Chapter L: J. Lautenbach, in a recent communication to the Philadelphia (4)

In several cases a brown or yellow exudate (plastic lymph?) is mentioned as extending along the cord far beyond the immediate neighborhood of the tumor.

The histology of tumors of the whole cerebro-spinal axis will be found described in the article on Tumors of the Brain.

DIAGNOSIS.—The diagnosis of tumors of the spinal cord presents itself naturally under two heads—the differential, or general, and the local diagnosis. The conclusions reached in this paper are based on a careful study of the cases appended, two of which were personal observations, and the remainder were collected from American, English, French, and German literature. It cannot be denied that much obscurity rests upon the diagnosis of tumors of the spinal cord, and that the doubts expressed by Erb and other writers have much to support them. It is hoped that the systematized study presented in this table will do something to dispel this obscurity.

(1) General Diagnosis.—The differential diagnosis has regard first to {1099} certain general phenomena which are broadly indicative of a spinal disorder as distinct from a cerebral or peripheral one. Thus, mental symptoms are absent, or if present are an accompaniment of tumors high up in the spinal axis, are the results of suffering, or appear very late in the disease because of progressive weakness. Briefly stated, the phenomena which point with comparative certainty to the existence of spinal tumors are symptoms of meningeal irritation gradually increasing, and symptoms of slow compression of the cord. These have been sketched at the beginning of Symptomatology. As to duration, the data in the cases studied were somewhat meagre. The usual duration is from six months to three years.

The differential diagnosis of spinal tumors will be considered in reference to the following affections: congestion, hemorrhage, meningitis (simple and specific), caries, traumatisms, sclerosis, aneurisms, neuritis, metallic and infectious disorders, and hysteria. Spinal tumors, it will be recalled, are from constitutional or special causes, as syphilis, cancer, and tuberculosis. The onset is gradual and irregular. The duration is comparatively long. The progress is by irregular advances toward a fatal termination. The symptoms are inclined to be at first unilateral or local; later, bilateral. Special symptoms, as paralysis, spasm, sensory and visceral disorders, occur irregularly as to time. Decubitus and trophic changes are common late in the history. Reactions of degeneration are often present. Gowers refers to the fact that two morbid processes often occur, one consecutive upon the other, as a secondary degeneration or a hemorrhage, after the establishment of the morbid growth, with characteristic increase of symptoms.

In spinal congestion a constitutional cause is not likely to be present. The onset is usually sudden and after exposure. The duration is shorter than in tumors, and is from a few days to four months. The disease is stationary for a while; then retrogression of symptoms toward recovery occurs. The symptoms are more uniformly bilateral, and motor and other symptoms develop about the same time. Decubitus is rare. Reactions of degeneration are rare (?). It is desirable that cases of so-called spinal congestion should be differentiated from the forms of peripheral neuritis above referred to, the most characteristic symptom of which appears to be tenderness of nerve-trunks.

In spinal hemorrhage there is no special history, or a history and signs of cardiac and vascular degeneration may be present. The onset is quite sudden and the progress of the case regular. The first symptoms persist, and secondary degenerations follow, and differ according to the extent and location of the lesion, but are most likely to be uniformly bilateral.

In meningitis the symptoms of localized compression are absent. The girdle symptom is absent. The affection is sometimes curable, and especially so if it has been of syphilitic origin. The reactions of degeneration are not marked.

In caries of the spinal vertebræ deformity is rarely absent, especially if the case has continued a few months. Rigidity of the muscles of the back is an important symptom, which, however, is occasionally found with tumor. Jarring of the spinal column by tapping upon the head or jumping from a chair or stool is more likely to elicit pain in caries than {1100} in tumors. Strumous symptoms and evidence of tubercles in the lungs or other organs are often present.

In traumatisms usually a history of the injury can be obtained. The symptoms are those of caries, myelitis, meningitis, or of combinations of these, according to the character of the case.

In sclerosis the symptoms are usually those of progressive systemic affections, with absence of compression symptoms. The duration is longer. The progress is gradual and more regular.

Aneurisms are only to be distinguished when extra-spinal, causing erosion and compression.

In neuritis there is the soreness of the nerve-trunk already referred to, while compression symptoms and visceral disorders are absent. The motor and sensory symptoms are confined to the area of distribution of the affected nerve. It is amenable to treatment. In advanced stages the reactions of degeneration are marked. In the form of general peripheral neuritis, the existence of which, as a distinct disease, is being at present claimed, the characteristic symptoms are as yet not sufficiently determined or the pathology demonstrated by post-mortem research to admit of much discussion.

In metallic and infectious disorders a history of definite causation is present. Metallic disorders may present special distinctive signs, such as lead-line, wrist-drop, etc.

In hysteria a precedent characteristic history is usual. The onset is often sudden and an emotional element is present. The symptoms are bilateral and protean. Trophic changes are absent. No reactions of degeneration are present.

(2) Local Diagnosis.—It may be said of spinal tumors in a modified sense, as it can be said of brain tumors, that they are not good pathological experiments for illustrating the functions of the exact areas which they occupy. The spinal canal has such narrow limits, the tumor itself soon attains such a relatively large size and causes such wide vascular engorgement, and the different tracts and systems of the cord are so closely packed together, that the tumor does not often invade only one functional area and escape another. Hence the regional diagnosis presents special and greater difficulties than the diagnosis of the level of the cord at which the tumor presents itself. A tumor which destroys the trophic centres for the arm in the anterior cornua might exert sufficient backward pressure to paralyze the motor tracts running to the leg; or a cervical tumor, as in Case 5, might produce symptoms which are almost wholly observed in the legs. It will be seen, however, by reference to the table, that in Case 3, reported by Wilks, we have a tumor whose exact anatomical seat could have been predicted, and which seems to have reproduced almost the upper-arm paralysis of Remak. When we compare these two cases, in which the pathological conditions are so similar, it will be observed that the paralyzed arm is much wasted, which indicates a lesion of its trophic centre, whereas the affected legs in the other case are irritated by pressure and by isolation, but are not wasted, because their trophic centres are far below the point of lesion. The invasion of the trophic centres, and the accompanying wasting of particular groups of muscles, especially when this occurs early in the case, with the consequent reactions of degeneration in these muscles, would furnish very valuable indications {1101} both as to the region and the level of the cord involved (Case 29). Unfortunately, the exact observations are wanting in most of the cases as reported.

