The tremors of sclerotic affections, particularly those accompanying the disseminated forms, are from their distressing character prominent objects of special treatment. The bromides have been given with alleged good effect which I am unable to confirm. Curare has caused the tremor to disappear for two days in one of Erlenmeyer's patients. I have seen good results from the descending galvanic current applied in long sittings to the head and neck, sliding in to the point of tolerance, and sliding out before discontinuing. The mydriatics, atropine, and particularly hyoscyamin, often remove tremor radically for the time being; unfortunately, it is necessary to give them in almost toxic doses to obtain this effect. Recently, Feris recommended veratrum in doses of half a milligram repeated every four to five hours. It acted very well in every case in which I tried it, but, as it became necessary to increase the dose, the same objection was encountered as in the case of hyoscyamin. All these measures should be used as emergency remedies only; they cannot, in the nature of the case, prove curative, while their continued use produces a physiological indifference to their effect, and to that extent decreases their value as the case progresses.
MANAGEMENT OF SPECIAL SYMPTOMS AND COMPLICATIONS.—Among the most distressing features of many sclerotic affections is pain, which is usually associated with sleeplessness. The fulminating variety may be often relieved by the use of the actual cautery applied over the affected level of the cord and along the course of the nerve involved. But in the majority of cases morphine will have to be resorted to. Erb cautions against the use of this anodyne in cases where there is much reflex irritability of the cord, as morphine is said to increase this irritability when administered in small doses, and to reduce it again only when larger ones are administered. It is the latter alone which are serviceable with pain, and I have not yet seen any bad effects in the direction apprehended by Erb from such doses as it is necessary to give. That the physician administering it should be always on guard against the possible formation of a drug habit it is unnecessary to add. But it is also unnecessary to add what alternative he shall adopt when his choice lies between the lesser evil of the opium or morphine habit and the terrible martyrdom which some patients would be compelled to submit to if not allowed to indulge in it.176 The evil effect of opium and its preparations on the visceral functions is to be neutralized, as far as possible, by the administration of laxatives and bitter tonics.
176 Few sufferers from spinal disease use anodynes habitually; opium and its preparations are not fascinating to the majority of persons. On the other hand, there are two cases of tabes dorsalis now under my observation in which the patients have been compelled to use hypodermic injections of Magendie's solution for two and three years without any materially bad effect.
The deep-seated diffuse pains, such as are found in disseminated and diffuse sclerosis, are not as markedly relieved by opium as the terebrating and lightning-like variety. Frequently spastic or other signs of increased reflex excitability are associated with them; and as both are favorably influenced by the bromides, the latter are doubly indicated in such conditions.
With pains of a rheumatic character static electricity has been recommended. It undoubtedly relieves such pains, as skilfully-applied galvanism would. Its chief effects, it seemed to me from a six months' trial with it, are on the imagination and hopes of the patient.177
177 A large apparatus of the new and improved make was at my disposal at the nervous department of the Metropolitan Throat Hospital. It was very popular with sufferers from rheumatism, who had been allowed to accumulate in the class before I took charge, and with a paretic dement who suffered with the rheumatoid pains often found with diseases such as his.
The bromides and camphor178 are recommended for the obstinate priapism found in some cases of early tabes and transverse myelitis. I have seen better results from warm hip-baths and general baths in this condition than from any drug. As a general rule, the exercise of the sexual function, where not already forbidden by the results of the disease, should be limited as much as possible. The frequency of normal seminal emissions in a given case is a guide to the amount of indulgence in this direction which may be permitted. Where there is the slightest indication of irritative or destructive lesions in the upper lumbar cord sexual acts should be entirely prohibited, for under these circumstances no greater injury could be done the weakened centres than to permit them. This is particularly noticed in those cases of tabes dorsalis which are marked by satyriasis in the early period.
178 Particularly the monobromate of camphor.
The treatment of the bladder trouble and of bed-sores is carried out in the manner described in the section on Acute Myelitis. For bed-sores Hammond recommends the application of a stabile galvanic element consisting of a plate of silver and one of zinc, the two being united by a wire isolated in the usual way. The silver plate is laid on the bed-sore; the zinc plate, covered by a piece of moistened cloth, is laid on the unbroken skin somewhere in the neighborhood. The result is a weak current under whose stimulant effect the healing process takes place very rapidly. I have seen excellent results that had been obtained by this means in indolent ulcers of the leg. It does not, however, seem to have been tested with the malignant variety of bed-sore.
