Chapter 3

Soon after this, and three years and a half after the fall, Doctor Maty first saw the patient, and gives the following description of his situation. "A more melancholy object I never beheld. The patient, naturally a handsome, middle-sized, sanguine man, of a cheerful disposition, and an active mind, appeared much emaciated, stooping, and dejected. _He still walked alone with a cane, from one room to the other, but with great difficulty, and in a tottering manner_; his left hand and arm were much reduced, and would hardly perform any motion; _the right was somewhat benumbed, and he could scarcely lift it up to his head; his saliva was continually trickling out of his mouth, and he had neither the power of retaining it, nor of spitting it out freely_. What words he still could utter were monosyllables, and these came out, after much struggle, in a violent expiration, and with such a low voice and indistinct articulation, as hardly to be understood but by those who were constantly with him. He fetched his breath rather hard; his pulse was low, but neither accelerated nor intermitting. He took very little nourishment, could chew and swallow no solids, and even found great pain in getting down liquids. Milk was almost his only food; his body was rather loose, his urine natural, his sleep good, his senses, and the powers of his mind, unimpaired; he was attentive to, and sensible of every thing which was said in conversation, and shewed himself very desirous of joining in it; but was continually checked by the impediment in his speech, and the difficulty which his hearers were put to. Happily for him he was able to read, and as capable as ever of writing, as he shewed me, by putting into my hands an account of his present situation, drawn up by himself: and I am informed that he spent his time to the very last, in writing upon some of the most abstruse subjects."

This gentleman died about four years after the accident, when the body was examined by Dr. Bellett and Mons. Sorbier, who made the following report:

"We first examined the muscles of the tongue, which were found extenuated and of a loose texture. We observed no signs of compression in the lingual and brachial nerves, as high as their exit from the basis of the cranium and the vertebræ of the neck; but they appeared to us more compact than they commonly are, being nearly tendinous. The dura mater was in a sound state, but the pia mater was full of blood and lymph; on it several hydatids, and towards the falx some marks of suppuration were observed. The ventricles were filled with water, and the plexus choroides was considerably enlarged, and stuffed with grumous blood. The cortical surface of the brain appeared much browner than usual, but neither the medullary part nor cerebellum were impaired. We chiefly took notice of the Medulla Oblongata, this was greatly enlarged, surpassing the usual size by more than one third. It was likewise more compact. The membranes, which, in their continuation, inclose the spinal marrow, were so tough that we found great difficulty in cutting through them, and we observed this to be the cause of the tendinous texture of the cervical nerves. The marrow itself had acquired such solidity as to elude the pressure of our fingers, it resisted as a callous body, and could not be bruised. This hardness was observed all along the vertebræ of the neck, but lessened by degrees, and was not near so considerable in the vertebræ of the thorax. Though the patient was but nine and thirty years old, the cartilages of the sternum were ossified, and required as much labour to cut them asunder as the ribs; like these they were spungy, but somewhat whiter. The lungs and heart were sound. At the bottom of the stomach appeared an inflammation, which increased as it extended to the intestines. The ileum looked of that dark and livid hue, which is observed in membranous parts tending to mortification. The colon was not above an inch in diameter, the rectum was smaller still, but both appeared sound.--From these appearances, we were at no loss to fix the cause of this gradual palsy in the alteration of the medulla spinalis and oblongata."

Dr. Bellett offers the following explanation of these changes. "I conceive, that, by this accident, the head being violently bent to the right, the nervous membranes on the left were excessively stretched and irritated; that this cause extended by degrees to the spinal marrow, which being thereby compressed, brought on the paralytic symptoms, not only of the left arm, but at last in some measure also of the right. This induration seems to have been occasioned by the constant afflux of the nutritive juices, which were stopt at that place, and deprived of their most liquid parts; the grosser ones being unable to spread in the boney cavity, by which they were confined, could only acquire a greater solidity, and change a soft body into a hard and nearly osseous mass. This likewise accounts for the increase of the medulla oblongata, which being loaded with more juices than it could send off, swelled in the same manner as the branches of trees, which will grow of a monstrous size, when the sap that runs into them is stopt in its progress. The medulla oblongata not growing so hard as the spinalis, was doubtless owing to its not being confined in an osseous theca, but surrounded with soft parts, which allowed it room to spread. The obstruction from the bulk of this substance must have affected the brain, and probably induced the thickening of the pia mater, the hydatids, and the beginning of suppuration, whereas the dura mater, being of a harder texture, was not injured[11]."

[Footnote 11: Medical Observations and Inquiries, Vol. III. p. 257.]