M. Allen Starr, in a recent paper,[7] has devoted much labor to the elucidation of the functions of different segments and regions of the cord. He demonstrates the existence of groups of cells in the gray matter, especially in the anterior horns, each of which he believes constitutes a physiological unit. He affirms that these cell-groups preside over certain associated movements or combinations of certain muscles, and, quoting from Spitzka, says that “the nearer a muscle is to the ventral aspect of an animal the nearer will its nucleus be to the median line of the cord; and the nearer the muscle is to the dorsal aspect of the animal the nearer will its nucleus be to the lateral cornua of the cord. Flexor nuclei are therefore in internal, extensor nuclei in external and posterior, cell-groups.” The only light that such a theory throws upon the subject of diagnosis is by affording a possible explanation of the fact that spastic flexion is much more common than spastic extension, and may be due to the fact that the cell-groups for flexion lie deeper and are more protected than those for extension; and the additional fact above referred to, that a paralysis of associated muscles or groups of muscles, with degeneration, as in the types of Remak, would indicate with great clearness the destruction of the cell-group which presides over them. Starr, in his article, also tabulates the various reflexes and their seats in the cord. As this subject is of much importance in any exact study of spinal-cord diseases, we will state here some of the facts as given in that article: The neck-pupil reflex (dilatation of the pupil on irritation of the neck) has its seat from the fourth to the seventh cervical segment; the elbow-tendon reflex in the fifth and sixth cervical; the wrist tendons from the sixth to the eighth cervical; the palmar in the seventh and eighth cervical; the epigastric and abdominal skin reflexes in the fourth to the eleventh dorsal segments; the cremasteric reflex in the first to the third lumbar; the patellar tendon in the second to the fourth lumbar, and bladder and sexual centres in same; the rectal centre in the fourth lumbar to the third sacral; the foot-clonus and Achilles-tendon reflex in the first sacral. A destructive lesion, such as a tumor, at any one of these points would cause abolition of that particular reflex, and this would probably occur early in the case. Our table of cases does not present any such observation, whereas exaggerated reflexes, such as occur from a compressing lesion above the seat of the excited centre, are recorded in abundance. Many of these deductions are of course only possible early in the history of the case, as at a late stage the secondary degenerations have caused too widespread havoc to admit of any exact localization. The distinction must also be sought for between a destructive lesion and the symptoms of irritation which it may project to distant parts. Fürstner's cases of syringo-myelia,[8] in which were marked vaso-motor changes, such as pallor, flushings, copious sweat, and trophic disorders in the integument and its appendages, seem to show that a lesion in the gray matter just posterior and external to the central canal is necessary for such phenomena. Similar vaso-motor changes may be observed in some of the tabulated cases, as in No. 4, in {1102} which there were islands of heat and cold in the leg, with a hydromyelia in the cord. Sensory symptoms are very common in cases of spinal tumor, but they furnish indications rather of the exact level of the lesion than of its region.

[Footnote 7: “Localization of the Functions of Spinal Cord,” _Am. Journ. Neur. and Psych._, 2-3, p. 443.]

[Footnote 8: Quoted by Starr.]

Before considering briefly the indications which point to the various levels of the cord as a possible seat of spinal tumor, it will be necessary also to make plain a few anatomical facts. It must be borne in mind, first, that the nerve-origins in the cord are never at the same level as their exits from the spinal canal, or, in other words, that the spinal segments do not correspond with the bodies of the same numerical vertebræ, and that there is, in fact, one more cervical segment than there are cervical vertebræ. The tendency is for the nerve-trunks to run downward before passing out of the canal, so that in every instance, without exception, from the medulla oblongata to the filum terminale the segments of the cord are above the corresponding vertebral body. This discrepancy increases as we descend the cord; whereas it is approximately correct to say of the cervical and dorsal regions that every segment is opposite the vertebral body which is numerically just above it, this difference becomes much greater in the lumbar and sacral regions. The cord itself terminates in the lumbar enlargement which ends opposite the interval between {1103} the first and second lumbar vertebræ. All the remainder of the canal is occupied by the descending trunks of the lumbar, sacral, and coccygeal nerves as they pass to their respective foramina, constituting the cauda equina. It must be recalled, however, that the vertebral bodies, lying very deep, cannot serve as guides, but that we are dependent upon the spinous processes as landmarks in diagnosis. These again differ in their levels from their respective vertebral bodies, as they are deflected at somewhat different angles at different regions of the spine. Gowers has illustrated these facts by a very graphic wood-cut[9] (Fig. 45), from which the general rule may be drawn that each vertebral spine is about opposite the spinal segment which is numerically two places below it; thus the eighth dorsal spine is opposite the tenth dorsal segment, etc. The indications afforded by this exact anatomical knowledge have reference largely to the existence of pain on pressure and to any deformity of the bony structures. The cases as reported do not indicate that this method of research has been utilized, and it may possibly be of only theoretical importance; but it has been considered worthy of reference as an indication in diagnosis.

[Footnote 9: _Diagnosis of Diseases of Spinal Cord_, p. 6.]

It will be seen by reference to the table that usually certain general features in the symptomatology indicate the seat of the lesion. Thus in tumors of the cervical region pain and stiffness of the neck occur, while the first appearances of paresis and sensory disturbances are usually observed in the arms and about the chest. The centres for the forearm and hand lie in the lower portion of the cervical enlargement; that for the upper arm, including the supinator longus, in the upper portion. Mental symptoms are more marked, and in Case 4 several of the cranial nerves were implicated. In the lower cervical and upper dorsal region there are symptoms of dyspnœa, fixation of the chest (Nos. 20, 22, 24), and cough. The girdle symptom is an important indication at any level, {1104} as it is due to irritation of the nerves at the lowest level of healthy cord just above the transverse lesion. It has already been discussed under Symptomatology. In many of the dorsal cases (Nos. 32, 37, 38, 39, and 45) the symptoms are almost entirely confined to the legs and lower trunk, the arms escaping entirely. The condition of the bladder is usually given in the table as one of paralysis; this does not indicate whether automatic evacuation existed at the beginning of the case; which condition would indicate that the centre for micturition was below the lesion, and intact. It is probable that later in these cases the bladder is actually paralyzed by destruction of its centre in the cord, and this even when the tumor has been situated some distance above.

With reference to tumors of the cauda equina, Erb[10] says that they have in every respect a great resemblance to those which are situated higher and affect the cord proper. “They are hard to distinguish from the latter, but may be in many cases perhaps, if it is borne in mind that tumors of the cauda produce exclusively nerve-root symptoms, and that the signs of compression of the cord, of secondary myelitis, etc. are absent. The higher the tumor, the nearer it approaches the lumbar {1105} portion of the cord, the harder will it be to draw the distinction. In respect to tumors seated lower the following points may be attended to: the seat of the pains (which in such cases often attain enormous violence) 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 sciatica, while the crural and the dorsal nerves were perfectly free; constant violent pain in the sacrum. If palsy occurs the reflex actions necessarily cease at once. Spasms are seldom observed, more frequently contractures. Atrophy of the muscles occurs rather frequently. The palsy and anæsthesia by their localization often give us the opportunity of fixing the upper limit of the lesion. Increase of the reflex acts and marked tendinous reflexions do not occur. Paraplegia, palsy of the bladder, bed-sores, etc. may develop exactly as in tumors occupying a higher seat, {1106} 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 anæsthesia occurred.”

[Footnote 10: _Op. cit._]

PROGNOSIS.—The prognosis of spinal tumors is generally very unfavorable. Syphilitic cases are of course the most hopeful, but even in these cases it is only when they are recognized early that much can be expected. A gumma that has grown to any dimensions will have so compressed the cord that even when the tumor is melted away by specific treatment its effects will remain.

