319

No.25

cinatory delirium. The patient recovered. The fourth case was of the convulsive type, and proved fatal. The fifth case was one of mixed coma and convulsions, with periods of delirium with hallucinations. An intermission of six weeks was followed by a return of the convulsions and coma, after which recovery gradually occurred. Trimborne believes that the cerebral symptoms in those cases showing no lead in the brain at the autopsy are due to secondary toxic action upon the blood, similar to uræmia, but not necessarily involving albuminuria. Eichhorst contributes a pathological study of the muscles and nerves, with a résumé of the cerebral lesions observed in encephalopathia saturnina. One case is reported, with autopsy, of double extensor paralysis, showing cerebral œdema, chronic leptomeningitis of the brain and cord, with advanced changes in the radial nerves, involving the white substance of Schwann and destroying the axis-cylinder and medullary sheath. S. G. Webber gives the detailed histories of 5 cases of mild lead poisoning, with cerebral symptoms. The paper is worthy of special mention in that it illustrates the value of the urinary test for lead by iodide of potassium, the diagnosis in several of his cases having been impossible except for the evidence of lead in the urine.

99

Oct.29

L

DISEASES OF THE SPINAL CORD.

By W. R. BIRDSALL, M.D.,

NEW YORK.

NEOPLASMS.

57

Borgherini, of Padua, reports a case of osteosarcoma of the vertebra with secondary lesions of the cord; a case of echinococcus, extra-dural, with secondary irritative and paralytic phenomena; and a solitary tubercular growth in the lumbar enlargement. The article also contains a review of the literature upon this subject and a summary of the symptomatology, in which special attention is called to the slowly progressive character of the motor and sensory symptoms.

6

MENINGO-MYELITIS.

In

Mackay reports a case of cervical meningo-myelitis following influenza. A female, aged 38, had influenza, in July, 1890. This was accompanied by intense neuralgic pains in the back of the neck from the seventh cervical vertebra to the vertex, radiating toward the shoulders. After it had continued a fortnight, gradual loss of power occurred in the right hand. A few days later the right arm became weak; then, after a few days, she lost power in both legs. There were no sensory symptoms at this stage. September the examination showed a feeble grasp, particularly in the left hand, feeble power in the legs, uniform wasting of the hands and arms on both sides, less marked wasting in the legs, diminished galvanic and faradic irritability in the arms (and, to a less degree, in the legs); no rigidity; no spasm; ankle-clonus on both sides; knee-jerk exaggerated; plantar reflex increased; gluteal, abdominal, epigastric, and scapular reflexes not elicited; bladder and rectum normal; co-ordination and muscular sense apparently normal. Pain in the region mentioned; no girdle pain; numbness in finger-tips; tingling in calves of legs. Tactile sensibility normal, except at finger-tips. Scattered patches of hyper

66

æsthesia on the upper and outer surfaces of arms and flexor surfaces of thighs; also analgesia of finger-tips and parts of the palmar surfaces. Patient was then four months pregnant. She improved respecting the pains and paresis of the arms; then, after obstinate morning sickness," she became weaker, the pains returned, and paralysis of the respiratory muscles occurred, causing death in November. At the autopsy, twenty hours after death, only the cervical portion of the spine was allowed to be removed. The dura was injected, thickened, and opaque. No traces of tubercle or of caries were found in the membranes or vertebræ. On the anterior aspect the dura was firmly adherent to the vertebral bodies from the level of the sixth cervical upward. On the posterior aspect, the dura, from the fourth cervical body upward, was slightly adherent by a fibrinous exudation. This exudation formed a tough layer one-sixth of an inch thick, at the level of the second and third vertebræ, also adherent to the cord. At the atlanto-axial articulation it was nearly half an inch in thickness, and the cord at this point was completely disintegrated by softening. Lower levels of the cord were also softened. There was considerably more atrophy of all the left nerve-trunks than of those of the right side. It was impossible to properly harden the cord for good section, but teased and compressed osmic-acid preparations revealed the usual constituents of myelitic débris.

No.17; Oct.16

Polozoff 571 152 reports, as a case of meningo-myelitis of gonorrhoeal origin, the history of a soldier, who, six weeks after an acute urethritis, was attacked with constipation and retention of urine, followed by pain and weakness of the lower extremities. On examination, paresis of the lower extremities was found, the gait being tremulous and difficult. The lower lumbar vertebræ were tender to pressure, and there was complete anæsthesia of both lower extremities, which were also the seat of paræsthesia and lancinating pains. The reflexes were exaggerated, the temperature normal. Twelve days later, he had fever, increased pain in the legs and loins, hyperesthesia of the skin of the lower extremities and abdomen, sensation of a constriction-band at the level of the lumbar vertebræ. Later, diarrhoea replaced the constipation, tonic spasms occurred in the muscles of the thighs and legs, and, two months later, there was atrophy of the muscles of the lower extremities. At the time the case was reported he was still

paretic. The author is unable to find any other etiological factor than the gonorrhoea. There were no arthritic manifestations of gonorrhoea in this case.

