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 DIAGNOSIS OF DISEASES 
 
 SPINAL COED 
 
 W. R GO WEES, M.D., F.E.C.P. 
 
 ASSISTANT-PROFESSOR OF CLINICAL MEDICINE IN UNIVERSITY COLLEGE 
 
 PHYSICIAN TO UNIVERSITY COLLEGE HOSPITAL, AND TO THE NATIONAL HOSPITAL FOR THE 
 
 PARALYSED AND EPILEPTIC 
 
 THIRD EDITION 
 
 LONDON 
 
 J. & A. C HUE CHILL 
 
 NEW BURLINGTON STREET 
 
 188-1 
 

 Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/diagnosisofdiseOOgowe 
 
PREFACE TO THE THIRD EDITION. 
 
 The following introduction to the study of the Symptoms 
 and Diagnosis of the Diseases of the Spinal Cord, is founded 
 on an address, delivered in October, 1879, to the Members 
 of the Medical Society of Wolverhampton. 
 
 The third edition has been carefully revised ; additions 
 have been made in many places ; and a section has been 
 added on the diagnosis of " functional " from organic 
 disease. 
 
 The first edition has been translated into French 
 by Dr. Oscar Jennings, and the second into Russian by 
 M. Zatchek. 
 
 Queen Anne Street, London, 
 December, 1883. 
 
CONTENTS 
 
 Introduction 
 
 -Medical Anatomy of the Spinal Coed 
 Relation to Spinal Column 
 Structure 
 Secondary Degenerations 
 
 PAGE 
 
 1 
 
 5 
 
 7 
 
 10 
 
 II. - 
 
 - Physiology of the Spinal Coed in Relation to the Symptoms 
 of its Diseases 
 Motor Conduction 
 Sensory Conduction 
 Reflex Actions 
 
 "Tendon-Reflex" 
 
 Co-ordination of Movement 
 
 Controlling' Functions 
 
 Nutrition of Muscles 
 
 Use of Electricity in Diagnosis 
 
 Nutrition of Bones, Joints, and Skin 
 
 Micturition and Defaecation 
 
 Sexual Functions 
 
 Vaso -Motor Centres. . 
 
 Pain in Spinal Disease 
 
 Spasm in Spinal Disease 
 
 III. — Indications of Position of Disease — Anatomical Diagnosis 
 Antero-lateral White Columns 
 Posterior Columns 
 Anterior Cornua 
 Unilateral Lesions 
 Total Transverse Lesions ■. . 
 
 13 
 13 
 14 
 15 
 19 
 35 
 38 
 38 
 38 
 43 
 44 
 46 
 47 
 48 
 50 
 
 53 
 53 
 55 
 56 
 58 
 59 
 
Vlll CONTENTS. 
 
 PAGE 
 
 IV. — Indications of Nature of Disease: Pathological Diagnosis.. 63 
 
 Mode of Onset 64 
 
 Position and Distribution of Lesion . . . . . . 65 
 
 Causal and Associated Conditions . . . . . . . . 67 
 
 Anaemia and Hyperemia of the Cord . . . . . . 73 
 
 Spinal Meningitis . . . . . . . . . . . . 73 
 
 Nomenclature.. .. .. .. .. .. .. ..75 
 
 V. — Distinction of Functional and Organic Disease . . 75 
 
 VI.— Illustrations of Diagnosis .. .. .. .. .. ..81 
 
 Description of Plate.. .. .. .. .. .. .. ..91 
 
THE 
 
 DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 In the following pages an attempt is made to give an 
 outline of the Symptoms and Diagnosis of Diseases of the 
 Spinal Cord, with especial reference to those points on 
 which modern investigation has added to the knowledge 
 that is current in the profession. In order to make a 
 description of these points useful, it is necessary to 
 include them in a general outline of the subject, in 
 which they may take their proper place. 
 
 Our knowledge of the symptoms of these diseases is 
 in advance of our therapeutic power. But the study of 
 diagnosis must not, on that account, be undervalued. 
 Even for practical purposes our diagnostic knowledge 
 needs to be ample and exact. A very superficial study 
 of practical medicine will show that much diagnosis, 
 which is of no direct avail for treatment, is essential 
 for the diagnosis which enables us to treat successfully. 
 Of all organs there are some diseases for which we can 
 do little, there are others for which we can do much ; 
 but unless we are able accurately to distinguish the diseases 
 of each class, we shall often fail to apply our skill where 
 it would be effective. Moreover, the diagnosis is easy in 
 some cases ; while in others it is most difficult. The 
 diagnostic knowledge which is superfluous in the one is 
 essential in the other. 
 
 There is another reason why a general survey of the 
 elements of the diagnosis of diseases of the spinal cord may 
 
Z THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 be useful. In systematic treatises, types of disease are 
 described. But the mutual relations of all parts of the 
 nervous system are intricate, and its morbid states are 
 correspondingly complex. Cases which conform to types 
 are rare, and the untypical cases are often puzzling, and 
 can only be understood by a clear conception of the general 
 principles of diagnosis. 
 
 The first question in the diagnosis of diseases of the 
 spinal cord is whether the symptoms are due to organic 
 disease or to merely functional derangement. But although 
 this is the first question in any case, the answer to it 
 depends on the presence or absence of the signs of organic 
 disease ; this point in diagnosis cannot, therefore, be con- 
 sidered until we have discussed the character and signifi- 
 cance of those signs. It is, however, important to note, 
 at the outset, as a rule of cardinal importance, that the 
 presence of a cause of functional derangement is not, 
 in itself, sufficient ground for diagnosis. All signs of 
 organic disease must be searched for. and excluded, before 
 the presence of the causes of functional disease is admitted as 
 evidence. It is clear that, if there are any signs of organic 
 disease, the existence of the causes of functional disease 
 is of no significance whatever. Hence the importance of 
 knowing accurately all the signs of organic disease, even 
 those which are minute and may seem superfluous. 
 
 The causes of functional derangement frequently co-exist 
 with organic disease. Hysterical symptoms, for instance, 
 are often present in the subjects of organic disease in all 
 parts of the nervous system. There are two reasons for 
 this. Many organic diseases are the result of an inherited 
 neuropathic disposition, which may also cause hysteria. 
 Further, the damage from organic disease often affects 
 very widely the nutrition and function of the nervous 
 system, and thus leads to the manifestations of hysteria, 
 in addition to the symptoms of the organic disease. 
 Hysterical symptoms are often obtrusive, for instance, 
 in cases of tumour of the brain. Hence the existence 
 
THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 6 
 
 of such symptoms constitutes, alone, small evidence that 
 a given disease is merely functional. It may seem 
 superfluous to dwell upon so obvious a point, but I have 
 often known cases to be regarded as purely hysterical, 
 when the plainest signs of organic disease were to be found, 
 if looked for ; and this merely because the patient presented 
 manifestations of hysteria. The same thing is true of other 
 causes of functional derangement, and it is true of the simu- 
 lation of disease. Circumstances suggestive of malingering 
 should be allowed no weight until the signs of organic 
 disease are proved to be absent. Not rarely the neglect of 
 this obvious rule has led to cruel injustice. When we think 
 that symptoms are simulated, we should always look on our 
 diagnosis, as well as on the patient, with suspicion, and be 
 very sure that we are right, before we act on our opinion. 
 
 If there is evidence of the existence of organic disease, 
 we have to ascertain its seat and nature — to make, that is, 
 the anatomical and pathological diagnosis. It is of im- 
 portance to keep these two points distinct in our minds. 
 Their confusion is a fertile source of error in diagnosis. 
 It is true that certain parts of the nervous system are 
 frequently the seat of certain morbid processes ; but if we 
 infer that because this or that region is diseased, the morbid 
 process is of this or that character, we make a pathological 
 diagnosis from anatomical facts ; and such a diagnosis will, 
 not rarely, be erroneous. It is true we have sometimes to 
 use this mode of reasoning : in the absence of other evi- 
 dence, or as corroborating other evidence, it is legitimate 
 and useful ; but it is only thus to be used, and always with 
 full recognition of its character and uncertainty. As an 
 instance, we may take the case of inco-ordination of move- 
 ment of the legs — locomotor ataxy. This indicates disease 
 of a certain part of the spinal cord. In the majority of 
 cases the disease in this region is of a certain character ; 
 but in some, the symptoms being the same, the nature of 
 the disease is different; and to infer the character of the 
 morbid process, in the latter case, from the symptoms 
 
 b 2 
 
4 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 present, would lead us, not only . to a wrong diagnosis, 
 but to an erroneous prognosis and unwise treatment. 
 
 It is to be remembered, tlien, that we can only infer 
 from the symptoms present in a case at a given time — 
 the seat of the disease. To learn its nature we have to 
 study the way in which the symptoms came on, and any 
 associated conditions which may be present. 
 
 I have put this rule thus absolutely because it is one 
 of great importance, often overlooked. There are, however, 
 certain exceptions to it, especially the facts that pain, acute 
 spasm, and sloughing of the skin are sometimes (not 
 always) signs of an irritative lesion. Even here, however, 
 the exception is rather apparent than real ; for it is the 
 acuteness of these symptoms, rather than their mere occur- 
 rence, which is of pathological import. 
 
 We will consider first, then, the elements of the ana- 
 tomical diagnosis, the signs which indicate the seat of the 
 disease — " localization," as it is the fashion to term it — 
 and afterwards glance at the elements of the pathological 
 diagnosis ; that is, the symptoms which indicate the nature 
 of the morbid process. 
 
 We can only learn the significance of symptoms by 
 ascertaining their nature and origin — what they are and 
 why they are. Hence our study of diagnosis must consist 
 to a large extent in what may be termed symptomatic 
 pathology. The symptoms of disease are alterations of 
 healthy function, and much, of our symptomatic pathology 
 is, literally, perverted physiology. We must, accordingly, 
 in the first place, have a clear conception of such points 
 in the structure and normal function of the spinal cord, as 
 may enable us to understand the origin of the symptoms 
 of its diseases. 
 
MEDICAL ANATOMY OF THE SPINAL CORD. 
 
 I.— MEDICAL ANATOMY OF THE SPINAL CORD. 
 
