or the cysticercus,
erosion of the vertebrae and consequent pressiue upon the cord due to aortic
aneurysms, malignant retroperitonaeal neoplasms and collections of pus,
retropharyngeal abscesses, etc.

Pathology. At the site of the compression the cord may be smaller in
size than normal, and irregular in outline on cross section; in recent lesions it
may be softened but in compression of long standing its consistence may be
harder, due to the replacement of previously degenerated areas by connective
tissue. Microscopically the nerve fibres are swollen and fatty degeneration
may be observed, later this condition is replaced by a growth of connective
tissue of more or less firmness depending upon the duration of the pressiire.
Ultimately secondary ascending and descending degenerations may occur.

Symptoms. In the most common variety of compression myelitis — that



760 DISEASES OF THE NERVOUS SYSTEM.

resulting from Pott's disease — the deformity may have existed for a long
period before any symptoms resulting from cord compression appear, while
in cases due to intrathoracic or abdominal lesions the cord symptoms may be
noted first. Pain is an early symptom and varies in degree from a dull ache
at the site of the pressure to very marked pain. The discomfort is increased
by bending the back. If the pressure is upon the nerve roots the pain may be
situated ?n the distribution of the nerves having their origin in the roots affected.
There are sensations of numbness and tingling. Sensation is not likely to
be disturbed although anaesthesia may occur in lesions of long standing.
Later, symptoms of motor disturbance, usually not symmetrical at first but
affecting one leg or arm before the other, may be noted; these consist of
muscular stiffness and varying disorders of motility ultimately becoming
complete paralysis.

As would be expected the symptoms differ with the area of the cord affected.
When the pressure is exerted upon the upper part of the cord just below the
medulla, movement of the neck may be accompanied by pain and the neck
muscles may be the seat of spastic contractions; in marked cases it may be
impossible to move the head. If the lesion is in the lower cervical cord the
muscles of the neck may be rigid while sensory and motor disturbances of
the arms occur. The skin and tendon reflexes are increased, because of
interference with the passage of inhibitory influences, the knee jerk is exag-
gerated and ankle clonus is present.

In pressure upon the dorsal and lumbar regions the legs only are affected
although in lesions involving the dorsal cord only, there is likely to be pain
in the distribution of the intercostal nerves, the girdle sensation may be
present, and there is ankle clonus with augmented patellar reflex. In involve-
ment of the lumbar cord there are motor and sensory disturbances in the
legs, the reflexes are diminished and vesical and rectal incontinence, pre-
ceded by difficult micturition and constipation, may occur.

Trophic disorders evidenced by a tendency to bed sores, atrophy of the
muscles of the paralyzed parts, skin eruptions, desquamation and dryness
of the nails may be observed.

The prognosis in compression due to Pott's disease is good because of the
possibility of removing the cause of the lesion, in that due to other causes
it is unfavorable. It is possible for the symptoms to disappear even after
they have endured for months.

Treatment varies with the cause of the condition; that of Pott's compres-
sion consists of the use of appliances calculated to reduce the deformity and
the administration of antituberculous medication, codliver oil, creosote,
especially in the form of the carbonate, iron, arsenic and other tonics com-
bined with plenty of fresh air, proper exercise and nourishing food. Suspen-
sion has been employed with good results in the earlier stages. When the



TUMORS OF THE SPINAL CORD AND ITS MENINGES. 76 1

condition is the result of syphilitic gummata or meningitis the administration
of mercury and potassium iodide is indicated.

The pain may be relieved by the coal tar analgesics, such as salipyrine,
acetphenetidine, acetanilide; hydrated chloral and morphine may be employed
as last resorts only, on account of the possibility of habit formation. When
this symptom is due to cervical meningeal thickening counterirritation by
means of the electro- or thermo-cautery may be beneficial.

The muscular tv^itchings should be combated by the bromides.

Rest and hydrotherapeutic measures, especially warm baths, are impor-
tant adjuncts to treatment.

Massage and electricity influence the course of the disease not at all but
may be used to maintain the nutrition of the atrophied muscles.

Compression by neoplasms necessitates surgical intervention. The removal
of non-malignant growths may be followed by recovery, that of malignant
tumors by temporary benefit only, as a rule.

Laminectomy is necessary in conditions of fracture and dislocation com-
pression and has been employed in tuberculous spondylitis. Surgical treat-
ment is also indicated in pressiure upon the cord resulting from intrathoracic
and intraabdominal abscesses. Aneurysmal compression may be treated by
the various operations advocated for the relief of the primary condition.

TUMORS OF THE SPINAL CORD AND ITS MENINGES.