In some of the symptoms which appeared in this case, an agreement is observable between it and those cases which are mentioned in the beginning of these pages. The weakened state of both arms; the power first lessening in one arm, and then in a similar manner in the other arm; the affection of the speech; the difficulty in chewing and in swallowing; as well as of retaining, or freely discharging, the spittle; the convulsive motions of the body; and the unimpaired state of the intellects; constitute such a degree of accordance as, although it may not mark an identity of disease, serves at least to show that nearly the same parts were the seat of the disease in both instances. Thus we attain something like confirmation of the supposed proximate cause, and of one of the assumed occasional causes.

Whilst conjecturing as to the cause of this disease, the following collected observations on the effects of injury to the medulla spinalis, by Sir Everard Home, become particularly deserving of attention. It thence appears, that none of the characteristic symptoms of this malady are produced by compression, laceration, or complete division of the medulla spinalis.

"Pressure upon the medulla spinalis of the neck, by coagulated blood, produced paralytic affections of the arms and legs; all the functions of the internal organs were carried on for thirty-five days, but the urine and stools passed involuntarily[12].

[Footnote 12: A coagulum of blood, the thickness of a crown-piece, was found lying upon the external surface of the dura-matral covering of the medulla spinalis, extending from the fourth vertebra colli to the second vertebra dorsi. The medulla spinalis itself was uninjured.]

"Blood extravasated in the central part of the medulla, in the neck, was attended with paralytic affection of the legs, but not of the arms[13].

[Footnote 13: The sixth and seventh vertebra colli were dislocated, the medulla spinalis, externally, was uninjured; but in the centre of its substance, just at that part, there was a coagulum of blood nearly two inches in length.]

"In a case where the substance of the medulla was lacerated in the neck, there was a paralysis in all the parts below the laceration, the lining of the oesophagus was so sensible, that solids could not be swallowed, on account of the pain they occasioned[14].

[Footnote 14: The seventh vertebra colli was fractured, and the medulla spinalis passing through it, was lacerated and compressed.]

"When the medulla of the back was completely divided, there was momentary loss of sight, loss of memory for fifteen minutes, and permanent insensibility in all the lower parts of the body. The skin above the division of the spinal marrow perspired, that below did not. The wounded spinal marrow appeared to be extremely sensible[15]." _Philosophical Transactions_, 1816, p. 485.

[Footnote 15: The spinal marrow, within the canal of the sixth vertebra dorsi, was completely destroyed by a musket ball. The person lived four days.]

In two of the cases already noticed, symptoms of rheumatism had previously existed; and in Case IV. the right arm, in which the palpitation began, was said to have been very violently affected with rheumatic pain to the fingers ends. The consideration of this case, in which the palpitation had been preceded, at a considerable distance of time, by this painful affection of the arm, led to the supposition that this latter circumstance might be the cause of the palpitations, and the other subsequent symptoms of this disease. This supposition naturally occasioned the attention to be eagerly fixed on the following case; and of course influenced the mode of treatment which was adopted.

_A. B._ subject to rheumatic affection of the deltoid muscle, had felt the usual inconveniences from it for two or three days; but at night found the pain had extended down the arm, along the inside of the fore-arm, and on the sides of the fingers, in which a continual tingling was felt. The pain, without being extremely intense, was such as effectually to prevent sleep: and seemed to follow the course of the brachial nerve. Whilst ascertaining the propriety of this conclusion, the pain was found to ramify, as it were, on the fore and back part of the chest; and was slightly augmented by drawing a deep breath.

These circumstances suggested the probability of slight inflammation, or increased determination to the origin of the nerves of these parts, and to the neighbouring medulla. On this ground, blood was taken from the back part of the neck, by cupping; hot fomentations were applied for about the space of an hour, when the upper part of the back of the neck was covered with a blister, perspiration was freely induced by two or three small doses of antimonials, and the following morning the bowels were evacuated by an appropriate dose of calomel. On the following day the pains were much diminished, and in the course of four or five days were quite removed. The arm and hand felt now more than ordinarily heavy, and were evidently much weakened: aching, and feeling extremely wearied after the least exertion. The strength of the arm was not completely recovered at the end of more than twelvemonths; and, after more than twice that time, exertion would excite the feeling of painful weariness, but no palpitation or other unpleasant symptom has occurred during the five or six years which have since passed.

The commencement, progress, and termination of this attack; with the success attending the mode of treatment, and the symptoms which followed, seem to lead to the conjecture, that the proximate cause of the disease, in this case, existed in the medulla spinalis, and that it might, if neglected, have gradually resolved itself into that disease which is the object of our present inquiry.