With regard to the management of muscular atrophies by electricity, massage, and strychnia, the same rules are to be followed which are laid down in the section on the Myopathic Atrophies. It is only to be specially remarked that few authorities encourage the administration of strychnia in sclerotic affections, and fewer still in such large doses as could be of any benefit in a wasting process.
Faradization of the affected eye-muscles is often useful in diplopia. The current may be applied by means of a cup-shaped eye-electrode, or, better, by using a finger as an electrode.
The moral management of sufferers from sclerotic spinal affections is very important. The popular notion about spinal disease generally is such that the announcement made to a patient that he is suffering from any form of it is as alarming as would be the discovery of a tumor in his brain or a cancer in his stomach, and exerts a depressing effect. This it should be sought to avoid. A large number of sufferers from sclerosis live longer and suffer less than a portion of those afflicted with rheumatic and gouty affections; and the physician is justified in obtaining the desirable effect which a hopeful or resigned state of the mind undoubtedly has on the body, by laying great stress on this undeniable fact.
The writer was asked to contribute a short article upon Concussion of the Brain and Spinal Cord for this work, as these injuries are apt at first to come under the notice, if not charge, of the general practitioner. The article will therefore not be an exhaustive one, and there will be little but the details of personal experience and less quoting of authorities. Much has been written recently upon the subject both in volume and in pamphlet.
Diverse views of equally competent judges of the matter have been put forth, and the brains and spinal cords of the partisans appear to have received as severe a shaking up as the real recipients of the lesions, if absolute lesions there be.
This, in fact, is the point of controversy, for there are those who seem to deny that there can be a jarring or shaking of the cerebro-spinal mass sufficient to cause positive symptoms without producing positive lesions, whilst others are as firm in their convictions that pronounced symptoms may follow a mere disturbing ripple of the nervous elements. How is the question to be settled? The slightly shocked or injured recover rapidly, whilst some who only appear to be as slightly injured or shocked at first, go on to death, during the progress to which event there is no doubt as to the existence of lesion and no difficulty in finding it at the autopsy. Hence, say the lesionists, the first ones had it, but got well, whilst the non-lesionists affirm that it never existed in them.
The logician would think that these differences in opinion were only differences in degree about the same thing, but, nevertheless, the question is one for serious discussion, and is of much greater importance than would appear to be the case to the average layman.
This importance lies in the medico-legal aspects of the suits arising out of the alleged injuries and their consequences. Judges, lawyers, and doctors know them well. In doubtful cases authorities of equal eminence are quoted, and the results of trials are equally as doubtful as to whether justice or injustice has been done. These remarks, as will be seen, are especially applicable to injuries of the spine, but they also may have place in the consideration of consequences arising from concussion of the brain.
Whatever doubts there may be as to concussion of the spine, there are none, I believe, who deny the appropriateness of the expression as to the brain, it being, by its anatomical relations, so much more exposed to shock than the spine.
We understand that pure concussion, uncomplicated with fracture, refers to a condition caused by external violence, direct or indirect, which communicates a jar or shock to the cerebral mass, and which expresses itself by certain well-defined symptoms. The nervous system and the circulation are most manifestly involved, but in a pure case it may be said that all of the symptoms arise from central nervous disturbance. Even could it be shown that they were dependent on temporary congestions, these congestions, I think it will be admitted, would be due to vaso-motor derangements.
The anatomical appearances after early death from concussion of the brain are often insufficient for us to comprehend the fatal result, for we know that the organ will bear, both from disease and other kinds of injury, vastly greater inroads upon its structure and surroundings without causing death. Often there is mere localized cerebral congestion, with no ruptures of vessels; then there are slight extravasations shown as points or dots of blood in the nerve-matter; and, again, there is what is called the bruised brain. Sometimes there is nothing abnormal whatever to be found. Most of these cases, under modern criticism, have been justly shut out from the record as having no value; for it has been shown that the post-mortem examinations of them have been very imperfect, the brain only having been inspected, whereas the chest, the abdomen, or the spine might readily have revealed the cause of death.
It is fair, however, to assume that there must be a capacity for serious results in the vibratory jar, as the discoverable lesions in many well-examined cases have been in themselves insufficient to kill. The rapidity of recovery of those who get well also bears weight on this point.