 The position of the cord, and of the origins of the nerves, 
 in relation to the bony canal in which it lies, is the first 
 important point which we have to consider. It will he 
 remembered that the cord does not, in the adult, extend 
 through the entire length of the spinal canal. It ends 
 opposite the 1st lumbar vertebra, or opposite the interval 
 between the 1st and 2nd lumbar vertebrae. Hence the 
 various pairs of nerves (except the highest) do not arise 
 from the cord opposite the vertebrae at which they leave 
 the canal, and after which they are named, but at a 
 higher level. The difference between the level of origin 
 and of exit, slight in the cervical region, increases as we 
 descend the cord, until, as you know, in the cauda 
 equina, the lowest nerves have a very long course from 
 the end of the cord to their foramina. It is important 
 to know what nerves correspond in their origin with a 
 given part of the vertebral column, because the cord often 
 suffers secondarily to disease or injury of the bones. The 
 relation is rendered more complex by the fact that the 
 vertebral spines, which alone we can feel, and which con- 
 stitute, therefore, our localizing guides, do not correspond 
 in all parts to their vertebrae. Since these points are im- 
 portant in diagnosis, and are not adequately described in 
 any English work, I have prepared a diagram (Fig. 1) 
 showing the average relations of the spines to the bodies 
 of the vertebrae, and of both to the origins of the spinal 
 nerves. The tips of the cervical spines correspond nearly 
 to the lower borders of the corresponding vertebrae. Each 
 of the upper three dorsal spines corresponds nearly to the 
 upper border of the body of the vertebra below. From 
 the 4th to the 8th dorsal, each spine corresponds to the 
 middle of the body of the vertebra below. The 9th, 10th, 
 and 11th spines slope less, and their tips again correspond 
 to the upper borders of the next vertebrae, while the rest 
 of the spines are opposite the bodies of their own vertebrae. 
 
THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 ,b 
 
 a 
 
 Di 
 
 d 
 
 10 
 
 J2 
 
 L/ 
 
 What is the relation of the 
 
 spines to the nerve origins?* 
 
 ----- 1 C rp^ g rs £ three cervical spines 
 
 3 are opposite the origins of the 
 
 4 3rd, 4th, and 5th cervical nerves. 
 
 -«5 The 6th and 7th pairs arise 
 ■—-6 opposite the intervals between 
 -7 the 4th and 5th, and the 5th 
 —-8 and 6th, cervical spines respec- 
 — - 1 D tively. The 6th cervical spine 
 
 2 corresponds to the origin of the 
 
 — -s 8th cervical nerve, and the 7th 
 
 4 cervical spine to the first dorsal 
 
 nerve. The first four dorsal 
 spines vary. The 1st spine 
 corresponds to the interval 
 between the 2nd and 3rd 
 "" 8 pairs, or to the origin of the 
 
 9 3rd pair. The 2nd spine is 
 
 between the 3rd and 4th pairs, 
 
 or opposite the 4th pair. The 
 
 3rd spine is opposite the 5th, or 
 
 "~" 12 the interval between the 5th and 
 
 , 6th pairs. The 4th spine is 
 
 opposite the lower part of the 
 
 origin of the 6th pair, or even 
 
 — 3 below it. The 5th spine always 
 
 corresponds to the origin of the 
 
 — - 4 7^ p^ . the 6th spine to the 
 
 --.5 8th pair; the 7th to the 9th 
 
 I s pair ; the 8th to the upper part 
 
 , of the 10th pair ; the 9th to the 
 
 Fig. 1. 
 
 ■ — ~ 3 * The only recorded observations on 
 
 4 this point are those of Nuhn and Jadelot. 
 
 The facts stated in the text are partly 
 the results of a fresh examination of the 
 relations, kindly made for me by Mr. 
 V. Horsley, Demonstrator of Anatomy 
 in University College. 
 
MEDICAL ANATOMY OF THE SPINAL CORD. / 
 
 11th pair, and the 10th to the 12th pair. The 1st 
 lumbar rierve arises opposite the 1 1th dorsal spine ; the 
 2nd lumbar opposite the interval between the 11th and 
 12th spines ; the 3rd and 1th opposite the 12th spine ; 
 the 5th dorsal and 1st sacral opposite the interval between 
 the 12th dorsal and 1st lumbar spines, while the remaining 
 sacral nerves arise nearly opposite the 1st lumbar spine. 
 
 I need not describe in detail the relations of the origins 
 of the nerves to the bodies of the vertebras, since they 
 may be inferred from the facts I have given, or ascertained 
 by a reference to the diagram. 
 
 Thus the cervical enlargement of the cord, which ends 
 at the origin of the 1st dorsal nerves, corresponds nearly to 
 the bodies and spines of the cervical vertebras, while the 
 lumbar enlargement, which commences at the 12th dorsal 
 nerves, corresponds to the bodies of the 11th and 12th 
 dorsal and 1st lumbar vertebras, and to the lower three 
 dorsal and 1st lumbar spines. 
 
 We may next consider, briefly, the general structure of 
 the cord, seen in a transverse section, such as is represented 
 in the accompanying diagram (Fig. 2). It is divided into 
 two halves by the anterior and posterior fissures, of. and 
 pf. The latter is rather a septum than a fissure. The 
 position of each is marked by a depression in the surface. 
 In addition there are two other depressions, one where the 
 posterior nerve-roots enter (pr.) ; another (at s.) about midway 
 between this and the posterior fissure. The two " fissures " 
 do not meet, being separated by the commissure which con- 
 nects the two halves. The grey matter, in each half of the 
 cord, is surrounded by the white substance, and is divided into 
 two portions, or " cornua." The anterior cornu (ac.) varies 
 much in size and shape in different parts of the cord, being 
 much larger in the cervical and lumbar enlargements than 
 in the dorsal region. It does not come to the surface ; the 
 anterior nerve-roots (ar.) reach it by passing through the 
 anterior column. The posterior cornu (pc, Fig. 2) is much 
 smaller, and comes almost up to the surface at the depression 
 (pr.) where the posterior nerve-roots enter. It is much larger 
 
8 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 in the lumbar enlargement than in the cervical and dorsal 
 regions. The white substance is composed of nerve-fibres 
 running vertically ; and since these end at different levels, 
 the white substance lessens in amount from above down. 
 The relative amount of the grey and white substance, and 
 the differences in size and shape of the grey cornua in various 
 regions of the cord, may be understood from the accompany- 
 ing diagrams of sections at different parts. 
 
 The posterior cornua, coming to the surface, cut off from 
 the rest of the white substance, that which lies between them, 
 and this constitutes the posterior columns. Each posterior 
 column thus lies between the posterior median septum and the 
 posterior cornu. The posterior roots of the nerves do not 
 all immediately enter the grey substance, but some of them 
 
 Fig. 2. — Diageam of Section op Spinal Coed in the Ceevical Region. 
 The reference letters are explained in the text. 
 
 course through the outer part of the posterior column, which 
 we may term the postero-external column (p.e.c, Fig. 2). 
 It has been termed by Charcot the " posterior root-zone." 
 A septum of connective tissue (s., Fig. 2) separates off, from 
 this area, that part of the posterior column which is adjacent 
 to the posterior median fissure, and the part so marked off is 
 termed the " posterior median column." The distinction of 
 these two portions of the posterior column is, as we shall see, 
 very important in pathology. But it is to be noted that the 
 fibres of the posterior roots only pass through the outer part 
 of the postero-external column, and that these fibres in the 
 lumbar region pass further into the column than the cervical 
 region. 
 
MEDICAL ANATOMY OF THE SPINAL CORD. 
 
 9 
 
 The portion of white matter which lies in front of and 
 outside the grey, from the anterior median fissure to the 
 posterior cornu, is structurally undivided, and is termed the 
 
 L. 3. L. 5. Sac. 2. Sac. 4. Co. 
 
 Fig. 3. — Diageams of Sections of the Spinal Coed at Diffeeent 
 Levels. 
 The letters and numbers indicate the spinal nerves to which the sections 
 correspond. Each is figured twice the natural size. (From Quain's 
 "Anatomy," 8th Edition.) 
 
 antero-lateral column. It has been artificially divided into 
 an anterior column, lying to the front and inner side of the 
 anterior cornu, and a lateral column, lying outside the grey 
 
10 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD.- 
 
 matter (Fig. 2). But pathology indicates a more important 
 division than this, and the study of. the development of the 
 cord corroborates the teachings of pathology. If certain 
 parts of the brain (concerned in voluntary motion) are de- 
 stroyed, certain fibres degenerate throughout the cord, and 
 this degeneration marks out for us the fibres which are in 
 direct connection with the motor region of the brain. Two 
 tracts are thus picked out, one in the posterior part of the 
 lateral column, on the opposite side to the cerebral lesion ; 
 and one on the same side, in the anterior column, close to 
 
 a..j>.b. 
 
 P.M.C. 
 
 Fig. 4. — Aeeas of Secondary Degeneration. 
 
 p.m.c, postero-mediau columns, one on each side of the posterior median 
 septum ; d.p.t., direct, or anterior, pyramidal tracts, one on each side of 
 the anterior median fissure ; c.p.t., crossed, or lateral, pyramidal tract 
 in the posterior part of each lateral column, and separated from the 
 surface of the cord by (*), the direct cerebellar tract of Flechsig. The 
 areas of ascending degeneration are shaded vertically : those of descend- 
 ing degeneration transversely. 
 
 the median fissure (see Plate, Fig. 1, a and b). These are 
 called the "pyramidal tracts," because the connection of 
 these tracts with the brain is by means of the anterior 
 pyramids of the medulla. They are shown on both sides, 
 shaded transversely, in Fig. 4. Those adjacent to the 
 anterior median fissure are the " anterior (or direct) pyramidal 
 tracts " ; those in the lateral column are the " lateral (or 
 crossed) pyramidal tracts." 
 
 The crossed (or lateral) pyramidal tract contains the 
 motor fibres which have decussated in the medulla ; the 
 direct (or anterior) tract, those which have not decussated 
 
MEDICAL ANATOMY OF THE SPINAL COED. 
 
 11 
 
 there. The relative size of these tracts varies in different 
 individuals; the more fibres that have crossed in the 
 medulla, the smaller is the direct tract, and vice verm. The 
 direct tract may even be absent, all the fibres having crossed 
 above (Flechsig). 
 