Some few months after the occurrence of the preceding case, the writer of these lines was called to a female about forty years of age, complaining of great pain in both the arms, extending from the shoulder to the finger ends. She stated, that she was attacked in the same manner as is described in the preceding case, about nine months before; that the complaint was considered as rheumatism, and was not benefited by any of the medicines which had been employed; but that after three or four weeks it gradually amended, leaving both the arms and hands in a very weakened and trembling state. From this state they were now somewhat recovered; but she was extremely anxious, fearing that if the present attack should not be soon checked, she might entirely lose the use of her hands and arms.

Instructed by the preceding case, similar means were here recommended. Leeches, stimulating fomentations, and a blister, which was made for sometime to yield a purulent discharge, were applied over the cervical vertebræ; and in the course of a very few days the pain was entirely removed. It is regretted that no farther information, as to the progress of this case, could be obtained.

On meeting with these two cases, it was thought that it might not be improbable that attacks of this kind, considered at the time merely as rheumatic affections, might lay the foundation of this lamentable disease, which might manifest itself at some distant period, when the circumstance in which it had originated, had, perhaps, almost escaped the memory. Indeed when it is considered that neither in the ordinary cases of Palsy of the lower extremities, proceeding from diseased spine, nor in cases of injured medulla from fractured vertebræ, any of the peculiar symptoms of this disease are observable, we necessarily doubt as to the probability of its being the direct effect of any sudden injury. But taking all circumstances into due consideration, particularly the very gradual manner in which the disease commences, and proceeds in its attacks; as well as the inability to ascribe its origin to any more obvious cause, we are led to seek for it in some slow morbid change in the structure of the medulla, or its investing membranes, or theca, occasioned by simple inflammation, or rheumatic or scrophulous affection.

It must be too obvious that the evidence adduced as to the nature of the proximate and occasional causes of this disease, is by no means conclusive. A reference to the test therefore which will be yielded by an examination of some of the more prominent symptoms, especially as to their agreement with the supposed proximate cause, is more particularly demanded. Satisfied as to the importance of this part of the present undertaking, no apology is offered for the extent to which the examination is carried on.

If the palpitation and the attendant weakness of the limbs, &c. be considered as to the order in which the several parts are attacked, it is believed, that some confirmation will be obtained of the opinion which has been just offered, respecting the cause, or at least the seat, of that change which may be considered as the proximate cause of this disease.

One of the arms, in all the cases which have been here mentioned, has been the part in which these symptoms have been first noticed; the legs, head, and trunk have then become gradually affected, and lastly, the muscles of the mouth and fauces have yielded to the morbid influence.

The arms, the parts first manifesting disordered action, of course direct us, whilst searching for the cause of these changes, to the brachial nerves. But finding the mischief extending to other parts, not supplied with these, but with other nerves derived from nearly the same part of the medulla spinalis, we are of course led to consider that portion of the medulla spinalis itself, from which these nerves are derived, as the part in which those changes have taken place, which constitute the proximate cause of this disease.

From the subsequent affection of the lower extremities, and from the failure of power in the muscles of the trunk, such a change in the substance of the medulla spinalis may be inferred, as shall have considerably interrupted, and interfered with, the extension of the nervous influence to those parts, whose nerves are derived from any portion of the medulla below the part which has undergone the diseased change.

The difficulty in supporting the trunk erect, as well as the propensity to the adopting of a hurried pace, is also referable to such a diminution of the nervous power in the extensor muscles of the head and trunk, as prevents them from performing the offices of maintaining the head and body in an erect position.

From the impediment to speech, the difficulty in mastication and swallowing, the inability to retain, or freely to eject, the Saliva, may with propriety be inferred an extension of the morbid change upwards through the medulla spinalis to the medulla oblongata, necessarily impairing the powers of the several nerves derived from that portion into which the morbid change may have reached. In the late occurrence of this set of symptoms, and the extension upwards of the diseased state, a very close agreement is observable between this disease and that which has been already shown, proved fatal to the Count de Lordat. But in this case, the disease doubtlessly became differently modified, and its symptoms considerably accelerated, in consequence of the magnitude of the injury by which the disease was induced.

CHAP. V.

CONSIDERATIONS RESPECTING THE MEANS OF CURE.