DURATION AND TERMINATION.—Most cases of spinal tumor last from about six months to three years. Occasionally death may result, as from a rapidly-developing sarcoma, in less than six months, and somewhat more frequently in slowly-developing tumors, or in those which are held more or less in abeyance by treatment the sufferings of the patient are prolonged to four or five years or more. Hemorrhages into or around the growths sometimes take place, and are the cause of death, or more frequently of a sudden aggravation and multiplication of severe symptoms. Death sometimes takes place from the complete exhaustion which results from the disease and its accompanying secondary disorders, such as bed-sores, pyelitis, etc. Occasionally death results from intercurrent diseases, such as pneumonia, infectious fevers, etc., whose violence the weakened patient cannot well withstand. Sometimes the symptoms of a rapidly-ascending paralysis appear, probably due to an ascending myelitis or meningo-myelitis.

COMPLICATIONS AND SEQUELÆ.—Spinal tumors are sometimes complicated with other similar growths in the brain or the evidences of the same constitutional infection in other parts of the body. In one case of cysticercus of the cord sclerosis of the posterior columns was also present.

TREATMENT.—The treatment of spinal tumors can be compressed into very small compass. In cases with syphilitic history, or when such history is suspected, although not admitted, antisyphilitic remedies should be applied with great vigor. It should be borne in mind, however, that even in syphilitic cases after destruction of the cord by compression or softening specific remedies will be of no avail. In tubercular cases and in those in which the system is much run down tonics and nutritives are indicated. Bramwell[11] advises an operation in any case in which the symptoms are urgent, in which the diagnosis clearly indicates the presence of a tumor, when there is no evidence of malignant disease, when the exact position of the growth can be determined, and when a vigorous antisyphilitic treatment has failed to produce beneficial results. As some meningitis, meningo-myelitis, or myelitis is usually present in cases of spinal tumor, treatment for the complication will assist in relieving the torments of the patient. Anodynes, particularly opium and its preparations, should be used freely in the later stages of the affection. Bromides and chloral are of little value except in association with opiates. Operation offers even less hope than in brain tumor, but in very rare cases should be taken into consideration.

[Footnote 11: _Diseases of the Spinal Cord_, Edinburgh, 1884.]

{1107} TABLE OF FIFTY CASES OF SPINAL TUMOR.

1. Sex and Age: M. 33.

Clinical History: Paresis of forearms, left worse. Paraplegia, then paralysis of all limbs; paralysis of intercostals. Contractures of hands, then of feet. Pain and stiffness of neck on motion. Wasting of interossei. Diplegic contractions of legs. Only partial paralysis of sphincters. Sensation perfect. Bed-sores. Duration, thirteen months.

Path. Anat. and Location: Glioma; syringo-myelus. Dilated lymphatics.

Entire length of cord, and involving medulla oblongata. Upper four inches of cord greatly enlarged.

Remarks: T. Whipham, _Trans. Path. Soc. London_, 1881, xxxii. 8-12.

2. Sex and Age: F. —.

Clinical History: Constricting pains about abdomen. Paresis of legs. Persistent subsultus. Temporary improvement after labor. General paralysis. Scoliosis.

Path. Anat. and Location: Glio-myxoma.

In gray columns from medulla oblongata to cauda equina.

Remarks: Schueppel, _Arch. d. Heilk._, viii. Bd., 1867 (quoted by Rosenthal).

3. Sex and Age: M. 15.

Clinical History: Paresis of left arm. Pain back of neck. Later, paralysis of left arm, and wasting of arm, shoulder, and neck muscles. Slight paresis of right arm. Prolonged vomiting. Constriction of neck; dysphagia; paralysis of chest.

Path. Anat. and Location: Gelatinous tumor left side of cord, and involving in some parts the gray matter.

From medulla to sixth cervical vertebra.

Remarks: S. Wilks, _Lectures on Dis. of Nervous System_, p. 266.

4. Sex and Age: M. 18.

Clinical History: Paresis of left leg, increasing; some atrophy. Weakness in left arm. Later, numbness in both legs. Contracture of fingers. Some mental confusion. Left hand and leg livid and cold. Hyperæsthesia of left leg; anæsthesia of right leg, perineum, penis, scrotum, rectum, and inguinal region, and of left arm. Right arm normal. Islands of heat and cold in leg, and of cold in arms. Left ankle clonus. Left pupil contracted. Vomiting. Dysphagia. Occipito-cervical pain and contracture of cervical muscles. Leg contractures and tremor. Later, hyperæsthesia disappeared. Incontinence of urine. Patellar and skin reflexes increased. Facial spasm. Amblyopia, optic neuritis, diplopia, deafness, paralysis of left abducens; pupils contracted. Sacral bed-sores. Thick speech.

Path. Anat. and Location: Round-celled sarcoma or glio-sarcoma, growing from ependyma of central canal, causing hydromyelia, softening, and secondary degeneration. Dura mater thickened. Brown exudate in cord and base of brain.

From medulla oblongata to dorsal cord.

Remarks: Schultze (F.), _Arch. f. Psychiat._, Berlin, 1878, viii. 367-393, 1 pl.

5. Sex and Age: F. 48.

Clinical History: Pain in abdomen and down legs, worse on left side. Tonic spasm in flexors and adductors of thighs. No anæsthesia. Two months before death paralysis of sphincters. Great emaciation.

Path. Anat. and Location: Tumor (psammoma), growing from dura mater on right side in cervical region.

Upper part of cervical region.

Remarks: J. Hutchinson, Jr., _Tr. Path. Soc. Lond._, 1881-82, xxxiii. 23, 24.

6. Sex and Age: ——

Clinical History: Pain in arms. Contracture of fingers of right, then left side. Numbness in right foot, then upward, then left foot. Girdle feeling. Priapism and dysuria. Complete anæsthesia, later, up to third rib, with paralysis of legs and paresis of fingers. Respiration diaphragmatic. Legs very jerky. Later, arms paralyzed.

Path. Anat. and Location: Sarcoma of left post. aspect of cord; adjacent cord compressed and soft. Belt of yellow substance enveloped cord to cauda equina.

Between cervical bulb and second cervical vertebra.

Remarks: E. Long Fox, _Bris. Med.-Chir. Journ._, 1883, i. 100-106, 2 pl.

7. Sex and Age: F. 31.

Clinical History: Pain, stiffness in neck; pain radiating, aggravated by jarring. Sudden paralysis of both arms; next day paralysis of legs, incomplete. Partial anæsthesia. Marked skin reflexes in legs. Patellar reflexes retained, weaker on right than left. Dyspnœa. Profuse perspiration. Cardiac irregularity. Day before death temperature in right axilla 100°; left, 102.2°.

Path. Anat. and Location: Gumma of dura mater two inches long, with intercurrent hemorrhage; flattening and softening of cord, with secondary sclerosis.

From first to fifth cervical vertebra.

Remarks: Charles K. Mills, _Philada. Med. Times_, Nov. 8, 1879, p. 58.