 Regarding the lateral pyramidal tract, it may be observed 
 that it is situated behind the level of the anterior cornu, 
 that it does not usually extend quite 
 up to the posterior cornu (although it 
 may do so behind), and that it does not 
 extend up to the surface of the cord, 
 being limited by a zone (* Fig. 4) , in 
 which there is no descending degene- 
 ration. The fibres of this zone are 
 said (by Flechsig) to descend from 
 the cerebellum.* 
 
 We have further evidence that the 
 fibres in the posterior parts of the 
 lateral columns descend from above, 
 in the fact that, if the cord is de- 
 stroyed at any level, these fibres on 
 each side degenerate below the lesion, 
 just as they do on one side after a 
 
 cerebral lesion. Such bilateral degeneration is shown in 
 Fig. 5, 0, c c, the lesion causing it being indicated at A. 
 Bilateral degeneration of these tracts is shown also on the 
 Plate, Fig. 2, b b. This degeneration is currently, although 
 not very happily, termed " sclerosis," and the degeneration 
 
 Fig. 5. 
 
 * The direct pyramidal tract is also called the column of Tiirck ; the 
 postero-median column is called the column of Goll, and the postero- 
 external column is called the column of Burdach. I have avoided the 
 use of these terms. This system of nomenclature is full of inconvenience, 
 increasing the difficulties of the student, and leading to frequent mistakes 
 in scientific "writings. There are very few observations in medicine regard- 
 ing which it is not obvious that they would speedily have been made by 
 some jone other than the actual observer ; that it was very much of an 
 accident that they were made by certain individuals. Scientific nomen- 
 clature should be itself scientific, not founded upon accidents. However 
 anxious we may be to honour individuals, we have no right to do so at the 
 expense of the convenience of all future generations of learners. 
 
12 THE DIAGNOSIS OF DISEASES OE THE SPINAL CORD. 
 
 of this area is designated " lateral sclerosis " — " descending 
 lateral sclerosis," when it is the result of a lesion higher up. 
 
 I mentioned that the fibres of the white columns end at 
 different levels, and so the white columns become progres- 
 sively smaller. The portions of the white columns which 
 constitute the pyramidal tracts follow the same rule, and 
 hence the descending degeneration becomes smaller in area 
 the lower we descend in the cord, and in the lowest part 
 of the lumbar enlargement it is very small indeed. The 
 fibres of the anterior pyramidal tracts disappear in the 
 dorsal region, probably passing to the other side of the 
 cord. Hence the descending degeneration from the brain, 
 in the lower dorsal and lumbar region, is confined to the 
 opposite lateral column. Hence, too, if the cord is com- 
 pressed, the descending degeneration appears in the anterior 
 pyramidal tracts only when the compression is high up. 
 
 A similar process of " secondary degeneration " furnishes 
 corroboration of the distinctive division of the posterior 
 column, which, as we have just seen, is suggested by 
 anatomy. Below a point at which the cord is completely 
 destroyed, although the lateral columns degenerate, the 
 posterior columns present no change. Above the point 
 destroyed, however (as at B, Fig. 5), while the lateral 
 columns, and the postero-external columns present no change, 
 in the postero-median columns the nerve-fibres disappear 
 and become replaced by connective tissue.* This ascending 
 degeneration is also shown in the Plate, Fig. 3, c. These 
 are the only secondary degenerations commonly described. 
 But I have found, in a spinal cord of which the lower 
 extremity was crushed, a symmetrical area of slight ascend- 
 ing degeneration in the anterior part of the lateral columns, 
 
 * This statement, although that which is current, is not strictly accu- 
 rate. Some distance above ' the damage the ascending degeneration is 
 confined to the postero-median columns ; but close above the compression 
 the degeneration extends outwards into the posterior portion of the postero- 
 external column, not, however, to that part of it through which the 
 posterior roots pass. Hence it is probable that the fibres which cotu-se 
 upwards in the postero-median column enter it from the postero-external 
 column. 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL CORD. 13 
 
 in front of the pyramidal tracts (Plate, Fig. 3, e). Of its 
 possible significance I will speak presently. 
 
 The grey substance is composed of nerve-cells and 
 interlacing fibres ; some of the cells in the anterior cornua 
 are very large and with many processes, and are called 
 the " ganglionic " or " motor " nerve-cells. One process 
 from each cell is undivided and constitutes the axis cylinder 
 of a nerve fibre of an anterior roof. The other processes 
 divide and subdivide in the substance of the grey matter. 
 
 II.— PHYSIOLOGY OF THE SPINAL COED IN 
 RELATION TO THE SYMPTOMS OF ITS 
 DISEASES. 
 
 We may now consider the chief functions of the cord, and 
 the effects of their impairment. In the spinal functions we 
 have to distinguish two great systems of action — that by 
 which the cord transmits, and that by which it controls ; i.e., 
 its functions as a conducting organ, and as a nerve-centre, 
 reflex and automatic. 
 
 Motor Conduction. — The conduction of motor impulses from 
 the brain is in the antero-lateral white columns, probably 
 in the pyramidal tracts ; it is chiefly in the side of the cord 
 corresponding to the limbs moved, the crossing taking place 
 for the most part in the medulla. The motor path leaves 
 the cord by the anterior nerve-roots, but does not enter 
 them directly. The fibres of the pyramidal tracts enter the 
 substance of the grey matter, and are apparently connected 
 through this with the large nerve-cells from which the 
 anterior root-fibres proceed. Hence both the matrix of 
 grey matter and the motor nerve-cells form part of the motor 
 path. The power of voluntary motion may be arrested by 
 a lesion anywhere in this tract— lateral column of the cord, 
 grey matter, and anterior nerve-roots. If the lesion is on 
 one side of the cord, the loss of power will be on the same 
 side, and in degree proportioned to the number of pyramidal 
 fibres which have crossed in the medulla ; and this, as we 
 have seen, is not always the same. 
 
14 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 . Sensory Conduction. — All sensory impulses — of pain, touch, 
 temperature — enter the cord by the posterior roots, passing, 
 in part directly, in part through the postero-external 
 columns, into the posterior cornu, and quickly crossing to the 
 other side of the cord. There is some reason to believe that 
 the paths of these several sensory impulses up the cord are 
 not the same. That of pain has been commonly believed to 
 pass up the central grey matter ; that of touch, and perhaps 
 also of temperature, passes up, in the opinion of some 
 authorities, in the posterior column. But according to late, 
 most careful, and apparently conclusive experiments by 
 "Woroschiloff (confirmed by Ott), such sensation as can be 
 tested in the lower animals is conducted, in the dorsal region 
 in the lateral columns. No facts have been hitherto recorded 
 suggesting that this is true of man. But if sensation is con- 
 ducted in part in the lateral columns, it is certainly not in 
 that portion of them which is occupied by the pyramidal 
 tracts, because there may be no loss when these are com- 
 pletely degenerated. It is probably, therefore, in front of 
 these. This is the situation in which I have found the 
 ascending degeneration in the case of crushed cord in which 
 sensation was greatly impaired. (See p. 13, and Plate, 
 Fig. 3, e.) This fact at present stands almost alone,* but, 
 taken in conjunction with the experiments on animals, it 
 points, I think, to the probability that some sensation is con- 
 ducted in this region in man ; what or whence, whether 
 from the skin or deeper structures, we do not know. 
 
 "We are still too ignorant of the paths of sensation 
 for us to infer much from the form of its affection in 
 spinal disease. One thing, however, seems clear — the path 
 of sensation is less definite than that of motion. A very 
 small portion of undestroyed cord will conduct sensation, 
 but it is then, at least in its intenser form, commonly 
 retarded. Each form of sensation may be impaired by 
 disease of the posterior roots, either outside the cord or 
 
 * A confirmation of the occurrence of limited degeneration in this 
 situation is furnished by an interesting observation by Dr. Haddon 
 ("Path. Trans." vol. xxxiii. p. 21). 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL CORD. 15 
 
 in the postero-external column through which they pass ; 
 or by disease of the conducting structures of the cord 
 higher up ; and, since the paths decussate in the cord, if the 
 lesion is unilateral, sensation will be affected on the side of 
 the body opposite to the lesion (motion being affected on 
 the same side). A strong reason for believing that the paths 
 are not the same is, that the senses of touch and pain and 
 temperature are often impaired in different degrees. The 
 most common change is for the sense of pain to be lost and 
 touch preserved (analgesia). In such a condition the slightest 
 touch of the finger may be felt readily, but a needle may be 
 driven into the skin, and the patient experiences only the 
 sensation of a touch. In other cases the sense of touch 
 may be lost, and only the perception of painful impressions 
 remain (anaesthesia). In other cases both are changed pro- 
 portionately. To ascertain impairment, it is necessary to 
 examine carefully the sensitiveness to each form of stimu- 
 lation, to note how the patient feels the impression (since the 
 sensation, when not lost, may'be perverted) , to note whether 
 it is localized accurately, and to note whether it is unduly 
 retarded. Sensations of pain and temperature are never so 
 rapid as that of touch, and it is in these that the chief 
 retardation takes place. 
 
 The functions of the ascending fibres of the postero- 
 median columns are still unknown. Their degeneration 
 does not seem to be accompanied by any impairment of 
 sensation. We also know little of the function of those 
 fibres of the antero-lateral column which lie in front of the 
 anterior cornua. 
 
 Reflex Actions. — The next important function of the cord 
 is its action as a reflex centre. We may regard the reflex 
 system of the cord as made up of a series of nerve-loops 
 or arcs, each posterior, sensory, root being connected with 
 certain anterior, motor, roots by means of the grey matter 
 (Fig. 6). This consists partly of the large motor nerve-cells, 
 and partly of a network of the finest nerve-filaments and 
 minute nerve-cells. The connection of the roots, through the 
 grey matter, is apparently by this network of fine fibres, which 
 
16 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 interlace like the filaments of a sponge. But in this there 
 are paths of different resistance, so that a slight stimulus may 
 pass by the most ready path to a certain anterior root, while 
 a stronger stimulus may diffuse itself more widely and affect 
 many nerve-roots. For instance, a gentle touch on the sole 
 may cause only a movement of the toes ; a stronger touch, a 
 start of the whole leg. A similar wide diffusion may occur 
 in pathological states of the cord. These reflex loops are also 
 connected with the conducting tracts to and from the brain. 
 