Of nineteen cases of recovery from concussion of the brain of which I have record, the average stay in hospital was eight days. The range of stay was from one to twenty-five days. Many of these were at first profoundly shocked, some of them apparently hopelessly so when we compared their symptoms with those who died. As they recovered, however, in so short a time, there surely could not have been any gross lesion to account for their symptoms. What else, then, can account for them than vibratory jar? and if this can produce such severe results within the line of recovery, why cannot the degree of it be so extended as to involve, for example, the respiratory centres, and so kill without leaving perceptible sign?
The SYMPTOMS of concussion of the brain range from a mere daze or stunning to those of deep unconsciousness. There is no paralysis of the extremities in pure cases. Often the patient is very restless, and throws his limbs about in all directions. When these are quiet there is response to irritation and electricity. Loud speaking to him may elicit some attention, but the answers are mostly incoherent. There is pallor, often extreme, coldness of surface, and sweating. Vomiting is usual, and may come on immediately or later, and it continues as long as there is anything to discharge; sometimes there is retching. In favorable cases the cessation of vomiting is accompanied by a slow return to consciousness, which may be preceded by delirium. This return is never sudden, and the method of it serves to distinguish the case from that of some forms of epilepsy. The pulse is generally frequent and feeble, often irregular; in extreme cases it may be slow and feeble, very rarely, if ever, strong or bounding. After reaction it becomes more natural, and if recovery follows it will not show much variation. The temperature is depressed at first. In one characteristic case it was 98° on the first day, reached 101° on the third day, and receded to 98½° on the eighth day, when the brain symptoms disappeared.
There may be retention of urine and sluggishness of the bowels, but in bad cases coincident with the vomiting there is sometimes involuntary discharge both of feces and urine. The respiration is irregular, sometimes almost ceasing, and then returning with great rapidity.
Much has been said and written about the condition of the pupils in concussion of the brain. I have made this matter a subject of observation, and am convinced that the state of the pupils is of no diagnostic value whatever as to determining the existence of concussion or compression. Their state is of great value in telling us that the functions of certain brain-centres are partially or wholly impaired. The progress of the case will tell us whether the impairment is due to clot or effusion, congestion or jar.
It is wrong, therefore, to say that the pupils are one way in compression and another in concussion. It is right to say that in either case they are sluggish or wholly irresponsive to light. In one person they may be dilated, in another contracted, and in the same person the eyes may present marked contrasts.
In the light of modern physiology this is what might be expected. The condition of the pupils is dependent on that part of their nerve-connections which is involved in the injury, and also upon the method of that involvement. Clinical experience, I think, amply sustains this view.
The reaction from what may be called pure concussion is generally slow. The patient is apt to be dazed for some time, although the pulse and temperature may be normal. When there is a rebound with fever, and florid complexion, and suddenly or gradually another but deeper unconsciousness supervenes, it is almost certain that positive lesion took place at the time of injury, and that the reaction has brought with it great congestion if not extravasation.
Now, really, compression to be followed by inflammation is the condition demanding attention.
DIAGNOSIS.—The history of the case and the symptoms as detailed will enable us to reach a conclusion in most cases as to the existence of concussion of the brain. There are some conditions, however, from which it is to be carefully distinguished. These are simple fracture, with or without depression, compression from any cause, drunkenness, and epilepsy.
There may be such profound shock with fracture that at first concussion symptoms mask those of the lesion, or even keep them for a time completely in abeyance. The head bruises are often very deceptive to the touch in the search for fracture.
I am in the habit of directing students to feel their own scalps, in order that they may appreciate the fact that the touch gives no sensation whatever of the natural thickness of the cranial covering. It seems as though something like a piece of thin parchment only intervenes between the fingers and the bone. The fact is, the scalp varies from an eighth to a quarter of an inch thick, differing in different places, and where muscles, as the temporal, for example, are beneath it, the bone is much deeper. The importance of this observation lies in the fact that a pulpefied bruised mass of scalp will cause the edges of its healthy surrounding part to feel almost precisely like bone around the borders of a depressed fracture. The accompanying general symptoms will mostly not be in accord with this condition, but in some cases the deception is so complete that it is very difficult to persuade those not familiar with the fact that a fracture does not exist, and to induce them to refrain from rash proceedings.