Aug.

MYELITIS.

68 Oppenheim, in a paper on myelitis, expresses the opinion that (1) our knowledge of this disease is still shrouded in obscurity, and, in respect to definition and diagnosis, greater uncertainty and confusion exists than prevail in most of the remaining divisions of diseases of the cord; (2) primary myelitis is, on the whole, a rare disease; (3) there is a disseminated and a diffuse form of myelitis, which often shows a tendency toward cerebral complications, change in the cranial nerves, and, more rarely, in the peripheral nerves; (4) in the etiology of myelitis, infectious processes play the most important rôle; (5) the prognosis is more favorable, according to this sharper differentiation,-that is to say, after the exclusion of disseminated sclerosis and combined sclerosis. These conclusions were reached after an analysis of the material which he had observed, during eight years, at the Charité, in Berlin. Only 3 autopsies revealed lesions that could be regarded as those of primary myelitis. The larger number diagnosticated as primary myelitis were cases of compression myelitis. A smaller group belonged to myelitis secondary to syphilitic meningitis; some were cases of multiple sclerosis, and others of combined sclerosis; many of the cases classed as chronic myelitis were cases of disseminated sclerosis. Some cases diagnosticated as myelitis ended in complete recovery; 1 case developed upon a malarial basis, another was complicated by neuritis. Diffuse myelitis from tuberculosis and from carcinoma were observed. Disseminated myelitis occurs in the course of such infectious diseases as variola, typhoid fever, scarlet fever, erysipelas, gonorrhea, puerperal fever, malaria; also, in syphilis, tuberculosis, and malignant neoplasms.

1

Mar.28

The following is a Society report of C. A. Herter's important paper, entitled entitled "Clinical and Pathological Observations on Injuries of the Cervical Spinal Cord": The histories of 5 cases of injury to the spinal cord were detailed. The first 4 were

all examples of severe crushing; the fifth was an instance of injury to the cervical vertebræ, with relatively slight damage to the nervous structures in this region. Among the most interesting features of these particular cases were their bearings upon the

localization of the functions of the cervical cord. In Case I there was an upward extension of the motor paralysis from the interossei and flexors of the fingers to the extensors of the fingers and wrists, the pronators and supinators, and the tricipites, bicipites, and deltoids, successively. In Case II the order of advance was much the same. In both cases the anesthesia occupied the body and legs, below a V-shaped line across the upper part of the chest, and the inner half of the arms, forearms, and hands. While the motor symptoms progressed upward in both cases, the area of anaesthesia made no advance. When the patients were first seen, they presented essentially the same motor and sensory phenomena, namely, weakness of the hand-muscles and the distinctive anæsthesia above mentioned. The cord-lesion was the same in both cases, i.e., complete crushing at the eighth segment, and partial softening of the seventh and sixth segments. There was no doubt that the peculiar distribution of the anesthesia was due to the crushing of the eighth segment. In both cases the bone-lesion was a fracture-dislocation of the sixth upon the seventh cervical vertebra. In 3 of the 4 cases there was pressure of the displaced or fractured vertebræ upon the cord at the time of the operation or autopsy. In all total transverse lesions of the cord, and especially in those of the cervical and lumbar enlargements, certain symptoms were referable to the damage of the cord as a central organ, as opposed to those symptoms which depended on the obliteration of the functions of the cord as a conductor of impulses. These symptoms in the cervical region included loss of power and cutaneous sensibility, muscular atrophy, and degenerative electrical reactions. In 2 of the cases (IV and V) there were abdominal symptoms worthy of note. In cach case, on the day after admission, the abdomen became tympanitic and exceedingly tender to pressure, and repeated vomiting occurred, the vomitus having at one time a greenish color. The abdominal distension became very great, but began to subside, together with the pain and tenderness and vomiting, in the course of a few days. The temperature, in cases of injury to the cervical cord, varied much, according to the severity of the damage. The last feature of these cases to which it was desired to call attention was the state of the reflexes, especially that of the knee-jerk. The superficial reflexescremasteric, plantar, and abdominal—were commonly lost from the