 Fig. 6. — Diagram of a Reflex Loop. 
 
 M, conducting motor tract ; m, anterior, motor, nerve-roots ; s, conducting 
 sensory tract ; s, posterior, sensory, nerve-roots. 
 
 A motor impulse, passing down the cord in the white column 
 (m), leaves the cord by the anterior roots (m), which are part 
 of the reflex loop, and enters the anterior roots by the grey 
 matter and motor nerve cells, which may be regarded as part 
 of the reflex centre. So, too, the sensory impulse enters the 
 cord by the posterior nerve-roots (s) , which are also part of the 
 reflex loop, and then, leaving this loop, ascends the opposite 
 side of the cord to the brain. Thus the same peripheral im- 
 pression excites a conscious sensation and a reflex action ; and, 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL CORD. 17 
 
 on the other hand, we can, if we wish, execute voluntarily a 
 movement of the leg quite the same as the reflex action. 
 Moreover, we can exercise some voluntary control over the 
 reflex movement, and prevent or lessen the start of the leg. 
 
 The value of the reflex actions in diagnosis is, that their 
 persistence is proof that there is no considerable disease in the 
 reflex loops by which they are produced. They thus yield 
 us very important diagnostic information. Both their absence 
 and their excessive degree are significant. It will be well, 
 therefore, to study them in more detail. 
 
 It is necessary to distinguish two forms of reflex actio a. 
 The first is that excited by stimulation of the skin, by a 
 touch, scratch, prick, etc. On gentle stimulation, contrac- 
 tion occurs in the muscles at or near the spot. A series of 
 such reflex actions can often be obtained in the normal spinal 
 cord, from the lowest extremity of the cord to the lower part 
 of the cervical enlargement. In some cases they are of con- 
 siderable diagnostic importance. Beginning below, we have 
 the well-known reflex from the sole (plantar reflex) which 
 depends on the lower part of the lumbar enlargement, when 
 the movement which results is confined to the foot-muscles. 
 (See Table, p. 60.) Next, irritation of the skin of the but- 
 tock, in some individuals, excites a contraction of the glutei — 
 the gluteal reflex, we may call it — depending, I believe, on 
 the cord at the level of the 4th or 5th lumbar nerve. Next, 
 there is the well-known cremaster reflex, by which the 
 testicle is drawn up when the skin on the inner side of the 
 thigh is stimulated. This arises at the level of the 1st and 
 2nd lumbar pairs. It may often be excited by stimulation 
 of any part of the front and inner side of the thigh.* Next, 
 there is the abdominal reflex — a contraction in the abdominal 
 muscles, when the skin is stroked on the side of the abdomen, 
 from the edge of the ribs downwards. This is produced in 
 the cord from the 8th to the 12th dorsal nerves. Next, 
 a stimulation on the side of the chest, in the 6th, 5th, and 
 sometimes in the 4th intercostal spaces, causes a dimpling 
 
 * This reflex has been carefully studied by Jastrowitz, and by Weir 
 Mitchell. 
 
18 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 of the epigastrium on the side stimulated. I think that it 
 depends on a contraction in the highest fibres of the rectus 
 abdominis ; it is singularly uniform in its occurrence. We 
 may term it the epigastric reflex; it depends on the spinal 
 cord from the 4th to the 6th or 7th pairs of dorsal 
 nerves. There ia no higher reflex on the front of the 
 trunk. If we turn to the back, we shall find that in some 
 patients, from the angle of the scapula to the iliac crest, 
 stimulation of the skin along the edge of the erectors of the 
 spine excites a local contraction in these muscles. These 
 dorsal and lumbar reflexes, as they may be termed, are only 
 of corroborative value, as they are less active than the more 
 convenient abdominal and epigastric reflexes, which are pro- 
 duced in the same region of the cord. Irritation of the skin 
 in the interscapular region gives us, however, the highest 
 reflex available — a contraction in some of the scapular 
 muscles, when slight, chiefly marked at the posterior axillary 
 fold (teres) ; when more considerable, involving almost all the 
 muscles attached to the scapula — trapezius, teres, serratus — 
 and even moving the bone a little outwards. We may term 
 it, therefore, the scapular reflex, and it is produced in the 
 cord at the level of the upper two or three dorsal and lower 
 two or three cervical nerves. 
 
 Thus in these reflexes — plantar, gluteal, cremasteric, abdo- 
 minal, epigastric, and scapular — we have the means of ascer- 
 taining something of the condition of almost every inch of 
 the spinal cord from the cervical enlargement downwards. 
 The presence of the reflexes is proof that the reflex path 
 through the cord is not seriously uninterrupted, but we cannot 
 simply infer from their absence that this path is impaired. 
 The reflex excitability of the cord varies much in different 
 individuals, is always greatest in early life, and is often 
 lessened in the old. Some of these reflexes are thus absent, 
 apart from disease, especially the gluteal and lumbar reflexes, 
 and sometimes the cremaster reflex ; the abdominal reflex 
 is also lessened by laxity or distension of the abdominal 
 parietes. It is a remarkable fact, also, that disease of 
 one cerebral hemisphere lessens or abolishes these superficial 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL COR]). 19 
 
 reflexes on the opposite (paralysed) side of the body. The 
 diminution may be observed immediately after the occurrence 
 of the cerebral lesion, and may be permanent. It is an effect 
 very difficult to explain, because these reflexes are increased if 
 the disease, which lessens voluntary power, is not situated in 
 the brain, but is high up in the cord.* The effect of cerebral 
 disease does not interfere materially with the use of these 
 reflexes as indications of spinal disease, and it affords us 
 an important additional indication of the existence of an 
 organic disease of the brain. I will presently give you 
 some instances of the utility of these reflexes in spinal 
 diagnosis. 
 
 The second group of phenomena which depend on reflex 
 action are those which have been termed " tendon -reflexes." 
 These phenomena are of great practical importance, and it is 
 necessary to describe their character and nature in some 
 detail, t 
 
 We will first consider the well-known jerk of the leg 
 which occurs when the patellar tendon is tapped. It has 
 been called the " knee phenomenon " by Westphal, the 
 " patellar-tendon reflex " by Erb. The latter designation 
 has come into general use, although, as we shall presently 
 see, it is an undesirable term. We may, therefore, speak of 
 it either by the somewhat cumbersome designation proposed 
 by Westphal, or by the simpler descriptive term " knee-jerk." 
 It is not a little curious that this knee-jerk, which has 
 
 * There is, I think, only one possible explanation. In the frog- the 
 superficial reflexes are controlled by a centre, situated in the optic lobes, 
 and are lessened, or at least retarded, if this is stimulated. It is probable, 
 as just observed, that there is also in the higher animals a centre which 
 has the power of controlling these reflex actions. If we assume that this 
 controlling centre is itself under the influence cf the highest motor 
 centres — not an improbable assumption — all the phenomena are intelligible. 
 The motor centres nominally restrain the controlling centre : if the motor 
 centres (or path from them to the controlling centre) are damaged, this 
 centre is unrestrained, and inhibits the superficial reflexes on the paralysed 
 side. But disease in the cord interrupts, not only the voluntary path, but 
 also that by which the controlling centre influences the superficial reflexes 
 and so these are intensified in the paralysed parts. 
 
 | First systematically studied by Erb and "Westphal, but previously 
 partially recognized and employed in diagnosis by Charcot. 
 
 c 2 
 
20 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 for generations amused schoolboys, should have become an 
 important clinical symptom. 
 
 To obtain the jerk, the knee must be flexed so that the 
 quadriceps femoris is gently extended, and the leg must 
 be free to move. If then the patellar tendon is struck, the 
 quadriceps contracts and jerks the leg forwards. The most 
 convenient position is with the knee to be tested flexed 
 nearly, but not quite, at a right angle. The posture 
 commonly employed is with the leg to be tested across the 
 olher, the knee of the supporting leg being at a right 
 angle (Fig. 7). But if the leg to be tested is stout, its 
 tension in this position may be too great to permit of any 
 movement. In such case the best posture is for the observer 
 to place his arm beneath the patient's thigh, just above 
 the knee, and rest his hand on the patient's other knee 
 (Fig. 8). Not long ago I saw a rather stout man, well 
 known to many members of our profession, who . was uneasy 
 because a physiological friend had been unable to produce 
 this phenomenon upon him. His legs were so stout that, in 
 the posture commonly employed, no movement occurred 
 when the patellar tendon was struck. But when the thigh 
 rested on the observer's arm, in the way I have described, 
 the tap on the tendon caused a ready jerk, much to the 
 satisfaction of the individual examined, whose anticipations 
 of impending locomotor ataxy were thus removed. Children 
 may sit on the edge of a chair, adults on the edge of a table ; 
 but if so, and the legs are vertical, the effect of the blow and 
 of the muscular contraction must be carefully distinguished. 
 The side of the extended hand is a convenient instrument 
 for giving the blow (Fig. 7). Now and then, when very 
 slight, a percussion hammer (Fig. 8), or a stethoscope with 
 an india-rubber edge to the ear-piece,* elicits it more readily, 
 especially when (as in children) the space between the patella 
 and tibia is too small to permit of a suitable blow with 
 the hand. It may commonly be obtained as readily through 
 one or two garments as upon the skin. If its existence 
 
 * Such stethoscopes were formerly in use for percussion of the chest, 
 and can ba obtained of most instrument makers. 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL CORD. 21 
 
 is doubtful, however, the skin should be bared. In many 
 cases the movement may be obtained by a downward blow 
 upon the patella, by a blow on the quadriceps tendon 
 above the patella, or by a blow on the substance of the 
 muscle, almost as readily and strongly as by a blow on the 
 patellar tendon. In cases in which it is in great pathological 
 excess, it may even be excited by a blow on the tibia. 
 
 "When it is in excess, the same phenomenon may be 
 conveniently brought out in a somewhat different way. 
 
 Fig. 7. — Obdinaky mode of Obtaining 
 the Knee-Reflex. 
 
 The dotted line indicates the movement 
 which follows the blow on the patellar 
 tendon. 
 
 Fig. 8. — Knee -Reflex. 
 
 Method of obtaining it with 
 a percussion hammer when 
 it is not readily produced 
 in the ordinary way. 
 