8. Sex and Age: M. 34.

Clinical History: Pain in back of neck, with stiffness and torticollis. Paresis of arms; later, of legs. Anæsthesia of arms, then of legs; also paræsthesia of legs. Late symptoms: shortening and great rigidity of neck, with choking sensation (girdle sensation at neck). Dimness of vision. Atrophy of arms and less of legs. Complete paralysis of arms, almost complete of legs. Electro-contractility preserved. Violent skin reflexes in legs. Involuntary evacuations and incomplete priapism. Severe pains in knees and ankles. No acute bed-sores. {1108} Paroxysms of dyspnœa. Average temp. for two weeks before death, M. 97.9°, E. 98.3°.

Path. Anat. and Location: Gumma of dura mater; caries, probably syphilitic, of vertebræ. Abscess. Total (almost) transverse sclerosis of cord. Secondary degeneration. Some softening above and below tumor. Cervical nerves compressed and atrophied.

From second to fifth cervical vertebra; most in front.

Remarks: Charles K. Mills, _Philada. Med. Times_, Nov. 8, 1879, p. 58.

9. Sex and Age: M. 43.

Clinical History: Pain between shoulders. Numbness in right hand and arm, with weakness and swelling. Numbness in left arm, which spread over chest and abdomen. Unable at first to lie down. Felt as though encased in armor. Pain in back of neck. Tongue protruded to right. Exaggerated reflexes in legs. Right arm and leg weaker than left. Vertigo. Dysphagia. Sense of constriction about neck. Breathing impaired.

Path. Anat. and Location: At third cervical vertebra, to right of front of cord. Destruction of opposite vertebra.

Remarks: E. H. Clark, _Bost. Med. and Surg. Journal_, 1859-60, lxi. 209-212.

10. Sex and Age: ——

Clinical History: No record of symptoms especially referable to the cysticercus. Symptoms of tabes dorsalis.

Path. Anat. and Location: Cysticercus in substance of cord. Lesions of tabes dorsalis.

On level with third cervical nerve.

Remarks: Geo. L. Walton, _ibid._, vol. cv. p. 511.

11. Sex and Age: M. 25.

Clinical History: Pain in back of neck; stiffness. Numbness of left hand. Gradual loss of power of left arm. Jerking of arm. Paresis of left leg. Constriction of upper chest. Right limbs involved, and eventual complete paralysis of trunk and extremities. Severe headache. Last three days absolute anæsthesia of arms and legs. No ophthalmoscopic changes. Constipation and dysuria.

Path. Anat. and Location: Fibro-sarcoma at level of fourth cervical nerves. Cord compressed.

Remarks: H. A. Lediard, _Tr. Path. Soc. Lond._, 1881-82, xxxiii. 25-27.

12. Sex and Age: F. 25.

Clinical History: Œdema of ankles; pain in legs; afterward numbness, formication, and stiffness of legs. Painful contractures in upper extremities. Slight left scoliosis. Abdominal pains. Paresis of arms. Fingers flexed. Fever. Respiration became involved, and bowels and bladder paralyzed. Mind clear. Died in attack of suffocation. Duration, two years and three months.

Path. Anat. and Location: Fibroma, size hazelnut, under pia mater.

Between fourth and fifth cervical vertebræ.

Remarks: Bernhuber, _Deutsch. Klin._, Berlin, 1853, v. 406.

13. Sex and Age: M. 16.

Clinical History: Restlessness. Cramps in pharynx on swallowing. Excitability. Delirium. Hallucination. Pain in the neck. On touching neck general cramps. Grimaces. Salivation. In three days complete paraplegia. No fever. Sudden change. Pulse 120. Pupils alternating. Blepharospasm. Irregular respiration. Pulmonary œdema. Suspicion of hydrophobia, because patient had been with hydrophobic dog; when offered coffee had symptoms simulating rabies.

Path. Anat. and Location: Sarcoma.

Extending from fifth to seventh cervical nerve on antero-lateral face of cord, compressing left half and penetrating into right half, so that anterior longitudinal fissure described arc of circle around it.

Remarks: Adamkiewicz, _Arch. de Neurol._, Paris, 1882, iv. 323-336, 1 pl.

14. Sex and Age: F.

Clinical History: Paresis and partial anæsthesia in all limbs for many months, most marked on left side. Brain and special senses unaffected. Had a tumor at bottom of right side of neck. Extensive bed-sore.

Path. Anat. and Location: Carcinoma.

Tumor caused partial absorption of sixth cervical vertebra. Cord compressed and twisted. Right lateral aspect especially affected. Cord atrophied.

At level of sixth cervical vertebra.

Remarks: J. W. Ogle, _Tr. Path. Soc. Lond._, 1885, 6, vii. 40, 41.

15. Sex and Age: F. 34.

Clinical History: Pain in right foot, and paresis increasing to paraplegia. Paresis of arms. Contractures of legs. Hyperæsthesia in both legs up to crest of ilia. Later, great pain; paralysis of sphincters. Bed-sores.

Path. Anat. and Location: Sarcoma, growing from dura mater; nerves passing through and over tumor. Cord congested and pushed to one side. Thin, but not softened. Growth resembled psammoma.

Between sixth and seventh cervical nerves of left side.

Remarks: T. Whipham, _Tr. Path. Soc. Lond._, 1873, xxiv. 15-19.

{1109} 16. Sex and Age: M. 57.

Clinical History: Pain in right arm. Numbness in hand, and paresis. Paresis and coldness of left leg. Some anæsthesia and wasting of right leg. Later, paraplegia. Diminished reflexes. Contractures. Constriction sense about legs and abdomen. Triceps, deltoid, and serratus magnus of right side paralyzed. Incontinence of urine, difficult defecation, decubitus, fever. Abdominal muscles paralyzed. Later, other muscles of arms paralyzed. Complete anæsthesia of legs. Dyspnœa, œdema of lungs.

Path. Anat. and Location: Myxoma from arachnoid. Cord compressed and softened on right postero-lateral side. Secondary degeneration. Some œdema of brain.

At sixth and seventh cervical vertebra on postero-lateral surface of cord.

Remarks: Pel (P. K.), _Berlin. Klin. Wochensch._, 1876, xiii. 461-463.

17. Sex and Age: F. 35.

Clinical History: First, pain in right arm, weakness in right hand. Then paralysis almost complete in arms, and impaired sensation. In legs paralysis complete, sensation impaired. Alternate incontinence and dysuria. Ankle clonus and increased knee-jerks and plantar reflex. Tapping biceps causes reflex in little and ring fingers. No atrophy or bed-sores. Cold on one side, hot on other. Pain and little swelling over sixth cervical vertebra. No eye symptoms. Brain clear. Inability to turn head. Before death respiratory paralysis and bed-sores. Duration, fifteen months.

Path. Anat. and Location: Spindle-cell sarcoma, springing from arachnoid and destroying cord by pressure, except posterior columns. Cord below tumor soft.

At sixth cervical vertebra.

Remarks: E. Long Fox, _Bris. Med.-Chir. Journ._, 1883, i. 100-106, 2 pl.