One case I can call to mind where the opinion of the attending physician was only changed by the ultimate favorable result, which left no sign of permanent injury of any kind. These cases are particularly apt to occur with children.
I remember also another source of deception. A boy was severely injured by a blow upon the forehead. Concussion was marked. There was a lacerated wound reaching to the edge of the orbit; fractured bone could be felt, and at first sight what appeared to be brain-matter was oozing from the wound. A hasty unfavorable prognosis was given to the parents. On closer examination it was found that the fracture was of the external wall of the frontal sinus, and the supposed brain-matter was the delicate fat-lobules of the orbit. The patient recovered rapidly.
There is a marked distinction between the ordinary symptoms of concussion and those of compression, whether from depressed fracture or effusion, as of blood in apoplexy. Here there are flushed, often swollen, countenance, stertorous breathing, slow and it may be strong pulse, deep or absolute insensibility, and fixed pupils. The injury, if there is one, is mostly palpable and explanatory. If it is concealed, the other symptoms point to the true nature of the case.
The diagnosis from drunkenness is not always easy, although deep intoxication is more apt to be accompanied with compression than with concussion signs. Drunkards often have bruises on their heads caused by falls, and some of them are pale and sick after debauch. The smell of liquor is not always reliable, for it is so common after accident for friends to administer stimulants before the patient is seen by a medical man that he might be easily misled into too hasty a judgment. The general appearance of the old stager is well known, but in cases where there is the least doubt the patient, whether in hospital or in private, should be kept a sufficient time under observation for the effects of drink to pass off. Then it will be seen whether this has masked a more serious condition. Too hasty conclusions in this matter have led to most unpleasant occurrences. These are well known in police administration and to hospital men.
The convulsions of the epileptic, the foaming mouth, and the quick return to partial or complete consciousness will generally serve to distinguish the case from one of concussion, but at times there are those who require also to be kept under observation for some hours, and even a day or more, in order to come to a correct conclusion.
The PROGNOSIS in concussion is generally favorable, but if complete unconsciousness is present it is doubtful as to the individual so long as this lasts, for, as before intimated, the cases which recover may present as marked symptoms at first as those which prove fatal.
Recovery is mostly complete, but not suddenly so. The after-effects in any case may prove serious.
There is, however, an unwarranted tendency to attribute any defect in character, and even criminal lapses, to a blow upon the head, especially should the history or marks of one be discovered as having occurred at any time, no matter how long, previous to the inquiry.
The blow may be the cause of subsequent epilepsy, chronic inflammations, and insanity or imbecility. These cases have, however, an almost continuous history of trouble from the date of the injury, the manifestations varying in severity from time to time as pathological changes go on or as exciting causes develop them.
TREATMENT.—Absolute simple rest in bed is all that is necessary in mild cases of concussion. The patient should be well watched for any symptoms which might supervene and show that the injury was more severe than at first supposed. On the other hand, serious symptoms may be present without indicating any great gravity in the case. Children, for example, often have convulsions from the slightest cause. I have attended them when these set in immediately after the injury, but in a day or two there was entire recovery.
The more serious cases equally require rest, but also something more. To bring about reaction from shock, sinapisms to the extremities, to the nape of the neck, and over the stomach should be used. Hot-water bags should be placed along the sides of the body and limbs. Alcoholic stimulants must be sparingly used, if at all: they are rarely necessary. The stomach will often reject them unless in minute doses. If too much is absorbed, unpleasant consequences to the brain may follow. In extreme cases hypodermic injections of brandy or ether may be administered. Ammonia, camphor, and other diffusible stimulants may be useful, either externally or internally.
If the reaction is regular, with gradual restoration to consciousness and no noticeable rise in temperature, nothing further is required but a continuance of the rest and the use of cooling drinks and spare diet. The bowels and bladder must be attended to; the catheter may have to be used.
Restlessness, with or without delirium, is not unusual, but it generally subsides under full doses of bromide of potassium.
When reaction is followed by high fever, and especially when there is with it a passing on into secondary unconsciousness independent of true sleep, we have almost surely internal compression from congestion, effusion of serum, or hemorrhage to deal with. Now, blood may be taken generally or locally with great benefit. Cups, both dry and wet, to the temples and back of the neck are very useful. Leeching also is an efficient method of depletion. Ice in bags or towels, or cold water, should be applied to the head. Hot water, say about 120° to 130°, to the head is often of great service and very soothing.
