CLINICAL HISTORY.—Impairment of motion is the most constant early feature of chronic myelitis; in the transverse form it may be as absolute as in the severest forms of acute myelitis; as a rule, however, it is rather a paresis than a paralysis. The patient is usually able to walk, manifesting the paraparetic gait: he moves along slowly, does not lift his feet, drags them along, makes short steps; in short, acts as if his limbs were heavily weighted. This difficulty of locomotion is preceded and accompanied by a tired feeling before other sensory symptoms are developed. Rigidity of the muscles, like that found in disseminated sclerosis, is a common accompaniment, and may even preponderate over the paresis to such an extent as to modify the patient's walk, rendering it spastic in character. In such cases the muscles feel hard to the touch, and the same exaggerated reflex excitability may be present as was described to be characteristic of spastic paralysis.
If, while the leg is slightly flexed on the thigh, the foot be extended,149 so as to render the Achilles tendon and the muscles connected with it tense, and the hand while grasping the foot suddenly presses the latter to still further extension, a quick contraction occurs, which, if the pressure be renewed and kept up, recurs again and again, the succession of the involuntary movements resembling a clonic spasm. This action is termed the ankle-clonus or foot-phenomenon. Gowers has amplified this test of exaggerated reflex excitability by adding what he calls the front-tap contraction. The foot being held in the same way as stated above, the examiner strikes the muscles on the front of the leg; the calf-muscles contract and cause a brief extension movement of the foot. It is believed that the foot-clonus and the front-tap contraction are always pathological, but a few observers, notably Gnauck, leave it an open question whether it may not occur in neurotic subjects who have no organic disease. Gowers considers the foot-clonus found in hysterical women as spurious, and states that it differs from the true form in that it is not constant, being broken by voluntary contractions, and does not begin as soon as the observer applies pressure. But I have seen the form of clonus which Gowers regards as hysterical in cases of diffuse sclerosis. With regard to the front-tap contraction, its discoverer150 admits that it may be obtained in persons in whom there is no reason to suspect organic disease. It is significant only when unequal on the two sides.
149 By extension the approximation of the dorsal surface to the tibial aspect of the leg—what some German writers call dorsal flexion—is meant.
150 Gowers, The Diagnosis of the Diseases of the Spinal Cord, 3d ed., p. 33.
In severe cases contractures are developed in the affected muscular groups, being, as a rule, preceded by the rigidity, increased reflex excitability, and the thereon dependent phenomena above detailed. These contractures may be like those of spastic paralysis, but usually the adductors show the chief involvement, and sometimes the leg becomes flexed on the thigh and the thigh on the abdomen in such firm contraction that the patient, albeit his gross motor power is not sufficiently impaired, is unable to move about, and is confined to his bed, his heel firmly drawn up against his buttock. It is stated by Leyden that the contracted muscles occasionally become hypertrophied—an occurrence I have not been able to verify. As a rule, some muscular groups are atrophied, though the limbs as a whole, particularly in those patients who are able to walk about, are fairly well nourished.
Pain in the back is a frequent accompaniment of diffuse sclerosis. It is not pronounced, but constant.
The drift of opinion to-day is to regard pain in the spinal region as not pathognomonic of organic spinal affections. It is true that pain is a frequent concomitant of neuroses, and that it is more intense and characteristic in vertebral and meningeal disease; but in denying a significance to pain in the back as an evidence of diffuse disease of the cord itself, I think many modern observers have gone to an extreme. It is particularly in diffuse sclerosis that a dull heavy sensation is experienced in the lumbo-sacral region; and in a number of my cases of slowly ascending myelitis and of tabes dorsalis the involvement of the arms was accompanied by an extension of the same pain, in one case associated with intolerable itching, to the interscapular region. It cannot be maintained that the pain corresponds in situation to the sclerotic area. It is probably, like the pain in the extremities, a symptom of irradiation, and corresponds in distribution to that of the spinal rami of the nerves arising in the affected level.
As the posterior columns are usually involved in transverse myelitis, the same lancinating and terebrating pains may occur as in tabes dorsalis. As a rule, they are not as severe, and a dull, heavy feeling, comparable to a tired or a burning sensation, is more common. A belt sensation, like that of tabes, and as in tabes corresponding to the altitude of the lesion, is a much more constant symptom than acute pains.
Cutaneous sensibility is not usually impaired to anything like the extent found in advanced tabes. It is marked in proportion to the severity of the motor paralysis; where mobility is greatly impaired, profound anæsthesia and paræsthesia will be found; where it is not much disturbed, subjective numbness, slight hyperæsthesia, or tingling and formication may be the only symptoms indicating sensory disturbance; and there are cases where even these may be wanting.
The visceral functions are not usually disturbed. In intense transverse sclerosis of the upper dorsal region I observed gastric crises, and in a second, whose lesion is of slight intensity, but probably diffused over a considerable length of the cerebro-spinal axis, there is at present pathological glycosuria. The bladder commonly shows slight impairment of expulsive as well as retaining power, the patients micturating frequently and passing the last drops of urine with difficulty. Constipation is the rule. The sexual powers are usually diminished, though rarely abolished. As with sclerotic processes generally, the sexual functions of the female, both menstrual and reproductive, are rarely disturbed.