18. Sex and Age: M. 50.

Clinical History: Paresis in right arm. Stiffness in neck and back. Paralysis of all extremities gradually developed.

Path. Anat. and Location: Glioma in right half of cord. Old hemorrhages in adjacent parts and in medulla oblongata. A more recent hemorrhage in dorsal cord.

In lower cervical region.

Remarks: Schueppel, _Arch. d. Heilk._, viii. Bd., 1867 (quoted by Rosenthal).

19. Sex and Age: ——

Clinical History: Coldness, numbness, violent pains, first in left arm, later in both legs. Paralysis of all limbs and muscles of trunk. Atrophy. Reactions of degeneration. Violent leg reflexes.

Path. Anat. and Location: Tubercle, large as hazelnut. Consecutive myelitis of adjacent parts and left anterior horn.

In lower cervical region.

Remarks: Chvostek, _Med. Press_, 33-39, 1873 (quoted by Rosenthal).

20. Sex and Age: M. 45.

Clinical History: Interscapular pain. Chest-pressure and dyspnœa. Paræsthesia and pain in legs. Spastic paralysis. Difficulty in stools; bloody urine and dysuria. Œdema of legs. Bed-sores. Kypho-scoliosis. Pain on pressure over spine. Paralysis of left leg, paresis of right, some anæsthesia of both. Broncho-pneumonia, fever.

Path. Anat. and Location: Phlegmon of dura mater, compressing cord. Some infiltration of tissues of throat and mediastinal space.

From seventh cervical to second dorsal vertebra.

Remarks: Mankopff (E.), _Berl. Klin. Wochensch._, 1864, i. 33-46, 58, 65, 78.

21. Sex and Age: M. 22.

Clinical History: Pain in back and side of neck and in limbs. Marked pain in sternal region on coughing. Pressure and jarring cause pain. Rapid loss of power in both arms. Feeble and slow movements of thighs, legs, and feet. Right deltoid and flexors of fingers much wasted. No paralysis of face. Knee-jerks exaggerated. Later, complete paralysis, including bladder and rectum.

Path. Anat. and Location: Tumor of membrane. Cord beneath compressed and degenerated.

Lower cervical and upper dorsal region.

Remarks: H. C. Wood, “Proceedings of Philadelphia Neurological Society,” _Medical News_, vol. xlviii. No. 9, Feb. 27, 1886.

22. Sex and Age: F. 50.

Clinical History: Pain in neck, shoulders, and chest. Stiffness of neck, back, and arms. Chest fixed; breathing diaphragmatic. No paralysis or altered sensation.

Path. Anat. and Location: Secondary cancer of vertebræ.

Cervical region.

Remarks: Gull, by Wilks, in _Lect. on Dis. of Nerv. System_.

23. Sex and Age: F. 40.

Clinical History: Severe pain in back. At height complete paralysis in legs, some paresis in arms. Variable anæsthesia. Girdle sensation and mammary pain. Lively and distressing reflexes. Contractures in legs. Bed-sores and paralysis of sphincter of bladder. Toward close rigors (pyæmia?).

Path. Anat. and Location: Fibro-cyst on right side, between cord and dura, and between anterior and posterior nerves.

Top of dorsal region.

Remarks: Risdon Bennett, _Tr. Path. Soc. Lond._, 1855-56, vii. 41-45.

24. Sex and Age: M. 30.

Clinical History: Cough, dyspnœa, wasting, simulating phthisis. Pain in back of neck and shoulders. Pain in joints; paresis of legs and bladder. Pain in chest. Paresis of arms. Later, increased paralysis, bed-sores, sweating.

Path. Anat. and Location: Tumor, size of hazelnut, inner anterior surface of dura mater. Flattening and softening of cord.

Top of dorsal region.

Remarks: Gull, in _Guy's Hosp. Rep._, (quoted by Wilks in _Lectures on Dis. Nerv. Syst._, p. 264).

{1110} 25. Sex and Age: F. 43.

Clinical History: Pain in shoulders, chest, and sides. Contractures of legs; heels to nates. No anæsthesia. Later, retention of urine and bed-sores. Incessant pain in back and abdomen.

Path. Anat. and Location: Fibro-nucleated tumor from inner surface of dura mater.

Opposite third dorsal vertebra.

Remarks: Gull, by Wilks, _ibid_.

26. Sex and Age: F. 43.

Clinical History: Pain in chest and shoulder, then in legs. Paresis of legs. Contractures and jerking of legs. Spasm of abdominal muscles. No anæsthesia. Paresis of bladder and rectum. Wasting and bed-sores. Finally, paresis increased, but never complete paralysis. Duration, nine months.

Path. Anat. and Location: Fibro-nucleated tumor, size of a bean, from dura mater. Cord compressed backward, and softened.

Opposite third dorsal vertebra.

Remarks: Wilks, _Trans. Path. Soc. Lond._, 1855-56, vii. 37-40.

27. Sex and Age: M. 24.

Clinical History: Paraplegia. Depressed reflexes; girdle symptom. Partial anæsthesia. Dysuria. Vomiting. Pulse weak and intermittent. Partial recovery from paralysis, and anæsthesia in left leg, and reflexes in right foot regained. Later, complete paraplegia, anæsthesia, and bed-sores. Duration, five months.

Path. Anat. and Location: Probable gumma.

Middle dorsal region.

Remarks: B. G. McDowell, M.D., _Dubl. Q. J. Med. Sci._, 1861, xxxii. 299-303.

28. Sex and Age: F. 44.

Clinical History: Paresis in legs. Spine hypersensitive and inflexible; least attempt at bending causes great cervico-brachial pain. Paræsthesia; sense of falling out of abdominal viscera through abdominal walls. Pains in extremities increasing, and involving right shoulder, intercostals on both sides, and lumbar region. Paralysis of right arm (first); complete paralysis of leg. Excessive spinal tenderness. Loss of sensation (partial) in legs, body, and right arm. Later, dyspnœa, then dysuria, then complete inability to empty bowels or bladder. Great tympanites. Girdle sense above umbilicus, and finally complete paralysis and anæsthesia below this band. Sense of twisting of legs and feet, so that latter seemed close to face. Œdema. Later, paresis of left arm. One small bed-sore.

Path. Anat. and Location: Alveolar sarcoma.

Eighth and ninth dorsal vertebræ.

Remarks: G. W. H. Kemper, _Journ. Nerv. and Ment. Dis._, xii. No. 1, Jan., 1885.

29. Sex and Age: F. 42.

Clinical History: Projection of seventh, eighth, ninth, tenth, and eleventh dorsal vertebræ. Numbness below ankles, and early girdle sensation. Peronei and anterior tibial muscles first involved; then all leg-muscles, then sphincters, then arms. Died in a fit.

Path. Anat. and Location: Round-celled sarcoma. The anterior columns soft opposite tumor. Bodies of seventh, eighth, ninth, and tenth vertebræ soft.

Opposite seventh, eighth, ninth, and tenth dorsal vertebræ.

Remarks: E. Long Fox, _Brit. Med. Journ._, 1871, p. 566.