The choice between cold and hot water is to be determined by the effects produced. Sometimes surprisingly good results come from alternating their use. Hot mustard foot-baths may be given in bed while the patient is kept lying on his back with the limbs flexed.
The result only in these severe cases will determine whether the symptoms were due to great congestion or to extravasation, possibly with brain lesion. Complete recovery takes place in the first condition. In the latter a fatal termination is much more probable, and if there is recovery it is apt to be only partial, and the patient may be the victim of nervous troubles more or less pronounced throughout a long life.
John G. Johnson of New York is authority for the statement that English railways paid in five years two million two hundred thousand pounds, or eleven million of dollars, as damages awarded by juries in cases of concussion of the spine. The statement appears almost incredible, but the facts are ample to sustain it.
It also illustrates the powerful influence of one great authority (Erichsen) better than anything I know of in the history of the medical profession. After this celebrated surgeon's lectures and work on concussion of the spine, etc. were published, dating back to 1866, the great body of medical men received them as the standard and guide in all such cases. They were a godsend to plaintiffs and prosecuting attorneys, and the defendant had a poor chance with juries when the possible miseries of any one who claimed compensation for injury to the spine was pathetically pictured to them.
That the defendants have suffered injustice in a great number of cases I think there can be no doubt. Is it any wonder, therefore, that a reaction has occurred of late, and that the views formerly held by professional men have been subjected to sharp criticism founded upon a much more scientific and practical knowledge of the subject at issue?
As in all reactions, extreme views have been reached by certain observers, and there are those who seem to hold that concussion of the spine cannot occur. By spine here is meant the spinal cord or marrow.
It has been well remarked, I think by Page, that we do not speak of concussion of the skull. We always say concussion of the brain. The use of the term spine has given rise to much confusion, but the professional man will understand what is meant when so-called concussion of the spine is under discussion.
The advocates of the rarity or even impossibility of the injury call attention with much force to the anatomical facts. First, to the immense strength, pliability, and cushioning of the bony and ligamentous encasement or column; then to the ample calibre of the canal in which the nervous cord is suspended, and to the pliant structures intervening between its inner walls and the cord itself. From without inward, in the canal, we have fat, watery connective tissue, and the plexus of spinal vessels; then comes the dura mater, loosely investing the cord and unattached to the bone, not forming here, as in the skull, the internal periosteum. Within the dura mater is the arachnoid, its visceral layer separated by a wide interval from the viscus or cord, which interval contains the cerebro-spinal fluid; then the pia mater or vascular membrane, which closely invests the cord.
Besides these structures there is the ligamentum denticulatum passing from the dense pia mater to the parietes of the canal and supporting the cord and roots of the nerves in the most efficient way—pliable enough to yield and break the force of vibrations, and strong enough to sustain.
Thus we see that the cord is much more securely protected from the effects of external violence than the brain, and we can understand that there is reason for the doubt of the sceptics as to the frequency of the injury described as concussion of the spine.
Clinical observation is, I think, of far greater value in determining questions of the kind than any theory, however strongly supported by anatomical facts. Does transient concussion of the spine occur as transient concussion of the brain occurs? Page, if I understand him, says not. In his work on Injuries of the Spine and Spinal Cord (London, 1883), in criticising a well-known case as to the claim of persistent paraplegia without discoverable lesion, he says: “We italicize the word persistent, for simple concussion of the brain may give rise to a transient unconsciousness, and, if the analogy holds good, concussion of the spine should per se produce a transient paraplegia. We know of no case, nor can we discover the history of any case, where this has happened.”
I italicise the last sentence. In 1881 a boy came under my care who was shot in the back three inches to the right of the third or fourth dorsal vertebra. He at once had characteristic symptoms in the legs of being wounded in the spine in such a way as to affect the cord somehow. There was partial paraplegia, with pains in both limbs. Under rest these symptoms soon disappeared. In a few days I made a deep incision and removed some clothing and fragments of bone, and then from the depths of the spinal gutter I took a large conical ball which was resting against the bony bridge of a vertebra. The boy recovered rapidly. I saw him some months afterward perfectly well.