 As the patient lies in bed, the finger of one hand is placed 
 across the quadriceps tendon just above the patella, and the 
 patella pushed down, so as to make the quadriceps tense. 
 The finger is then percussed in the direction in which the 
 patella is - being pushed, so as, suddenly, to increase the 
 tension in the muscle. The blow is instantly followed by a 
 contraction, jerking the patella and finger upwards. Very 
 often this single contraction is immediately succeeded by a 
 second, and this by a third, and so on — a series of quick 
 
22 ti 
 
 zia?v:s:? :z z:szi=zs :z zzzz spi^ax cohd. 
 
 donic contractions, recurring as freque 
 second. By grasping the patella firm 
 
 • zsLzzg :: i:-*rz_— iris. s: :..= :: rzzke -'--. 
 \-'-— 'Z5l n:.y :1s: r =z: v.t. :. ; Z: : _:.s sjl: 
 tzzz.t is - :zz :. ; Tt^s::z is kzz: .::. : v.: irj 
 :_t zizs:-T is :s.:.zs: 
 
 The next important phenomenon 1 
 group occurs at the ankle-joint. If the < 
 are connected "with the Achilles tendoi 
 and this tendon is tapped, the muscled 
 a slight extension moTement of the 
 
 nfly as eight per 
 
 lj, and suddenly 
 muscle tense, this 
 iwn. It may eon- 
 
 zszzly t:.StS — _t_ 
 
 )elonging to this 
 alf-museles. which 
 l, are made tense, 
 
 ; ::z:::. ::. causing 
 foot : iust as the 
 
 £"::-. ': -:."::z:: r _ 
 
 Foot- _i::~ s ;t Passive 
 Foot. 
 
 muscles of the thigh contract, -when the patellar tendon is 
 struck. In cases in "which these phenomena are ez:rSsi~T. 
 — just as sudden tension in the thigh-muscles will cause 
 a contraction, followed by others in a continuous series — 
 so, in such cases, if the calf-muscles, which extend the 
 ankle-joint, are suddenly put on the stretch by pressing 
 the hand against the sole of the foot (Fig. 9), a quick 
 contraction occurs, instantly ceasing, hut, if the pressure is 
 kept up, instantly renewed, and recurring, as long as the 
 tension is maintained, as a clonic series of spasmodic con- 
 tractions — the • a V e-clonus," or "foot-clonus" (or "foot 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL CORD. 23 
 
 phenomenon" — Westphal). It can often be obtained best 
 when the knee is not completely extended. The movement 
 is very uniform, from six to ten contractions occurring 
 per second. By attaching a writing point to the foot, 
 and making it trace a line on a revolving cylinder covered 
 with blackened paper, I have obtained such tracings as I 
 now show you (Fig. 10), which are almost as regular as the 
 tracings of a tuning-fork. This foot-clonus can be more 
 frequently obtained than the clonus in the extensors of the 
 knee, but the two have the same time, and are evidently of 
 the same nature. 
 
 What is the nature of these phenomena ? "When a 
 tendon is tapped, and its muscle contracts, the occurrence 
 has somewhat the aspect of a reflex action. It was 
 
 Fig. 10. — Tbacing of the Foot-Clonus in Paraplegia. 
 (The tracing reads from right to left.) 
 
 assumed by Erb that the contraction is a true reflex 
 action, the stimulus being the excitation of nerves in the 
 tendon. Hence it has been termed " tendon-reflex." This 
 view has received apparent confirmation by the discovery 
 of certain facts : (1) That there are nerves in tendon.* 
 (2) That these phenomena depend for their occurrence on 
 the integrity of the reflex path to, through, and from the 
 spinal cord, and are arrested by a lesion in this path. 
 By experiments on animals (in whom similar contractions 
 may be obtained) it has been found that they are prevented 
 by division of the nerves to the muscles, by division of 
 either the anterior or posterior roots of the spinal nerves, 
 
 * It does not need the microscope to demonstrate this, as any one may- 
 ascertain who will take the trouble to give his Achilles tendon a sharp 
 pinch. 
 
24 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 or by destruction of the spinal cord.* The knee-jerk 
 cannot be obtained in locomotor ataxy (damage to the 
 posterior nerve-roots), or in infantile paralysis (damage 
 to the grey matter, the reflex centre). (3) That these 
 phenomena are in excess in some cases, in which the reflex 
 action from the skin is in excess. 
 
 These facts certainly prove that some reflex influence 
 is concerned in the production of the phenomena. But 
 (as Westphal has always maintained) they do not neces- 
 sarily prove that the contractions depend on a simple 
 reflex action from the tendons. A little consideration of 
 the facts which I have already described, will show that 
 
 Fig. 11. — Method of obtaining the Front-tap Contraction. 
 
 there is a good deal which cannot be explained by the 
 " tendon-reflex " theory. There is the great fact that 
 passive tension is necessary for the tap on the tendon to 
 be effective, and that when the phenomena are in excess, 
 sudden tension alone will suffice to develope the contraction. 
 But tension acts upon the muscle as well as upon the tendon, 
 and frequently the contraction may be distinctly excited 
 by stimuli which act on the muscle and have no action 
 on the tendon. For instance, in cases in which these phe- 
 nomena are in excess, if the foot be gently pressed up so 
 as to make the calf-muscles tense, and the muscles on the 
 
 * See Tschirjew : " Archiv fur Psychiatrie, " Bd. VIII. Heft 3. 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL CORD. 25 
 
 front of the leg be tapped, the calf -muscles contract, just 
 as they do when, under the same circumstances, the tendon 
 is tapped, and cause a brief extension movement of the foot. 
 I have termed this the " front-tap contraction." It is a 
 very delicate test of increased irritability, and it is also 
 of considerable theoretical interest, since we have in it a 
 contraction developed by a stimulus which does not in any 
 way affect the tendon. It can affect the gastrocnemius 
 directly, for by placing the hand on the calf, a vibration 
 may be felt through the leg. If the tibia, instead of the 
 muscle, is tapped, the contraction is much slighter, or does 
 not occur. 
 
 Moreover, a tap on the tendon itself only excites the 
 contraction when it increases the tension of the tendon ; 
 i.e., when it acts upon the muscle also. In the case of 
 the Achilles tendon, this may be easily demonstrated with 
 a little care. A gentle tap on the side of the tendon will 
 excite the contraction as readily as a tap on the back of 
 the tendon, but if the other edge of the tendon is supported 
 (as by the fingers of an assistant), the same tap will no 
 longer be effective, because it no longer increases the tension. 
 
 The strongest proof, however, of the independence of the 
 phenomena on any stimulation of the tendon is afforded by 
 the experiments of Tschirjew, who divided carefully all the 
 nerves to the patellar tendon, and still found that the tap 
 upon it made the tense muscle contract. 
 
 Thus the evidence seems conclusive that the contractions 
 are not excited by stimulation of the nerves of the tendon, 
 but that the stimulus originates in the muscle, the tendon 
 being only, so to speak, an instrument by which that stimu- 
 lation is produced. 
 
 But if the muscle is stimulated and then contracts, is not 
 the contraction excited locally, as Westphal has, from the 
 first, urged ? A reflex action takes a certain time, which is 
 needed for the stimulus to travel to and from the cord, and 
 for the reflex process to occur in the centre. According to 
 received physiological data, an interval of at least one- 
 fifteenth of a second would be needed for the knee-jerk, if it 
 
26 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 were a reflex process, and rather more for the movement at 
 the ankle. I have found that when the Achilles tendon, or 
 the front of the leg is tapped, the resulting contraction 
 occurs in about one-thirtieth of a second.* The interval for 
 the knee-jerk has been found to be about one-twenty-fifth or 
 one-thirtieth of a second, t If the patella is pressed down 
 and tapped, in the way I have just described, I have found 
 that the interval between the tap and the resulting contrac- 
 tion is often not more than one- fortieth of a second. The 
 shortness of the interval makes it difficult to believe that 
 these contractions can be reflex, and supports the theory that 
 they are excited locally. 
 
 But to this view, that the contractions are excited locally, 
 is apparently opposed the fact that they are prevented by 
 whatever lesion arrests reflex action. Some have endeavoured 
 to explain the discrepancy by the suggestion that reflex 
 action may occur in a much shorter time than is commonly 
 supposed. This suggestion is not at present justified by any 
 known facts. Another and, I think, much more probable 
 explanation is this. If we regard the contractions as local, 
 we have still to account for the irritability which permits the 
 local stimulus to cause a contraction. This irritability is 
 developed by passive tension. If the muscle is relaxed the 
 fibres may contract if they are struck directly, just as do 
 the fibres of a separated frog's muscle, but no contraction 
 can be produced by striking the tendon. Hence I have 
 suggested that the tension excites, by a reflex influence, a 
 state of extreme irritability to local stimulation, — such as 
 that of a tap on the tendon, or such as the vibration from 
 a tap near the muscle, or from a tap on the bone to which 
 
 * "Med.-Chir. Trans." 1879, p. 292. The measurement has been since 
 confirmed by Waller, " Brain," July, 1880. 
 
 t '039 sec. Burckhardt ; -032 — -034 sec. Tschirjew ; "04 sec. Brissaud ; 
 •03 — *04 sec. Waller ; -3 sec. Eulenberg. Some measurements which I 
 made of the interval (" Med.-Chir. Trans." 1879, p. 275) gave a longer 
 interval, probably in consequence of the movement of the foot being taken as 
 the indication of the commencing contraction. "Load" will increase greatly 
 the period of latent stimulation, probably by causing the initial contraction 
 to expend itself on the elasticity of the muscle. The measurements given 
 above were obtained by recording the commencing contraction of the muscle. 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL CORD. 27 
 
 the tendon is attached, — which thus excites a visible con- 
 traction.* 
 
 The explanation receives some confirmation from the 
 very interesting observations of Tschirjew.t He has found 
 that if the nerve to a separate muscle be divided, the 
 muscle remains of just the same length. If, however, a 
 weight be first attached to the muscle, when the nerve 
 is divided the muscle lengthens. This shows that the 
 tension does excite a slight contraction which is dependent 
 on a central influence. It is in this condition only that 
 the local stimulation is effective. If the tension put on 
 a muscle is gentle and gradual, it may only develope the 
 irritability, and an additional local stimulation is necessary 
 to produce a visible contraction. If, however, the tension 
 is sudden and forcible, it not only developes the irritability, 
 but produces visible contraction in the muscle thus rendered 
 irritable — as in setting up the foot-clonus. I have shown + 
 that the relaxation of the muscle, between the successive 
 contractions, is not complete : there is a persistent residual 
 contraction, i.e., a tonic contraction on which the clonic 
 contractions occur. When one clonic contraction is 
 over, the tension continuing, a second is instantly 
 developed. 
 