30. Sex and Age: F. —.

Clinical History: Ill-defined hemiplegia; later, paraplegia, with contractures and rigidity.

Path. Anat. and Location: Gumma and syringo-myelus. Small cavities in anterior cornua.

At ninth dorsal vertebra anterior aspect.

Remarks: Taylor, _Lancet_, 1883, p. 685.

31. Sex and Age: M. 7.

Clinical History: Paraplegia, except adductors and rotators of thigh. Reflex contractures; most intense from irritation of penis and scrotum. Rigidity of legs. Complete anæsthesia of lower half of body. Later, anuria, incontinence of feces. Anal sphincter reflex; figured stools. Cystitis. Pain on percussion in dorsal region. Pain in back. Complete paraplegia. Very late, brain symptoms. Duration, nine months.

Path. Anat. and Location: Tubercle (?).

Cord soft for two inches.

Tenth dorsal vertebra.

Remarks: Geoghegan, _Dublin Med. Press_, 1848, xix. 148-151.

32. Sex and Age: F. 46.

Clinical History: Fixed pain in left iliac region. Paresis in left leg, increasing to paraplegia. Formication. Girdle sensation. Incomplete, increasing to complete, anæsthesia of legs. Spontaneous twitchings. Bladder and sphincter ani paralyzed. Bed-sores. Duration, one year.

Path. Anat. and Location: Fibroma (?) from inner surface of dura. Cord hollowed out and softened.

Interval between tenth and eleventh dorsal vertebræ.

Remarks: William Cayley, _Tr. Path. Soc. Lond._, 1864-65, vol. xvi. 21-23.

33. Sex and Age: M. 30.

Clinical History: Hyperæsthesia; later, anæsthesia in legs; then complete paraplegia.

Path. Anat. and Location: Tubercle size of pea. Adjacent myelitis. In lower dorsal region.

Remarks: Chvostek, _Med. Presse_, 33-39, 1873 (quoted by Rosenthal).

{1111} 34. Sex and Age: M. 31.

Clinical History: Ataxia; stiffness of legs and cramps in abdomen and legs. Slight nystagmus. Difficulty in forming words. Ataxia of arms. Slight wasting of legs, especially of left. Lumbar pains; abdominal cramps. Dysuria. Impotence. Later, increased spastic state of legs. Mind depressed and emotional; attempts at suicide. Anuria. Bed-sores. Urine albuminous. Duration, one year.

Path. Anat. and Location: Myxoma of dura mater 3 inches long. Dura mater of brain contained fluid and lymph.

Dorsal region, left side.

Remarks: Shearman, _Lond. Lancet_, vol. ii. 1877, p. 161.

35. Sex and Age: F. 50.

Clinical History: Pains in limbs (thought to be rheumatic). Paresis in legs. Hyperæsthesia in right leg; burning pains alternating with sense or coldness.

Path. Anat. and Location: Cancer of vertebræ (sarcoma?).

Dorsal region.

Remarks: Gull, by Wilks, _Dis. Nerv. Syst._

36. Sex and Age: F. 35.

Clinical History: Paresis of left leg; soon of right leg. Pain in back and left side. Tonic spasms of legs. Darting pains in knees. Partial anæsthesia. Exalted plantar reflexes. Dysuria. Later, complete paraplegia and anæsthesia; violent reflexes; severe pain in back. Bed-sores. Duration, seven and a half years.

Path. Anat. and Location: Tumor, osseous or fibrous, three-fourths of an inch long, growing from dura mater. Cord flattened, and softened below tumor.

Lower part of dorsal cord.

Remarks: H. Ewen, _Tr. Path. Soc. Lond._, 1848-50, i. 179.

37. Sex and Age: F. 28.

Clinical History: Weakness in legs. Aching and shooting pains in legs. Numbness and formication. Slight spasm in legs. “Felt as if ground was some distance below feet.” Œdema of ankles. Later, numbness extended to abdomen. Paralysis of bladder. Hyperæsthesia in right leg. Obstinate constipation. Bed-sores. Some paralysis of respiratory muscles. Duration, fourteen months.

Path. Anat. and Location: Tubercle the size of cherry, which had almost obliterated cord. Tubercles in lungs, bowels, and uterus. Bed-sore had opened spinal canal.

Lower part of dorsal cord.

Remarks: S. O. Habershon, M.D., _Guy's Hosp. Rep._, London, 1872, 3d S., xvii. 428-436.

38. Sex and Age: M. 63.

Clinical History: Progressive paresis of left leg for five years. Right leg then paretic. Paralysis then in left leg. Rigidity on extension of right leg. Paroxysms of clonic spasms in right leg. Joint pains, sciatic pains. In left leg, hyperæsthesia, in right leg, anæsthesia. Plantar reflex retained; other reflexes exaggerated. Diplegic contractions in right leg from irritation in left. Late symptoms: purulent urine, with retention; chest and lumbar pains like bone pain; extension changed to flexion; swelling of legs and ecchymosis; sacral and other eschars.

Path. Anat. and Location: Psammoma adherent to dura mater. Cord softened. Ascending degeneration in posterior columns, and descending degeneration of lateral columns.

In dorsal region just above lumbar enlargement, anterior left side.

Remarks: Charcot, _Arch. de Physiol._, Paris, 1869, ii. 291-296.

39. Sex and Age: M. 20.

Clinical History: Paralysis of lower extremities; tremor; exaggerated reflexes, hyperæsthesia of trunk; bed-sores. Œdema of feet. Fever. Pus in urine.

Path. Anat. and Location: Organized blood-clot exterior to dura mater. Cord compressed and softened.

Opposite lower dorsal and upper lumbar.

Remarks: C. B. Nancrede, _Am. Journ. Med. Sci._, O. S., lxi. 156.

40. Sex and Age: F. 38.

Clinical History: Pain around abdomen, in back, and legs. Paraplegia. Anæsthesia and tingling of feet and legs. Paralysis of bladder.

Path. Anat. and Location: Hydatid cysts of vertebræ (?) and spin. canal.

Lower part of spinal canal (probably lumbar region).

Remarks: S. Wilks, _Dis. Nerv. Syst._, p. 265.

41. Sex and Age: F. 23.

Clinical History: Bronzing of skin for two years; then headache, giddiness, fever. Choreic movements in left arm, then in leg, then general. Bronzing increased. Vomiting after meals. Duration, two years and two months.

Path. Anat. and Location: Tumor, consisting of granular matter, with a few nerve-fibres and cells, springing from centre of cord backward to posterior fissure. Cord slightly widened. Suprarenal capsules large and nodulated.

Lumbar enlargement.

Remarks: W. H. Broadbent, _Trans. Path. Soc. Lond._, 1861-62, viii. 246.

42. Sex and Age: 10 ms.

Clinical History: Twitching and convulsive movements of right leg. After removal of exterior tumor the movements ceased. Child died of peritonitis.

Path. Anat. and Location: Tumor outside of sacrum, and also protruding through sacral opening. Reported to have been behind and pressing upon cord (?). Fatty growth within membranes.

