Isidor K——, æt. forty-four years, worker in tobacco. After over-exertion in the fall of the year 1879 he had numbness, tingling, dorsal pain, and paresis rapidly developed, which induced him to consult the physicians at the clinic of the University of the City of New York. After some slight improvement a relapse occurred, and several others followed, usually provoked by over-exertion, till he became completely paraplegic. He was, according to his account, several times exhibited to a medical class by William A. Hammond, and remembers that this authority spoke of a possible ascent of the affection and ensuing involvement of the arms. His bladder was at no time seriously disturbed. For four years and three months he was totally paraplegic; his lower extremities were without life; and for the greater part of the time he could not move his toes. The limbs were cold and pale, but underwent little atrophy. The only exercise obtained during this time was in a roller carriage. His sexual power was abolished throughout the whole four years and over. Nothing can be learned as to his reflexes in this period.103 The paralysis of sensation was as complete as that of motion, and the lower limbs never perspired. The arms remained free. There was a dorsal belt sensation.
103 Hammond has no notes of the case, having discontinued the clinic, and Ludwig Weiss, the physician in charge, saw him only occasionally in behalf of a benefit society.
On July 23, 1884, shortly before mid-day, while lying on the bed, in which he had lain a helpless cripple for over four years, except when lifted into the roller carriage, he felt a sudden rush of warmth. Surprised at this first sensation he had felt for years in limbs which had been quasi-foreign appendages, he raised up the bed-clothes and saw that they changed color. There was some tingling for about three minutes, and a perspiration broke out in the affected members. With this he found he could move his feet: half alarmed, half exulting, he sent for his physician, L. Weiss, who found that the patient could stand and walk with considerable freedom. I was then consulted, and found the patient presenting a picture of incomplete transverse myelitis. He could walk, turn about, stand with closed eyes with slight swaying, and his knee-phenomenon was of short excursiveness, but exceedingly spasmodic, and this symmetrically so. He was carefully watched, and against the advice of his physician engaged in peddling cigars, and subsequently took a position as attendant at the pauper asylum on Ward's Island. Here he was on his feet fully twelve hours a day, and his motion, which had continued improving until it was to all practical intents and purposes normal, aside from a slight stiffness, again became impaired, and a joint trouble in the metacarpo-phalangeal articulation of the right little toe, which had troubled him a week after his partial recovery, recurred.104 On January 15th of the present year I again examined him. His knee-phenomenon was greatly exaggerated, cutaneous sensations scarcely impaired, gait paraparetic, but he could walk great distances, and claimed to suffer less from the exertion than from the tenderness accompanying the joint trouble referred to. There had, therefore, occurred, without any assignable cause—for the patient was not under treatment for a year or more before the event—an almost instantaneous restoration of sensation, locomotion, and sexual power; all of which faculties, notwithstanding the infraction of every medical direction given, remained established for two years, with prospects of so continuing a longer period.
104 This was a trophic joint trouble.
TREATMENT.—Most of the therapeutic propositions relating to the treatment of the acute myelitic process are based on the theory that it is of a congestive character or associated with congestion. Accordingly, the internal administration of such drugs as ergotin, which diminish the calibre of the blood-vessels, and local measures, such as depletion, wet cupping, and counter-irritation, intended to act in the same way by derivation, are unanimously recommended by authorities. The suggestion of Hammond, that the patient occupy a ventral or lateral, and not the dorsal, position, is based on, and entirely consistent with, this same view. It is difficult to say what effect is attributable to these measures. Remarkable spontaneous changes—retrogressions as well as advances of the morbid process—occur equally under expectant as under active treatment. I have never seen any improvement in the active phase of simple myelitis which I felt confident I could attribute to any special remedy employed with a view of acting directly on the morbid process. Indeed, improvement has been claimed by Jewell as a result of the use of strychnia—a drug which under the very dogmas governing the orthodox treatment of the disease might be expected to do positive damage.105
105 Jewell gives very large doses of this alkaloid. L. C. Gray, in a discussion held before the American Neurological Association, cited numerous observations directly conflicting with those of Jewell. I cannot, in view of a recent observation in a typical case of acute anterior poliomyelitis, in which by accident the toxic effects of strychnia were obtained, consider this dispute as at all settled. In direct connection with the toxic symptoms the abolished patellar jerk returned in an exaggerated form; motion also returned, and rapid improvement ensued.
In relapses of acute myelitis which had been brought on by chilling of the feet I have obtained good results by derivation to the lower extremities, and on many grounds think that the morbid process in the cord, if it can be affected at all, can be affected by treating the periphery where the symptoms are noted more readily than by applying the cautery or bleeding over the proven site of the disease. Exposure of the dorsal region to cold has not yet been noted as a cause of acute myelitis, whereas such exposure of the lower extremities is a frequent one. This seems to show that the spinal cord is more vulnerable to influences affecting its nervous distribution than to those which are topographically nearer. If this is true as regards morbid influences, it may be urged that it is plausible as regards remedial influences if these are to drive out the disease tendency by the same door it entered.
Rest is imperative during the active progress of the disease. It may be stated as a canon that the earlier the patient takes to his bed, and the more thoroughly he obeys the injunction to attempt no motion of the affected members, the better, cæteris paribus, will the result obtained be. Countless cases are on record where a relapse was directly traceable to a walk undertaken prematurely or carried farther than was wise. As convalescence or partial restitution advances, gradually increasing exercise is to be attempted, not waiting for the danger-signal of a tired feeling to discontinue it; for that feeling, developed, means positive harm already done. It is therefore necessary to allow the returning function to be utilized only within small limits at first, and extending them slowly.
In all cases of severe myelitis where the formation of bed-sores is to be apprehended the water-bed should be employed. Owing to the low temperature which the rubber sac constituting it has, it is necessary to cover it with some well-warmed and non-conducting material and to have the room well warmed. If bed-sores are already formed, they are to be treated according to ordinary surgical principles. Antiseptic means should be in the foreground in the case of the malignant bed-sore. It is to be remembered that the latter is a gangrenous process, and, in so far as the formation of a line of demarcation between the necrotic and the conserved tissue is concerned, the ordinary expectant rules of surgery govern the case: the water-bath appears to yield the best results. Ordinary bed-sores yield readily to mechanical protection and stimulating ointments or the balsam of Peru. Iodoform is recommended, but it produces granulations of an indolent character as compared with those obtained through the use of resinous ointments.
The warm bath is probably the most useful measure in acute myelitis. In cases due to exposure I do not believe it can be applied too soon. Its temperature should, in the beginning at least, not be higher than about 88° F., and the duration about seven minutes. The continued administration will depend on the immediate effect on the patient, and the sittings can be ultimately prolonged to half an hour or even longer. It should be administered once daily, and, when the patient is not disturbed by the manipulation connected with its use, even oftener. Cold baths are recommended by the Germans, but it seems rather in the passive period of the disease than during its active phase.