 The sensory nerves of muscles have been shown by 
 Tschirjew to commence, not within the muscular fibrils, 
 but in the interstitial connective tissue. The afferent 
 impulse produced by tension is apparently due to the tension 
 acting on these nerves : the visible contraction is excited 
 by tension or vibration affecting the muscular fibres them- 
 selves. The latter is ineffective unless the muscles are 
 brought into a state of special excitability through the 
 cord. Of the reality of an afferent impulse from the muscle, 
 produced by tension, you may easily convince yourselves, 
 
 * This explanation was originally given for the "foot phenomenon" alone 
 (" Med.-Chir. Trans." 1879, p. 295). I now think that it is equally applicable 
 to the knee-jerk. The evidence of the identity in nature of the two is very 
 forcibly stated by Waller (loc. cit.). 
 
 t " Eeichert und Du Bois Reymond's Archiv." 1879. + Loc. cit. p. 280. 
 
28 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 if you will allow your ankle to be suddenly flexed. A 
 distinct pain is felt in the muscle (none, be it observed, 
 in the tendon). It is not surprising, therefore, that this 
 afferent impulse should, very often, not merely develope 
 the reflex excitability, or tonic contraction, but also cause 
 a more widely-spread reflex action. The attempt to get 
 the foot-clonus, for instance, will cause a flexion of the 
 hip- joint ; the attempt to obtain the knee-jerk may cause a 
 movement in the opposite leg or a start back of the body. 
 But these reflex contractions, if carefully observed, confirm 
 the theory which has been put forward in the preceding 
 pages, for they distinctly succeed, at an appreciable interval, 
 the local contraction. If, for instance, in a patient now 
 under my care, I depress the patella so as to make tense 
 the quadriceps, and then tap the depressing finger, the tap 
 is followed, after an interval too short to be recognized, 
 by a contraction in the muscle, and after a very distinct 
 interval (which I have found to be about three times as 
 long as the other), by a contraction in the opposite leg. 
 So, too, Burckhardt has found that the latent interval for 
 a skin-reflex is three times as great as for the knee-jerk. 
 I think that this theory of reflex irritability and local 
 stimulation affords a full explanation of all the rela- 
 tions of these phenomena to the central nervous system, 
 and to the other phenomena of disease, and it is the only 
 theory which adequately explains them. 
 
 It seems, therefore, most desirable to discard the term 
 " tendon-reflex " altogether. The phenomena are, according 
 to the explanation above given, dependent on a " muscle- 
 reflex " irritability, which has nothing to do with the 
 tendons. If we wish to describe them by a general term, 
 it will be best to employ one which does not involve 
 any special theory of their nature. They may be termed 
 " tendon -muscular phenomena," but the intervention of 
 tendons is not necessary for their production ; the one 
 condition which all have in common is that passive ten- 
 sion is essential for their occurrence, and they may more 
 conveniently be termed myotatic contractions (ran/cos, ex- 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL CORD. 
 
 29 
 
 tended).* The irritability, on which they depend, is due 
 to and demonstrative of a muscle-reflex action which depends 
 on the spinal cord. 
 
 A true " tendon-reflex " may be excited by pinching the 
 tendon, but this is a start of the whole limb, precisely such 
 as results from a pinch of the skin. 
 
 A clonus quite similar to that just described can be 
 sometimes obtained in the peronei (a lateral foot-clonus), 
 and also in the plantar muscles of the great toe — in each 
 case by passive tension. All have nearly the same time — 
 about eight per second. 
 
 It is of interest to note that modern physiologists know 
 nothing of muscular " tone " except as developed by tension, 
 and it is highly probable that the condition on which the 
 
 Fig. 12. — Noemal Foot-Clontts. 
 (The tracing reads from right to left.) 
 
 myotatic irritability depends, is identical with muscular 
 "tone." It is not, therefore, surprising that we are able, 
 even in health, to get evidence of a tendency to rhythmical 
 contraction. If a rhythmical contraction can be set up 
 voluntarily, and gentle tension in the gastrocnemius 
 maintained, as by sitting on the edge of a chair with the 
 ball of the foot resting on the ground, the contractions 
 will go on involuntarily — a normal foot-clonus, which has 
 precisely the same time (about six per second) as the 
 morbid clonus (Fig. 12). A prolonged voluntary contraction 
 
 * If it should ultimately be proved (which is very improbable) that so 
 short an interval as one-fortieth of a second is sufficient for a reflex action, 
 and that each contraction is reflex, the term "myotatic" will still be accu- 
 rate, since it will remain true that tension is essentia] for the production 
 of these contractions. 
 
30 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 of the calf-muscles against a considerable resistance (as 
 in standing for some time on tip-toe) is also broken into 
 clonus. These are evidently the same phenomenon, the 
 difference being that it cannot in health be excited by 
 passive tension. For this to be effective a morbid reflex 
 irritability is needful, such as only exists in disease. In 
 morbid states, in which the myotatic irritability is exces- 
 sive, the posture I have just described excites the clonus 
 very readily ; and the jerking legs of paraplegics as they sit 
 must be familiar to you. In attempting to walk, also, the 
 tension on the calf-muscles has the same effect, and the 
 patient may be jerked violently by the spasm. 
 
 It is probable that this reflex relation between tension 
 and contractility of muscles is of the highest importance in 
 their associated action, and that the reason why, in certain 
 muscles, as those of the calf, these phenomena are more 
 readily observed, is because in these, during the process of 
 walking, at every step contraction succeeds tension, and so 
 the reflex relation between the two has attained a higher 
 degree of development. It is rare to get a distinct clonus 
 in a child who has never walked, even in the pathological 
 conditions in which in adults it would certainly be obtained. 
 
 The excess of these myotatic contractions is especially 
 related to degeneration in the lateral column of the cord 
 (pyramidal tracts). It is seen in extreme degree, for 
 instance, in lesions of the cord higher up, which cause 
 descending degeneration in those columns. It is seen also 
 in cases of hemiplegia with similar descending degeneration 
 on the paralysed side. The excess is apparently not due 
 to the simple loss of a cerebral influence. It does not, as 
 a rule, occur immediately, but developes gradually at the 
 end of a week or ten days, i.e., after a time sufficient to 
 allow the nutrition-changes of commencing degeneration to 
 pass down the lateral (pyramidal) fibres to the neighbour- 
 hood of the muscle-reflex centres. Over-action of these 
 centres follows, and must be ascribed to the loss of some 
 controlling influence. But the control cannot be exerted 
 by the fibres themselves, or the over-action due directly 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL COJtD. 31 
 
 to their degeneration, since the fibres only conduct, and 
 do not originate nerve force. The pyramidal fibres enter 
 the grey substance, and apparently end in its interlacing 
 network of fine fibres and minute nerve cells, and by 
 means of this structure are connected with the large 
 ganglion cells of the motor nerves. The phenomena are 
 best explained by the hypothesis that this structure, in 
 the matrix of the grey matter, controls the muscle-reflex 
 centres (of which the ganglion cells are part), and that 
 the degeneration of the pyramidal fibres, which can be 
 traced to the grey matter, invades this structure. The 
 loss of its influence permits the over-action of the muscle- 
 reflex centre. The foot-clonus can often be obtained 
 in slight chloroform narcosis, but under the full action 
 of chloroform it disappears ; apparently this agent in- 
 fluences the controlling structure before it influences the 
 muscle-reflex centres. Ether and nitrous oxide do not 
 abolish myotatic irritability (Horsley). After an epileptic 
 fit, again, a clonus can be obtained for a few minutes, 
 while after a very severe fit, the myotatic irritability, 
 instead of being increased, may for a few seconds be lost, 
 so that not even the knee-jerk can be obtained. In the 
 first case the discharge appears to temporarily exhaust the 
 controlling structure ; in the second, the more severe action 
 exhausts also the muscle-reflex centre itself.* 
 
 It is uncertain whether we should ascribe all over-action of 
 these centres to loss of control. We are justified in doing 
 so when the over-action follows permanently a destroying 
 lesion, such as the degeneration of the lateral columns. 
 Slight over-action is sometimes present when there is no 
 
 * I do not know of any pathological observations of the state of the 
 matrix of the grey substance when there is degeneration of the lateral 
 columns without affection of the motor ganglion cells. The investigation 
 is very difficult on account of the character of the structure. In cases so 
 extremely rare as to be manifestly exceptional in mechanism, the foot -clonus 
 has been observed a few hours after the onset of hemiplegia. It is probable 
 that in these cases the controlling structure is inhibited by the irritation of 
 the cerebral lesion. A case lately seen suggests that the knee-jerk may 
 even be lost during the first hour after the onset, and then return : the 
 irritative inhibition extending" to the muscle-reflex centre itself. 
 
32 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 evidence of such a process, but in which there are indica- 
 tions of irritability of the spinal cord, as in cases of hysteria 
 with spinal tenderness. It is possible that in these cases 
 we have a primary over-action of irritable centres. 
 
 The diagnostic importance of a considerable increase in 
 myotatic irritability can hardly be over-estimated. By 
 "considerable increase" I mean such a degree that a 
 uniform clonus can be obtained by simple passive flexion 
 of the foot. I believe that such a clonus is always patho- 
 logical, always indicates grave nutritive changes in the 
 spinal cord, and that there is, in most cases in which it 
 can be obtained, actual degeneration in the fibres of the 
 lateral columns. 
 
