As the histological character of the different forms of sclerosis is similar—at least in the terminal period—the causes producing them identical even in name, and the indications furnished by leading symptoms analogous if not identical, the treatment of these various disorders is naturally based on the same leading principles. There are two objects to be aimed at in dealing with these chronic disorders: The first is the cure or arrest of the morbid process itself; the second is the amelioration of distressing and disabling symptoms.
It is generally recognized that a perfect cure of a sclerosis is a consummation never to be realized by any plan of treatment now at our disposal. The experiments of Kahler and others have shown that spinal tissue, once destroyed, is not regenerated. The post-mortem examination of cases of tabes which were considered as cured during life (Schultze) has shown that the sclerosis had not been removed; the process had merely become quiescent, and the apparent recovery had been due to the vicarization of other nerve-elements than those destroyed for the latter.
But if attempts at the regeneration of destroyed fibres and cells are to be regarded as futile, the arrest of the destructive process is to be considered as an object which offers better chances of realization, and which is worth attempting for other than merely conservative reasons. In a number of the forms of sclerosis described, notably in tabes and the disseminated form, it is remarked that the axis-cylinders lying within the morbid district are in part intact and in part but slightly affected. Here and there groups of nerve-tubes may be found which retain even their myelin. While subject to the vicissitudes inseparable from their position in the midst of active pathological changes, these channels of nerve-force, though anatomically patent, may have their function perverted or destroyed, just as a nerve outside of the cord may be paralyzed by pressure or anæmia though its structure be intact. Should the active phase of the sclerotic process be arrested, these intact or nearly intact fibres will resume their function, and thus an apparent improvement will be effected. The spontaneous ameliorations in the course of tabes dorsalis and the less marked ones of diffuse sclerosis, coupled with temporarily improved sensation in the former and improved motion in the latter disease, show that retrogressions of this character are possible and do occur. How is the physician to imitate the action of nature? how to intensify it so as to secure the permanent improvement which nature unaided does not grant? The first factor to be considered is the removal of the cause of the disease. A number of cases are due to exposure to wet and cold and to over-exertion. Such exposure and over-exertion, if not already rendered impossible by the disease, is to be discontinued. A large number of cases of tabes—according to many authors, a majority—a considerable number of cases of diffuse sclerosis, and not a few of other forms, are connected with the syphilitic dyscrasia. Here, at the very outset, we have a definite indication for treatment, and while we may be disappointed in the results of such treatment in a large proportion of cases, yet enough of well-assured and substantial success has been and is obtained to render it almost a matter of duty for the physician to try antisyphilitic measures in every such instance.
The mixed treatment in chronic spinal disorders should be followed out for long periods and faithfully. Most tabic and other sclerotic subjects affected with constitutional syphilis are in what is called the tertiary period of that disease, when iodide of potassium is less useful than mercury. I have never gained anything by pushing either drug to the extreme point in advanced cases, and it should be borne in mind that mercurialization carried too far may itself prove directly injurious to the nerve-centres.159 In cases where gastric crises, gross ataxia, muscular atrophy, and bladder disturbance have been of long duration this treatment is rarely successful.160 But in the initial and early periods of tabes and in diffuse sclerosis of slight intensity the effect is sometimes gratifying, and of such a nature that it cannot be attributed to a coincidence with spontaneous remissions of the disease. In one case both knee-jerks and the pupillary reflexes returned, to disappear on premature discontinuance of the treatment; and on resumption one knee-jerk again returned, and has remained demonstrable now over half a year. In a second case the fulminating pains and the bladder disturbance disappeared, a slight indication of the pupillary reflex developed, and the patient has remained stationary with this gain for a period of three years.161 In a third case, one of established ataxia, with which luetic osseous lesions occurred, the pupillary reflex has returned twice, disappearing after the first reappearance. In one case of combined sclerosis in which no syphilitic antecedents could be found the paresis of the arms has disappeared, and the ataxic paresis of the lower extremities has improved to such an extent that the patient can stand with his eyes closed and his feet together, and on one leg with the eyes open—feats which a year ago he was unable to perform. None of the changes in symptoms taking place in these cases occur spontaneously in sclerotic spinal disorders, and they must be attributed to the treatment. Such treatment is best carried out in conjunction with warm bathing. The Hot Springs of Arkansas, those at Las Vegas, New Mexico, and the baths of Aix-la-Chapelle in Europe enjoy a special reputation in this field. The springs of Arkansas, as regards the intrinsic character of the water, possess advantages which are probably not excelled by any European baths, but the therapeutical management162 is far from that ideal point of development attained, for example, at Aix-la-Chapelle.
159 Mendel thus found in his experiments made on dogs, developing cerebral disease from rotation with the head directed toward the axis of rotation, that dogs who had previously received subcutaneous injections of corrosive sublimate showed an increased vulnerability to the action of the rotary apparatus.
160 A remarkable exception is related in the section on Chronic Myelitis.
161 There was concentric limitation of all color-fields, and only central perception of green; to-day, if anything, the color-fields of this patient are a little greater than in the physiological average. The case was undoubtedly one of initial tabes.
162 Mercurial ointment is used by the hundredweight, to quote the expression of a patient, and in certain establishments the sufferers from the common taint plaster each other from head to foot, as with mud, with this panacea for most of those ills which flock to the springs. Still, there seems to be no doubt that enormous quantities of mercury are borne well by those who use the baths, and who under other circumstances are susceptible to its most undesirable effects.
Optic-nerve atrophy, according to the best authorities, constitutes a contraindication to the use of mercury in any form. It may be laid down as a general rule that the more rapidly the symptoms indicating a sclerotic process are developed, and the more recent its advent, the more energetically should the treatment be pushed. Mercurial inunctions and the so-called heroic doses of iodide are to be employed. But in cases progressing slowly and of long antecedent history what may be called a dilute plan is more apt to yield good results. Small doses of mercury,163 given steadily for years, and iodide of potassium, administered in well-tolerated doses for periods of ten days, alternating with corresponding periods of intermission, have, in my opinion, delayed or arrested the progress of tabes and other forms of sclerosis for the long periods referred to in the preceding sections.164 Although the antisyphilitic measures adopted in sclerosis of syphilitic origin are the most important, and the prognosis of no such case can be regarded as hopeless as to recovery or duration until they have been tried, other procedures, detailed under the head of Peripheral Treatment, should not be neglected. While some very severe cases improve rapidly on antisyphilitic treatment, other much less severe and more recent cases, in which the same cause is assigned with equal reason, are not affected by it in the slightest visible degree. The reason for this difference is unknown, but it necessitates the bearing in mind that by limiting the treatment to the etiological indication valuable time may be wasted in which the symptomatic indications could be profitably followed.
163 The tablet triturates of biniodide of mercury or corrosive sublimate furnished by Fraser & Co. of New York I have found peculiarly useful; one one-hundredth or more of a grain may be thus administered every two to four hours.