The inquiries made in the preceding pages yield, it is to be much regretted, but little more than evidence of inference: nothing direct and satisfactory has been obtained. All that has been ventured to assume here, has been that the disease depends on a disordered state of that part of the medulla which is contained in the cervical vertebræ. But of what nature that morbid change is; and whether originating in the medulla itself, in its membranes, or in the containing theca, is, at present, the subject of doubt and conjecture. But although, at present, uninformed as to the precise nature of the disease, still it ought not to be considered as one against which there exists no countervailing remedy.

On the contrary, there appears to be sufficient reason for hoping that some remedial process may ere long be discovered, by which, at least, the progress of the disease may be stopped. It seldom happens that the agitation extends beyond the arms within the first two years; which period, therefore, if we were disposed to divide the disease into stages, might be said to comprise the first stage. In this period, it is very probable, that remedial means might be employed with success: and even, if unfortunately deferred to a later period, they might then arrest the farther progress of the disease, although the removing of the effects already produced, might be hardly to be expected.

From a review of the changes which had taken place in the case of Count de Lordat, it seems as if we were able to trace the order and mode in which the morbid changes may proceed in this disease. From any occasional cause, the thecal ligament, the membranes, or the medulla itself, may pass into the state of simple excitement or irritation, which may be gradually succeeded by such a local afflux and determination of blood into the minute vessels, as may terminate in actual but slow inflammation. The result of this would be a thickening of the theca, or membranes, and perhaps an increase in the volume of the medulla itself, which would gradually occasion such a degree of pressure against the sides of the unyielding canal, as must eventually intercept the influence of the brain upon the inferior portion of the medullary column, and upon the parts on which the nerves of this portion are disposed.

From this review, and assuming that the morbid changes in this disease may not be widely dissimilar from those which occurred in the case of Count de Lordat, the chance of relief from the proposed mode of treatment may appear to be sufficient to warrant its trial.

In such a case then, at whatever period of the disease it might be proposed to attempt the cure, blood should be first taken from the upper part of the neck, unless contra-i(n)dicated by any particul(ar) circumstance. After which vesicatories should be applied to the (sa)me part, and a purulent discharge obtained by appropriate use of the Sabine Liniment; having recourse to the application of a fresh blister, when from the diminution of the discharging surface, pus is not secreted in a sufficient quantity. Should the blisters be found too inconvenient, or a sufficient quantity of discharge not be obtained thereby, an issue of at least an inch and a half in length might be established on each side of the vertebral columna, in its superior part. These, it is presumed, would be best formed with caustic, and kept open with any proper substance[16].

[Footnote 16: Cork, which has been hitherto neglected, appears to be very appropriate to this purpose. It possesses lightness, softness, elasticity and sufficient firmness; and is also capable of being readily fashioned to any convenient form. The form which it seems would be best adapted to the part, is that of an almond, or of the variety of bean called scarlet bean; but at least an inch and a half in length.]

Could it have been imagined that such considerable benefit: indeed, that such astonishing cures, could have been effected by issues in cases of Palsy of the lower extremities from diseased spine? although satisfied with ascribing those cases to scrofulous action, we are in fact as little informed respecting the nature of the affection, inducing the carious state of the vertebræ, as we are respecting the peculiar change of structure which takes place in this disease. Equally uninformed are we also as to the peculiar kind of morbid action, which takes place in the ligaments of the joints; as well as that which takes place in different instances of deep seated pains and affections of the parts contained in the head, thorax, and abdomen, and in all which cases the inducing of a purulent discharge in their neighbourhood is so frequently productive of a cure. Experiment has not indeed been yet employed to prove, but analogy certainly warrants the hope, that similar advantages might be derived from the use of the means enumerated, in the present disease. It is obvious, that the chance of obtaining relief will depend in a great measure on the period at which the means are employed. As in every other disease, so here, the earlier the remedies are resorted to, the greater will be the probability of success. But in this disease there is one circumstance which demands particular attention; the long period to which it may be extended. One of its peculiar symptoms, Scelotyrbe festinans, may not occur until the disease has existed ten or twelve years, or more; hence, when looking for the period, within which our hopes of remedial aid is to be limited; we may, guided by the slow progress of the malady, extend it to a great length, when compared with that within which we should be obliged to confine ourselves in most other diseases.

But it is much to be apprehended, as in many other cases, that the resolution of the patients will seldom be sufficient to enable them to persevere through the length of time which the proposed process will necessarily require. As slow as is the progress of the disease, so slow in all probability must be the period of the return to health. In most cases, especially in those in which the disease has been allowed to exist long unopposed, it may be found that all that art is capable of accomplishing, is that of checking its further progress. Nor will this be regarded as a trifle, when, by reference to the history of the disease, is seen the train of harassing evils which would be thus avoided.