Tumors causing symptoms referable to the spinal cord are of various types
and origin. They may arise from the bones, cartilages, or ligaments of the
spinal column — enchondroma, sarcoma, carcinoma — in the tissues of the
extradiual space and from the outer surface of the dura — sarcoma, carcinoma,
lipoma and tumors resulting from the growth of hydatids or cysticerci — in
the spinal membranes — sarcoma, tuberculoma, syphiloma and parasitic
growths — in the substance of the cord — glioma, tuberculous and syphilitic
tumors, sarcoma and myxoma. Mixed tumors in any of these situations
may occur. The tumors most commonly found are those due to syphilis
and tuberculosis, and sarcomata. Parasitic growths are seldom met. New
growths also develop in the spinal nerve roots inside the dura; these may be
myxomata, fibromata, lipomata, neuromata or tumors of mixed character.

Spinal neoplasms are usually single but multiple neuromata or sarcomata
sometimes occur. In size they seldom reach a greater diameter than two
inches and frequently they are much smaller than this; when within the spinal
canal their growth is limited by its calibre.

Symptoms. Slowly developing tumors may exist for considerable periods
before causing noticeable symptoms; when these appear they depend upon
the site of the growth and the presstue exerted by it.



762 â–  DISEASES or THE NERVOUS SYSTEil.

The chief symptoms are senson- and motor. Pain is likely to be the earliest
of these and is usually due to the pressure of the tumor upon the sensory
ner\"e roots. It is of varying character. It may be a dull ache or a burning,
stabbing pain or a girdle sensation. Its situation differs in accordance with
the nerA"e roots involved, it may affect one or both sides of the body,
and appears first at the termination of the neri^es upon which the pressure
is exerted. There may be anaesthetic and h}-peraesthetic areas. Spinal
pain, increased upon motion, and tenderness are sometimes present.

Motor S}-mptoms consist of spastic contractions, marked oftentimes, if
the tumor is meningeal, and muscular rigidit}' at the level of the lesion; this
may aid in diagnosticating the site of the tumor. Spasm of the arm and leg
of one side suggests a tumor on the corresponding side somewhere in the
cervical region, whereas if the muscles of the leg only are affected the growth
is likely to be in the dorsal cord. Paralysis gradually develops as the tumor
increases in size and may finally become complete. If the neoplasm is in
the cervical region this s}Tnptom affects both arms and legs, if below this level
the lower limbs only. The paralysis may be more marked on one side if the
tumor presses more upon one side of the cord than upon the other.

Sensation is finally lost in the paralyzed parts if the tumor is below the sixth
dorsal segment, but if it is above this point and eccentric, the senson' disturb-
ance is likely to be greater upon the side affected by the smaller amount of
motor disturbance.

Vaso-motor disorders, oedema, mottling of the skin, etc., may occur and
if the lesion affects the cells of the anterior horns muscular atrophy results.
Ascending and descending degeneration of various tracts of the cord may
occur in cases of long standing, and true myelitis may at any time be engrafted
upon the primar}- condition and obscure the diagnosis.

The t}-pical manifestations of spinal tumor are the gradual appearance
of s\-mptoms referable to the spinal ner\-e roots, first of one side, later of the
other, and the development of motor and sensory paralysis. The fact that
the pain is, as a rule, at the level of or shghtly below the growth (it is never
above), is of practical value in ascertaining the seat of the growth. The char-
acter of the growth is difiScult of diagnosis unless a histor}' of s^-philis or the
presence of tuberculous disease in other parts of the body can be made out.

Treatment. This depends upon the cause of the compression and natur-
ally should be directed toward the relief of that condition. The treatment
of Pott's disease compression consists in the aUe^'iation of the deformity by
orthopedic apparatus and constitutional treatment directed against the causa-
tive tuberculous infection. The means at our disposal are the administration
of codliver oil and other tonics, the insistence upon proper hygiene and plenty
of nourishing food.

Compression resulting from growths of 5}-philitic tissue necessitates vigor-



SPIXAL MEXIXGITIS. -63

0U5 antiluetic treatment; in that due to tumors of gliomatous or sarcomatous
t}-pe arsenic and silver nitrate may be administered, with Httle hope of benefit,
however. The consideration of surgical interference is pertinent in all forms
of neoplasmic compression and the earlier this form of treatment is under-
taken the more likely will it be to reHeve the condition. Tumors outside the
dura are not difficult of removal, and even those in the cord substance may
be operated upon vnth some benefit. "WTien there is certaintv of the presence
of a new growth exploraton* operation is justifiable and when done by skillfiol
hands is of comparatively slight danger.