Surely, this was a case of spinal shock or concussion with transient paraplegia, and the cause of it could have been nothing else than the impact of the ball against the column, producing vibratory jar sufficient to affect the cord. The immediate symptoms and the rapid and complete recovery are, in my opinion, inconsistent with any theory of congestion or pronounced lesion of the medulla.
Here is another case of transient paraplegia also occurring in 1881, and, to my mind, still more significant: A man fell from a height of about twenty feet and landed directly on his feet. He was immediately paraplegic. On examination no injury to the spinal column could be detected, but there was fracture of both calcanea. The spinal symptoms were thoroughly marked. Besides the paralysis of the limbs there was loss of control of the bladder and bowels, and the other accessories in such cases. But all went on to recovery. Pari passu with the fractures the spinal symptoms improved. It is not necessary here to give further details, but simply to state that in four months, the time required being chiefly due to the fractures, the patient was discharged able to walk and well in every other respect.
If this is not a case of transient paraplegia owing to spinal shock or concussion, I am willing to admit that I do not know the requirements of the critics when they ask for such cases. I think that it is no matter how the blow or shock to the column is received, whether direct or indirect, so that it is shown that the medulla is influenced within the line of recovery, without having suffered fairly presumable lesion.
President Garfield surely suffered from transient spinal shock produced immediately by impact of the bullet upon the column. The symptoms soon passed off, and at the post-mortem the cord was healthy in every respect. The differences between his case and the others I have mentioned were those of degree only, his concussion not being severe enough to cause paraplegia.
Spinal concussion or shock from railway collisions does not differ from forms of the same injury received in other ways. It is absurd, therefore, to give a peculiar pathological history to so-called railway spine. That the injury occurs, I have no doubt; that the medulla is seriously affected in the vast majority of cases, I have very great doubt.
I cannot now, after thirty years of hospital and private practice, call to mind a single case of concussion of the spine arising from other accidents than on railways which has had the terrible after-history that is so often attributed to them; and I have seen in that time many cases of spinal injuries of all kinds.
There is another fact of personal experience. I have examined many cases of claimed irreparable or serious injury to the spine in private, both for plaintiff and defendant, in impending suits, but I cannot remember a single application of a patient for admission to the hospital to be treated for the after-effects of concussion of the spine, the original injury having been received in a railway collision.
As all sorts of people ride on railways, it is strange that the numerous recipients of concussions of the spine are pecuniarily independent of hospitals. One old fraud I do remember who fell from a street-car and claimed lasting injury to the upper part of the spine and the head, and adequate compensation for it in court. I was not called as a witness at the trial, and the plaintiff recovered very heavy damages. These were afterward reduced to a much smaller amount when it was discovered what I knew about the case.
Other structures of the spine besides the medulla are much more subjected to injury than it is, and their consequences often mislead both patient and doctor, especially the former.
The ligaments and muscles are exposed to contusions, strains, ruptures, and twists which are wrongly attributed to concussion. From these injuries and from so-called concussions the patient recovers rapidly or slowly according to their extent. If damages are looked for from a corporation, he is in a state of what may be called expectant pecuniosity, and shows no amendment until the question is settled. Otherwise, he gets well, as those do who are injured but have no expectations.
There is a striking want of confirmation by post-mortem examination of the terrible effects which are said to follow concussion of the spine.
In fact, the records of such examinations are so few, notwithstanding the immense number of those who have claimed to have the injury that the sceptics are somewhat justified in attributing the few cases which have shown great pathological changes in the cord and its membranes to the coincidence of disease, as myelitis or syphilis, or to much graver injuries than concussion.
I have reported a case in full in the Medical News and Abstract (Philada., Nov., 1881) which illustrates how coincidence might easily play its part in a supposed concussion. This feature of it is not alluded to in that paper. A gentleman began to complain of pain posteriorly at the root of the neck. Paralytic symptoms gradually developed. It is unnecessary to repeat the details here, but the history was a most dreadful one, and precisely that of the few serious ones described in the works on concussion. Within a year the patient died. The autopsy revealed a meningitis and softening and destruction of the cord to the extent of two and a half inches of its brachial enlargement. There was no other disease. Now, this patient frequently travelled on railways, and if he had been subjected to the slightest accidental shock it would have been received on all sides as the cause of the disease. There was, however, no such history, nor was anything ever known to account for the fact that a man in otherwise perfect health should have two and a half inches of his spinal cord as it were spontaneously destroyed.