Remarks: Arthur Johnson, _ibid._, 1856-57, viii. 28, 29.

{1112} 43. Sex and Age: F. 54.

Clinical History: Paresis, first of left arm and leg; then paralysis of these and of right arm and leg. Pain in back and hips early; then, suddenly, darting pains and incontinence of urine. Paræsthesia of left arm and leg; no anæsthesia. Coma.

Path. Anat. and Location: Hydatid cyst. Cyst also in liver. Fluid beneath membranes of cord and brain.

At first and second left sacral foramen, opposite last lumbar and upper three sacral vertebræ.

Remarks: H. S. Wood, _Australian Med. Journ._, 1879, N. S. i. 222.

44. Sex and Age: M. 46.

Clinical History: Fibrillary twitching. Increased patellar reflexes. Paræsthesia and hyperæsthesia in legs, disappearing. Constriction of chest (?). Headache. Dysuria for two years. Straining at stool. Indigestion. Bloody vomiting. Cardiac palpitation; intracardial murmurs; slow pulse. Swollen inguinal glands. Variations in temperature. Bed-sores.

Path. Anat. and Location: Glioma.

At filum terminale, upper part.

Remarks: Lachman, _Arch. f. Psychiat._, Berl., 1882, xiii. 50-62, 1 pl.

45. Sex and Age: M. 38.

Clinical History: Pain in legs. Œdema. After two years could not lie down: rested on hands and knees. Paralyzed in legs; pain in seat. Anæsthesia in legs, not complete in right. Paræsthesia in left. Dysuria and constipation. Before death had incontinence with hæmaturia, and was able to lie down.

Path. Anat. and Location: A lobulated tumor from pia mater at lower end of spinal canal, surrounded by nerves of cauda equina. Structure not made out.

At cauda equina.

Remarks: W. W. Fisher, _Tr. Prov. M. and S. Ass._, 1882, x. 203-208.

46. Sex and Age: ——

Clinical History: This case had symptoms of posterior spinal sclerosis, which possibly had no relation to growth, according to reporter.

Path. Anat. and Location: Myo-lipoma attached to conus medullaris. Crescentic, clasping cord from anterior to posterior fissure. Nerve-roots of cauda equina imbedded in it. Contained striated muscular fibres.

Remarks: W. R. Gowers, _Tr. Path. Soc. Lond._, 1875-76, xxvii. 19-22.

47. Sex and Age: Und. 1 yr.

Clinical History: Spina bifida (?); hydrocephalus; convulsions, bloody stools; partial paraplegia. (Above symptoms came on after closing of sacral opening by surgical operation.)

Path. Anat. and Location: Congenital sacral neuroma amyilinicum.

Remarks: W. F. Jenks, M.D., _Trans. Path. Soc. Philada._ (1871-73), 1874, iv. 190-192.

48. Sex and Age: M. 30.

Clinical History: Pain in back; abdominal girdle sensation. Pain in legs; paraplegia; nearly complete anæsthesia; paralysis of bladder; bed-sores.

Path. Anat. and Location: Aneurism, eroding vert. and compressing cord. Location not given.

Remarks: Wilks, _Dis. Nerv. Syst._

49. Sex and Age: M. 54.

Clinical History: Paralysis of both legs, of sphincter ani, and of bladder; urine alkaline, with pus and blood. Partial anæsthesia. Pyonephritis.

Path. Anat. and Location: Gumma from inner layer of dura mater and involving pia mater. Location not given.

Remarks: Delafield, _N. Y. Med. Rec._, 1875, x. 131.

50. Sex and Age: Stillborn.

Clinical History: ——

Path. Anat. and Location: Tumor, size of head of child two years old, projected between legs from spinal column. Nerves of cauda equina over anterior part. Some bone in tumor (dermoid cyst?).

Remarks: Virchow, _Monatschr. f. Geburtsk._, Berl., 1857, ix. 259-262.

{1113}

INFANTILE SPINAL PARALYSIS.

BY MARY P. JACOBI, M.D.

SYNONYMS.—Essential paralysis of childhood (Rilliet and Barthez); Myogenic paralysis (Bouchut); Acute fatty atrophic paralysis (Duchenne); Atrophic paralysis (Ferrier); Acute anterior poliomyelitis (Kussmaul, Erb, Seguin); Regressive paralysis (Barlow); Tephromyelitis (Charcot).

DEFINITION.—Of all the titles which have been given to the disease it is our purpose to describe, two alone may be considered irreproachable. In the present state of our knowledge it is unnecessary to argue that this disease is not essential—_i.e._ destitute of characteristic anatomical lesions. Neither can the theory of its myogenic origin be maintained; nor even is fatty degeneration invariably present in the paralyzed muscles. Finally, the disease cannot longer be regarded as peculiar to childhood,[1] since cases in adults have been in these last years quite numerously reported[2]—four with autopsies demonstrating the identity of the lesion. But there are two definitions in our list of synonyms which embrace between them the most striking characteristics of the disease, yet contain no error of fact. Atrophic paralysis describes at once the two most salient symptoms; acute anterior poliomyelitis defines at once the seat and nature {1114} of the lesion, classes it with the systematic diseases[3] of the spinal cord, and notes the peculiarity in the mode of invasion by which it is so remarkably distinguished from nearly all the organic diseases of this centre.

[Footnote 1: W. H. Barlow, _On Regressive Paralysis_, 1828. See _Brain_, April, 1879.]

[Footnote 2: In Dec., 1873, I quoted 14 cases of adult spinal paralysis, as follows: Duchenne, 4 cases; Charcot and Petitfils, 3; Moritz Meyer, 2; Bernhardt (_Archiv Psych._, 1873), 1; Cumming (_Dublin Quart. Journ._, 1869), 1; Lucas Championnière (by Hallopeau, _Archives gén._, 1861), autopsy, 1; Gombault (_Archives de Psych._, 1873), 1; personal, 1.

In 1874, Seguin published a summary of all the foregoing cases except the last, and added 6 personal observations, also 3 from Duchenne and 1 from Hammond. In the enlarged edition of his essay in 1877, Séguin increased the list to 45—by new personal cases, 3; cases related by Frey (_Berlin. Wochens._, 1874), 4; cases by Erb (_Arch. f. Psych. u. Nervenkrank._, v.), 4; case by Cornil and Lépine (_Gaz. méd._, 1875), autopsy, 1; case by Soulier (_Lyon méd._, 1875), 1; case by D. H. Lincoln (_Boston Med. and Surg. Journ._, 1875), 1; case by Lemoine (_Lyon méd._, 1875), 1; case by George M. Beard, 1; case by Leyden (_Klinik Ruckenmarks Krankheiten_) Bd. iv. 1; case by Hammond (6th ed. _Treatise_), 4; case by Courty (_Gaz. méd._, 1876), 1; case by Dejerine (_Arch. de Phys._, 1876), 1.