 A circumstance which gives to this sign a special diag- 
 nostic importance, is that in the cases in which it occurs the 
 nutrition of the muscles and sensibility of the skin are often 
 unimpaired, and the weakness in the legs is likely to be re- 
 garded as " functional," or, if in a woman, as " hysterical." 
 In hysterical paraplegia the myotatic irritability is often 
 perfectly normal. It is not uncommon, however, in these 
 cases, to have, with spinal tenderness, an increased knee-jerk, 
 but I have never seen, in any case of hysterical paraplegia, 
 a foot-clonus such as is above described, and is so common 
 in organic cases. But a spurious, or voluntary foot- 
 clonus is occasionally met with in hysteria, which needs 
 to be carefully distinguished from the typical form. In 
 the latter, when the foot is first pressed up, the clonus at 
 once commences and continues without variation as long 
 as the pressure is maintained. But in the voluntary form 
 there is no clonus during the first few seconds, then the 
 foot and observer's hand are pressed down by a voluntary 
 contraction in the calf-muscles which is broken by clonus. 
 This clonus may continue, but varies in degree (together 
 with the pressure downwards of the foot) from time to 
 time. This variation and the dependence of the clonus on 
 voluntary contraction of the calf-muscles, can be readily 
 recognized. 
 
 Similar myotatic contractions may be obtained in the 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL CORD. 33 
 
 arm. A tap on the extensor tendon above the olecranon will 
 cause a contraction in the triceps. When they are in excess 
 a tap on the bone to which the tendon is attached will 
 cause a contraction in the muscle. Thus a tap on the 
 radius will cause a contraction in the biceps, slightly flexing 
 the elbow ; a tap on the ulna will produce contraction in 
 the triceps, or in the forearm muscles connected with 
 the bone, just as a tap on the tibia, in similar conditions, 
 will cause the knee-jerk. A clonus may even sometimes 
 be obtained in the biceps, or flexors of the fingers, by sudden 
 tension, quite similar in time and character to the ankle- 
 clonus. In many cases these contractions can be obtained 
 without any other passive tension than is involved in 
 the posture of the arm. In hemiplegia the increased 
 muscular tension which is involved in the condition of 
 rigidity seems to suffice for permitting their occurrence. 
 Each contraction is excited by the mechanical stimula- 
 tion of the jar or of the increase of tension produced by 
 the tap. 
 
 The myotatic irritability is lost in diseases which separate 
 the muscle from the spinal cord (as a lesion of the nerve), 
 in disease of the posterior roots (such as exists in posterior 
 sclerosis), in disease of the anterior roots (as in chronic 
 meningitis compressing the nerve-roots), and in disease of 
 the grey matter at the level from which the nerves for the 
 muscle proceed (as in infantile paralysis and allied diseases). 
 It is also lost in diphtheritic paralysis * (in which there is an 
 affection of the motor nerves and their cells) and in pseudo- 
 hypertrophic paralysis (probably by reason of the disease in 
 the interstitial tissue of the muscle in which the afferent 
 nerves begin). 
 
 In employing these contractions for purposes of diag- 
 nosis, it must be remembered that they are, in health, 
 similar on the two sides. A difference between the two 
 sides is always pathological. For instance, the front-tap 
 contraction can sometimes be obtained in persons in whom 
 there is no reason to suspect organic disease. But the 
 
 * Erb, Buzzard. I have several times observed the same fact. 
 
 D 
 
34 THE DIAGNOSIS OF DISEASES OF THE SPIXAL CORD. 
 
 presence of the front-tap contraction on one side, and its 
 absence on the other, shows, without doubt, some structural 
 change. Not long ago I saw a young married lady suffering 
 from weakness of the legs. She was very anEemic, and the 
 paraplegia had been regarded as unquestionably "hysterical," 
 and she bad been urged to exert herself and shake it off. 
 The only absolute objective sign was that the front-tap 
 contraction was very well marked on one side, and entirely 
 absent on the other. This was strong evidence of structural 
 change in the cord. This diagnosis was confirmed, only 
 too sadly, by the subsequent progress of the case, for I 
 afterwards heard that the patient became completely 
 paraplegic, bed sores formed, and it seemed likely that 
 she would die. 
 
 Before leaving these spinal reflex phenomena, I may, 
 parenthetically, illustrate, by an example, the manner in 
 which they are changed in cerebral disease, and the 
 occasional diagnostic importance of their alteration. The 
 cutaneous reflexes, especially the trunk reflexes, are often 
 lessened, but the myotatic contractions are increased when 
 tbere is any degree of descending degeneration in the cord. 
 Under these circumstances the foot-clonus and front-tap 
 contraction may be obtained. Not long ago, in investigating 
 these reflexes, I examined a man who was thought to be 
 suffering from idiopathic epilepsy. No weakness was 
 complained of. The epigastric and cremasteric reflexes 
 were, however, absent on the right side, and the abdominal 
 reflex was slight, although all were well marked on the 
 left. In the right leg the knee-jerk was excessive, and 
 the foot-clonus and front-tap contraction could readily be 
 obtained, while they could not on the left. This alteration 
 affords the strongest grounds for suspecting organic 
 brain disease, and its discovery led to careful examination 
 of the strength of the right limbs. Slight but distinct 
 weakness of the right arm and leg was found, and sub- 
 sequently increased, and optic neuritis developed. In 
 this case organic disease of the brain might readily have 
 been overlooked, and probably would have been overlooked 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL CORD. '■>■') 
 
 for a time, had it not been for the indications afforded by 
 these phenomena.* 
 
 Co-ordination of Movement. — The next function of the 
 spinal cord to be mentioned is that by which it influences 
 the co-ordination of muscular movements. This function 
 apparently depends upon the posterior columns, for it is lost 
 when there is disease in this situation, as in locomotor ataxy. 
 It is not, however, the whole of the posterior columns which 
 are related to the function, but merely the part distinguished 
 as the postero-external column or root-zone, that through 
 which the fibres of the posterior roots pass. The most 
 distinct ataxy may result from disease limited to this 
 situation (Plate, Fig. 5). 
 
 Why does disease of the posterior columns interfere with co- 
 ordination ? We have seen that, by means of the muscular 
 reflex actions, muscular contractions become associated ; ten- 
 sion influences contractility ; and thus there is a reflex group- 
 ing of muscular actions, which undoubtedly plays a very 
 important part, not only in the actual arrangement of the 
 contractions, but also by, so to speak, moulding the spinal 
 centres by establishing lines of lessened resistance through 
 them, and so facilitating the voluntary co-ordination.f 
 There is, I believe, another mechanism by which the 
 impairment of reflex action may impair co-ordination. For 
 any movement there must be not only a contraction of 
 certain muscles, but also ' a proportioned relaxation of their 
 opponents. There is reason to think that the relaxation 
 
 * In this patient the right hemiplegia and the optic neuritis increased, 
 and ultimately left hemiplegia gradually supervened. After death there 
 "were found tumours in each hemisphere of the brain. That on the left side, 
 which was the larger, the size of a pullet's egg, was situated above the 
 lateral ventricle, beneath the upper extremity of the ascending frontal con- 
 volution, and it had extended through the lateral ventricle to the surface of 
 the optic thalamus. It had clearly interrupted the connection of the upper 
 "motor convolutions " with the motor tract. 
 
 t The springing movements observed by Woroschiloff in the hind legs 
 of the rabbit after section of the dorsal cord, and regarded by him as 
 "co-ordinated" in the lumbar enlargement, were probably merely a con- 
 secutive series of muscle-reflex actions, analogoiis to the slow knee-clonus 
 which I have described ("Med.-Chir. Trans." 1879, p. 289). 
 
 p 2 
 
36 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 is really due to a reflex action,* and this is also suggested 
 by the fact, long ago pointed out by Duchenne, that the 
 late rigidity of hemiplegia may commonly be readily 
 relaxed by faradization of the opponents of the rigid muscles. 
 If this is so, we obtain a glimpse of a very complex series 
 of reflex actions, by which a relation is established between 
 tension, contraction in the same muscles, and relaxation 
 in their opponents, which must undoubtedly play a very 
 important part in muscular co-ordination. These muscle- 
 reflex processes in locomotor ataxy are almost always 
 impaired (if we are to judge by the knee-jerk, which is 
 commonly and early lost). Their loss is probably one 
 factor in the inco-ordination of ataxy. It is possible also 
 that, as Todd long ago taught, these postero - external 
 columns contain fibres which connect groups of nerve-cells 
 at different levels, and that upon this connection depends in 
 part the association of muscular contractions, which is essen- 
 tial for co-ordinated movement. The impairment of this 
 association, by posterior sclerosis, may be another element 
 in the ataxy. 
 
 But there are cases in which ataxy exists without loss of 
 the kneerjerk, and with the foot-clonus. In these cases there 
 is always loss of power as well as inco-ordination, and there 
 is sclerosis of the lateral columns as well as of the posterior. 
 The lateral sclerosis will tend to increase the muscle- 
 reflex action, and, apparently, the damage to the posterior 
 roots is then insufficient to arrest it, or the sclerosis is so 
 situated as not to affect the posterior roots, although it may 
 perhaps interfere with the connection between different groups 
 of nerve-cells. It may be remarked that the inco-ordination 
 is in these cases never quite like that in typical ataxy — 
 there is more unsteadiness than inco-ordination. In other 
 symptoms also these cases differ from those of pure ataxy. 
 " Lightning pains " are rare and sensation is usually normal. 
 
 When superficial sensation is lost from the extensive 
 damage to the posterior roots, this loss will greatly increase 
 the ataxy by the removal of an important indication for 
 
 * See " The Movements of the Eyelids."— '-Med.-Chir. Trans." 1879. 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL CORD. 37 
 
 cerebral guidance of movement. But since ataxy may exist 
 without loss of superficial sensation, this is evidently not 
 the chief element in the condition. 
 
 In the inco-ordination of movement which depends on 
 the spinal cord, we greatly intensify the manifestation of 
 the trouble by reducing the base of support, since the 
 smaller this is, the more accurate is the adjustment of 
 muscular actions that is needed to maintain perfect 
 equilibrium. Hence the ataxic has a difficulty in standing 
 with his toes and heels close together ; and if his feet 
 are uncovered, the irregular muscular contractions are shown 
 by the twitching of the tendons. Moreover, we increase 
 his difficulty by making him close his eyes, — withdrawing, 
 thus, the visual guidance. It has been said that this test 
 is only effective when sensation is impaired in the legs, 
 i.e., when the sensory impressions from the legs are 
 insufficient for cerebral guidance. This is, however, not true. 
 The effect may be very marked when sensation is perfect. 
 The maintenance of equilibrium is partly a muscle-reflex 
 act, and if this function is slightly impaired, we can easily 
 understand tha.t it should be inadequate, unless supple- 
 mented by the visual information. Even when there is no 
 inco-ordination, under perfectly normal conditions, closure 
 of the eyes causes slight unsteadiness. In ataxy this is, 
 so to speak, multiplied by whatever defect may exist. 
 