I will state in passing that this case did not confirm the views of Johnson and others as to there not being any severe pain on pressure in myelitis. It showed also that clinical observation is not always in accord with plausible anatomical facts or reasoning.
Thus, Johnson says: “It is a mistake to suppose that meningitis or myelitis is accompanied by pain on pressure: the spinal cord is surrounded by a bony wall thicker than the bones of the skull, and you might as well press on the head to see if the brain is diseased.”
Now, in this case the pain was simply atrocious and greatly increased by pressure. To relieve both it and the disease the actual cautery was applied on both sides of the spinous processes; and some estimate may be made of the sufferings of the patient, who would not take ether, when he exclaimed as the hot irons were burning through his tissues, “Oh, that is better than the pain.”
To sum up, then, I think I have shown that concussion of the spinal cord proper occurs. I also believe it may occur in a railway collision just as it occurred in the man who fell twenty feet. Why should not a traveller sitting in a peculiar position—with his feet, for example, firmly against a partition or wall of the car—suffer it in a collision.
On the other hand, the great majority of those who after accidents claim injury to the spinal cord as the cause of their disabilities are wholly mistaken. The question is of great importance, for upon it depends the testimony as to whether the patient has sustained temporary or permanent injury.
Each case must be studied on its own merits. There is no class of injuries so full of opportunity for the exaggerator or malingerer. The history of many of them is by no means complimentary to human honesty. Those interested can study the special works on the subject: space is not given to detail them in this paper.
The SYMPTOMS and PROGNOSIS of concussion of the spine may be almost inferred from what has been written above. There are tinglings, pain, and sometimes cramps in the limbs; there may be partial or complete paraplegia which is transient in character. Complete paraplegia is very rare, and when it exists it almost always indicates a more serious injury than concussion. The case I have cited is an exceptional one.
The bladder is almost always affected; there is either suppression or incontinence. The bowels are sluggish for a time. The pulse is mostly quickened; the temperature does not vary much from the normal. Priapism, which is so frequently present in wounds involving the spinal column and cord, is not present in concussion.
I have in the Medical News (Nov., 1881) given my reasons for believing this symptom to be due to a coincident impression or laceration of the sympathetic nerve when there is a fracture or other injury of the vertebra. This view I have been able to sustain by a case reported in the Medical News (Philada., Feb. 25, 1882).
The PROGNOSIS of concussion of the spine is generally favorable. The recovery is slow in pronounced cases. Where such terrible consequences follow as are described in some of the cases which have been caused by railway collision, there is reason to believe that the original injury was either too severe to come under the head of concussion, or that some coincident deterioration was present at the time of the accident.
The DIAGNOSIS from fractures and dislocations is mostly easy. In these cases the local and general symptoms are nearly always so definite as to give no trouble in coming to a conclusion as to their nature. In obscure cases time will develop the truth.
In the TREATMENT of concussion of the spine the great remedy is rest. Under this alone the slight cases will rapidly recover. The more severe ones will require other aids, such as cupping, both wet and dry, to the spine over and about the chief seat of complaint. Sinapisms, blisters, and iodine are useful in the order named. Opium will be borne much better for the relief of pain and restlessness than in like injuries of the head. The natural functions must be looked after. Both the catheter and enemata may be required. Great care must be taken to provide against chafing of the skin and bed-sores. For this I know of nothing better than repeated sponging with alcohol, and drying the surface at once by a good rubbing. The points of pressure should be frequently changed by shifting the patient.
As soon as the acute symptoms pass away the patient should be encouraged to rise and use moderate exertion. This, if well borne, should be increased day by day, for it will be soon found whether the efforts are injurious or not. All the requirements are present in these cases to produce chronic hysterical invalids, both male and female. It is therefore incumbent upon the medical attendant to protect his patient from discouraging surroundings of any kind. It is also his duty to so act that while he will be careful to work no injustice, he will at the same time be on the watch for malingering, for this will often be practised, especially by those who are among the expectants already mentioned in this article.
The various subjects embraced in this article are so closely united to each other, both in a clinical and in a pathological point of view, that they must be considered to a certain extent in common. It is of course more systematic to group them entirely according to the obvious and final lesion, as hemorrhage, thrombosis, or embolism; but when it is considered how very closely the symptoms of one affection may counterfeit those of another—so closely, in fact, that a diagnosis with absolute certainty is not only difficult, but often impossible—and also that similar conditions of the vessels may give rise either to rupture or occlusion, so that not infrequently two sets of lesions may be found in the same brain, and, finally, that the basis of prognosis and of the later treatment is not unlike in different lesions,—we are surely justified in bringing them, at least in the beginning, under a common head.