To these may be added—case by Goltdammer (_Berl. klin. Wochen._, 1876), 1; case by Webber (_Trans. Amer. Neurol. Ass._ for 1875, vol. i.), autopsy, 1; case by Klose (_Diss. Breslau_, 1876), 1; case by Schultze (_Virchow's Archiv_, Bd. lxviii.; also Bd. lxxiii.), autopsy, 1; case by Bernhardt (_Archiv für Psych._, Bd. ix., 1879); case by Sinkler (_Amer. Journ. Med. Sci._, Oct., 1878), 5; case by Althaus (_ibid._, April, 1878), 2; case by Ross (_Dis. Nerv. Syst._, vol. ii. p. 139), 1—total, 57 cases.

Morton (_St. Bartholomew's Hospital Reports_).

Others have doubtless been published since this date, but, as they do not immediately concern our subject, need no further citation.]

[Footnote 3: Vulpian, _Leçons sur les Myelitis_, 1880.]

SUMMARY OF CLINICAL HISTORY.—The clinical features of an acute attack of infantile paralysis are well known. The children affected are usually between eighteen months and four years of age (Henoch). The attack is more likely to occur in summer than in winter, as Sinkler[4] found that 47 out of 57 cases began between May and September, and Barlow noted 27 out of 53 in July and August.[5]

[Footnote 4: _Amer. Journ. Med. Sci._, April, 1875.]

[Footnote 5: _Loc. cit._, p. 75. Among Sinkler's 57 cases, only 6 furnish autopsies, thus:

Case by Cornil and Lepine and case by Webber (quoted and accepted by Erb in _Ziemssen's Handbuch_, Bd. xi.); case by Gombault (rejected by Erb and Westphal); case by Schultze; cases by Dejerine and Lucas Championnière (quoted by Hallopeau).

The influence of heat is perhaps shown in the case related by Dyce-Duckworth in the _Lancet_ of 1877: a child two and a half years, after exposure to great heat on a steamboat-landing, became paralyzed in all four limbs, but the paralysis was subsequently confined to the lower extremities. Coincidently, the patient became delirious; suffered from anæsthesia and temporary paralysis of the sphincters. The paralyzed muscles wasted rapidly and lost faradic contractility. Treatment by faradization was begun in a month from the date of the attack, and recovery was complete three months later.]

The onset of the paralysis is either really sudden, occurring in the daytime, while the child is under competent observation, or apparently sudden, being discovered in the morning after a quiet night, the child having gone to bed in health (West); or is preceded by some hours or days of fever or of nervous symptoms, especially convulsions, or both. The paralysis is almost always at its maximum of extent and intensity when first discovered, and from this maximum begins, within a few hours or days, to retrocede. The improvement may, however, be delayed much longer. A variable number of muscles remain permanently paralyzed, and in these, within a week (thirty-six hours, according to some observers), faradic contractility is first diminished, then abolished; galvanic reaction is exaggerated, ultimately is characterized by the degeneration signs (entartungs reaction). The temperature of the paralyzed limbs falls; the muscles waste; the atrophy may rapidly become extreme. The paralysis and loss of faradic contractility are complete, however, while the atrophy is only incipient and progressing. The absence of lesions of sensibility, of visceral disturbance, of trophic lesions of the skin, or of sphincter paralysis is as characteristic of the disease as are the positive symptoms above enumerated.

In the third or chronic stage the paralyzed limbs often become contracted and deformed. At other times, and with more complete paralysis, the growth of the bones is arrested, the muscles remain flaccid, the entire limb shrivels, and dangles so loosely from its articulations that it may be dislocated by slight effort (membre de Polichinelle). The general health of the patient remains remarkably good, the intelligence clear, the disposition lively. The duration of life seems to be in nowise shortened by the paralysis. Thus, suddenness of development, intimate association of trophic, motor, and electrical disturbance, absence of cerebral or sensory lesion, peculiar localization and grouping of the permanent paralyses,—such are the salient characteristics of this remarkable disease.

SYMPTOMS IN DETAIL.—Three well-defined stages exist—the initial, the paralytic, and the chronic.

{1115} Initial Stage.—Seeligmüller[6] signalizes three principal varieties in this stage. The first is characterized by fever; the second by nervous symptoms, principally convulsions, sometimes delirium or coma; in the third no symptoms either precede or accompany the local disease—“la paralysie est toute la maladie.”[7]

[Footnote 6: _Gerhardt's Handbuch der Kinderkrankheiten_, 1880 (separat Abdruck).]

[Footnote 7: Rilliet et Barthez, _Traité des Maladies des Enfants_, ii. p. 551.]

Mode of Invasion.—I have elsewhere[8] described eight different modes of invasion: absolutely sudden, coming on in the daytime; morning paralysis (West), discovered after a quiet night, preceded by fever or by vomiting alone (?), or by another typical disease, especially one of the exanthemata, or, finally, by a traumatism, generally slight. An interval of time almost always elapses between the occurrence of the traumatism and the development of the paralysis—a fact which already indicates that a definitely-evolved morbid process must intervene between the two occurrences. An exception is related by Duchenne fils;[9] and some apparent exceptions, in which recovery occurred rapidly, seem to belong to the temporary paralysis of Kennedy,[10] more recently described again by Frey.[11]

[Footnote 8: _Am. Journ. Obstet._, May, 1874.]

[Footnote 9: _Archives gén._, 1864. A father pulled his child from a table by the right arm, and set it rather roughly on the ground. Immediate pain, almost immediate paralysis of arm, which persisted, and was followed by atrophy of its muscles.]

[Footnote 10: _Dublin Quarterly_, 1850.]

[Footnote 11: _Berlin. klin. Wochens._, 1874. Frey considers these cases to be identical in nature with, though differing in severity from, anterior poliomyelitis.]

PRODROMATA.—There is rarely any lengthened period of prodromata. Seeligmüller has noticed in some cases an indisposition on the part of the child to stand or walk during several weeks before the occurrence of the paralysis. He does not say whether such children were rachitical. In marked contrast with cases of cerebral paralysis is the habitual absence of generalized nervous symptoms. Thus in only 1 case of Seeligmüller's (total of 75) did the child suffer, and that during six months preceding the paralysis, from intermittent muscular contractions, and also from attacks of laryngismus stridulus.

The fever is usually of moderate severity (Seeligmüller), but sometimes extremely high (Erb)[12]—as much as 41° C. (Henoch),[13] or 104° F. (Barlow).[14] Duchenne fils observed 7 cases alleged to be entirely without fever, and Laborde counts 10 cases out of 50 as apyretic.[15]

[Footnote 12: _Ziemssen's Handbuch_, Bd. xi. Abh. 12.]

[Footnote 13: _Vorlesung. über Kinderkrank._, 2d Aufl., 1881. Seeligmüller (_Jahrb. für Kinderheilk._, 1878, p. 345) quotes another case from Henoch's clinic where the fever lasted thirty-six hours, the temperature on the first evening being 39.2°, the following morning 39.0°, the second evening 39.5°; the second morning, at which date the paralysis was discovered, it was normal. The author states this to be the only case known to him in which thermometric measurements were taken.]

[Footnote 14: _Loc. cit._]