Intracranial hemorrhage, and especially cerebral hemorrhage, is the lesion which more frequently than any other gives rise to the group of symptoms known as apoplexy, and from this fact has arisen the frequent incorrect application of the word apoplexy, in a pathological as well as a clinical sense, to indicate an extravasation of blood, as in the so-called pulmonary apoplexy, where the anatomical lesion, being an extensive effusion of blood into the tissues of the lung, bears an apparent resemblance to the state of the brain often found in apoplexy primarily and properly so called, the symptoms, however, being entirely different. This error receives additional support from the fact that in some injuries to the brain, especially to the base, pulmonary hemorrhage may secondarily take place. Apoplexy, however, is not always the result of hemorrhage, but occurs with many cases of embolism and of thrombosis, and is sometimes, so far as we can tell, dependent upon neither of these conditions, recovery in one set of cases taking place so rapidly as to preclude the supposition of a considerable organic lesion, and in others, which are fatal, nothing being found beyond an excess of serum or of vascularity, and sometimes not even that. The first of these conditions has been called simple apoplexy, but with our present knowledge its simplicity seems to border closely on ignorance, or at any rate is not of a character to satisfy the inquiring mind. It is therefore better to retain the term apoplexy strictly as a convenient term for a certain set of symptoms, but, whenever possible to substitute for it an anatomical description of the lesion found post-mortem or diagnosticated with reasonable probability during life.
The practitioner may very properly, and without laying himself open to criticism of his diagnostic accuracy, return the cause of death in a case of sudden death, or where his opportunity for observation has been limited, or where no post-mortem examination has been held, as being apoplexy; but in others, where the symptoms were decisive or a post-mortem has disclosed the exact lesion, the condition of the cranial contents should be stated. It is also a not uncommon mistake—or rather piece of carelessness—to speak of small hemorrhages in the brain as small apoplexies. A small extravasation may give rise to slight symptoms or next to none, but a real apoplexy can hardly be small, although it may be short.
The root from which the word apoplexy is derived seems to have been used by the classic writers in something like its present clinical signification (Απορληκτος, seized with (apoplexy or) stupor—Aristophanes; mad—Demosthenes; Αποπλησσομαι, to be struck with amazement—Sophocles). Morbus attonitus, another of its names, expresses a somewhat similar idea.
Morgagni was familiar with cerebral hemorrhage, and Bonetus in the Sepulchretum gives several cases. The allusions of Galen and Hippocrates supposed to refer to this lesion are not unequivocal, although the Father of medicine could hardly have helped being familiar with the symptoms of so striking a form of disease.
Cerebral softening has been recognized since the early part of the present century, and in some of the cases thirty years ago an efficient cause, in the form of arterial disease, assigned to it; but the complete theory of its causation forms a part of the general doctrine of embolism and thrombosis which was so largely developed and systematized by Virchow. Andral and Durand-Fardel had apparently no idea of the exact mechanism of its origin, the latter supposing it to depend upon inflammation, while Todd mentions a case where softening giving rise to paralysis depended upon a dissecting aneurism of the carotid. He seems to have generalized so far as to say that white softening is atrophic, but the precise way in which this localized atrophy was usually brought about evidently escaped him. According to him, the suddenness of the attack was owing to a gradual disorganization of the brain-substance with few or no symptoms, and then a sudden rupture of diseased fibres by some accidental cause or by their having reached the extreme limit of cohesion.
Intracranial hemorrhage may be situated outside of the dura mater, separating this membrane from the bones of the skull and producing more or less compression of the brain. It is usually the result of a blow, but not necessarily of a fracture of the skull. When a fracture is present, blood may pass through it from the interior and give rise to an external extravasation in addition to that which is likely to be the direct result of the blow upon the skin and subjacent soft parts. The middle meningeal artery is a frequent source of this hemorrhage. Hemorrhage in this position will naturally give rise to symptoms of compression, and, if the fact of the blow be not known or the fracture manifest, may be mistaken for some of the deeper-seated forms.