 It is important to be aware that the inco-ordination may 
 not be equally distributed through the legs. In some 
 patients it is marked in the muscles of the hips and knees, 
 and the legs are raised too high, and brought down too 
 suddenly. In other cases this characteristic is wanting ; 
 the inco-ordination affects chiefly the muscles of the feet, 
 and causes unsteadiness of gait and irregular action of 
 the foot-muscles in standing, or in movement of the feet, 
 very conspicuous when they are uncovered. 
 
 Ataxy may be manifested, not only in the muscular 
 contractions which produce movement, but also in those 
 which should keep the limbs in a fixed position. It may 
 be conspicuous, as already stated, in the attempt to stand 
 
38 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 upright. If the arms are affected it may be seen when the 
 patient holds his hands out and tries to keep them in the 
 same posture. Slow involuntary movements of the hands 
 and fingers take place. These are increased in degree by 
 closure of the eyes, and may resemble the movements of 
 athetasis. The patient is unaware of their occurrence. 
 
 Controlling Functions. — "We may consider next the con- 
 trolling functions of the cord ; and first, the influence 
 which it exerts over nutrition. The nutrition of the 
 limbs, etc., is, to a considerable extent, under the influence 
 of the cord ; that of the muscles, and probably also of the 
 bones and joints, through the anterior nerve-roots ; that of 
 the skin probably through the posterior. 
 
 Muscular Nutrition. — For diagnostic purposes the most im- 
 portant is the influence on the nutrition of the muscles. The 
 path of the influence is the motor-fibres in the anterior roots 
 and nerve-trunks. Changes in the nutrition of the muscles, 
 which are not due to local influence, depend on changes in 
 the nutrition of the motor nerve-fibres. But the motor 
 fibres are the prolonged processes of the motor nerve- 
 cells, and may be regarded as parts of the nerve-cells, 
 sharing all changes in the nutrition of the cells. The 
 nerve-fibres are excitable by electricity, and changes in their 
 nutrition are accompanied by changes in their excitability. 
 By the use of electricity we are thus able to ascertain 
 their state of nutrition, and to learn what is the condition 
 of the nerve-cells in the cord, provided there is no disease 
 separating the part of the fibre tested from the influence 
 of the cells. Hence the value of electricity in the diagnosis 
 of diseases of the spinal cord. 
 
 In a normal state, if you apply either the faradaic or the 
 voltaic current to a motor nerve, there occurs, as you doubt- 
 less know, a contraction in the muscles, continuous when the 
 faradaic current is applied, but, if the voltaic current is 
 used, occurring only when the current commences or ceases 
 to pass — i.e., when the circuit is " made or broken." In 
 proportion as the nutrition of the nerve-fibres is impaired, 
 their excitability is lowered ; a stronger current of each kind 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL CORD. 39 
 
 is required to excite them and cause contraction in the 
 muscles they supply. "When their nutrition is much 
 impaired — i.e., when the fibres are " degenerated " — no 
 contraction can be obtained even with the strongest 
 currents. 
 
 The changes in the excitability of the muscles are less 
 simple, because in them there are two excitable structures — 
 the terminations of the nerves, and the muscular fibres 
 themselves. Of these the nerve-fibres are the more sensitive 
 to faradization, and the faradaic stimulation of a muscle 
 under normal circumstances is by means of these motor 
 nerve-endings. Thus we find that its excitability corre- 
 sponds in degree to that of the motor nerve supplying it. 
 The muscular fibres themselves are, even in the normal state, 
 less sensitive to faradization than the nerve, apparently 
 because they are incapable of ready response to stimulus 
 so very short in duration as are the shocks of which the 
 faradaic current consists. (The proof of this consists in 
 the fact that under the influence of curara, which removes 
 the excitability of the terminations of the motor nerve, the 
 muscle requires a stronger faradaic current to stimulate it 
 than in the normal state.) But under these circumstances 
 the slowly interrupted voltaic current stimulates the muscle 
 as readily as in the normal state ; a contraction occurs when 
 the circuit is completed or broken — distinctly slower than 
 that which occurs when the nerve-fibres are intact, and 
 due to the stimulation of the protoplasm of the muscular 
 fibres themselves. The fact that, under normal circum- 
 stances, the contraction which is caused by the voltaic 
 current is as quick as that produced by the faradaic shock, is 
 ground for believing that, in health, the voltaic, as well as 
 the faradaic current, causes the muscle to contract chiefly 
 by exciting the motor nerve-endings. When the motor 
 nerve is degenerated, and will not respond to faradaic or 
 voltaic stimulation, the muscle also loses all its power of 
 response to the former. Apparently the nerve-degeneration 
 is accompanied by changes in the nutrition of the muscular 
 fibre, by which any power of response to faradization, 
 
40 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 which, it possessed in the normal state, is lost. But the 
 response to the voltaic current remains, and becomes quickly 
 more ready than in health, doubtless in consequence of 
 nutritive changes which develope what the older pathologists 
 called, truly enough, " irritable weakness." Moreover, there 
 may commonly be observed a change in the readiness of 
 response to a certain mode of stimulation with voltaism — 
 a " qualitative " change, as it is termed. In health, the 
 first contraction to occur, on gradually increasing the 
 strength of the current, is at the negative pole when the 
 circuit is closed, and a stronger current is required before 
 closure-contraction occurs at the positive pole. But, in the 
 morbid state we are discussing, closure-contraction may 
 occur at the positive pole as readily as at the negative, or 
 even more readily — and contractions, when the circuit is 
 broken, occur far more readily than in the normal state. 
 This condition, then — faradaic irritability lost, voltaic irrita- 
 bility increased and often changed in quality — is termed the 
 " degenerative reaction," because it occurs when the nerve- 
 fibres are degenerated ; and if we test them we shall find no 
 response to any stimulus, voltaic or faradaic. It occurs when 
 the nerves are separated from their motor nerve-cells, and if 
 no such separation exists it indicates .an acute degenerative 
 change in those nerve-cells. It is well seen in acute myelitis 
 of the anterior cornua (as infantile palsy). 
 
 But the motor nerve-cells and fibres often undergo changes 
 in nutrition of a much more chronic character. In this 
 condition the irritability of the fibres is lessened gradually 
 and slowly. The irritability of the intramuscular nerve- 
 endings is lessened in the same degree as that of the nerve- 
 trunks, and we have a diminution to both faradization and 
 voltaism. The nutrition of the muscular fibres is slowly, 
 gradually, impaired ; and when the nerve- fibres are much 
 affected the muscular fibres are also. There is no stage in 
 which the nerve-fibre irritabihty is lost, and the muscle-fibre 
 irritability retained; hence there is no condition of lost 
 faradaic and increased voltaic irritability such as charac- 
 terizes the degenerative reaction just described. Irritability 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL CORD. 41 
 
 is changed to the one form of stimulus just as to the other. 
 This condition is seen in many cases of progressive muscular 
 atrophy, and also, in slighter degree, when the nerve-cells 
 suffer, not in consequence of disease primary in them, but 
 as a result of degeneration or irritation spreading to them 
 from above. It is seen, for instance, in the wasting which 
 occurs sometimes in hemiplegia limbs. 
 
 Between these two forms there are intermediate conditions, 
 especially in cases of subacute disease of anterior cornua. 
 For instance, the nerves may present normal irritability, and 
 the muscle the increased voltaic irritability and changed order 
 of contractions met with in degeneration. Probably, in 
 these cases, some nerve-fibres are degenerated, and lead to 
 the increased irritability of some muscular fibres. In both 
 nerve and muscle the character of the reaction is determined 
 by the more irritable structures ; hence it is normal in the 
 nerve and altered in the muscle. This is termed the 
 "middle form" of degenerative reaction. It would be 
 more accurate to call it the " mixed form." 
 
 The various changes in irritability have been thought to 
 indicate the existence and various affections of separate 
 centres for the nutrition of the nerves and muscles, apart 
 from, though acting through, the motor nerve-cells. Ee- 
 membering that the nerves and muscles contain fibres which 
 suffer in different degrees, the phenomena at present ascer- 
 tained may all be explained on the simpler principle stated, 
 without the assumption of these special centres of the 
 existence of which there is, indeed, no evidence. 
 
 Frequently the lowered irritability of degeneration in the 
 nerves is preceded by a slight increase of irritability, very 
 transient when the degeneration is acute, of longer duration 
 when the degeneration is of the slower variety just noticed. 
 Thus, in the early wasting of hemiplegia, increased irrita- 
 bility may be found, slowly giving place to diminution. In 
 some morbid states, again, in which the change of nutri- 
 tion in the cells and fibres is extremely slight, an increase 
 may alone be discovered. I have found such an increase, 
 for instance, in diseases regarded as functional, as paralysis 
 
42 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 agitans and chorea, and it is an interesting proof of the 
 molecular changes which underlie, or result from, functional 
 maladies. 
 
 In employing electricity as a means of diagnosis, at least 
 one of the electrodes should be small, so as to be able to 
 concentrate the current on a single muscle. Great care 
 must be taken to place these electrodes on corresponding 
 points on the two sides. It is convenient to be able to 
 interrupt the current at the battery, so that the effect of 
 the passage of the current may not be obscured by the 
 mechanical effect of the application of the electrode.* In 
 Stohrer's faradaic battery the current can readily be stopped 
 by pressing the hammer with the third finger, while the 
 rod graduating the current is raised or lowered with the 
 thumb and first finger. By moving the hammer slowly 
 with the finger, we may employ the isolated faradaic shock. 
 (The current consists of a rapid succession of shocks.) The 
 isolated shock is often useful, because it is much less painful 
 than the rapid series of shocks, and is especially convenient 
 in the examination of children. A mechanical interrupter is 
 essential in the case of the voltaic battery, in which the 
 stimulation only occurs when the circuit is made and broken ; 
 and no battery is suited for use for diagnostic purposes which 
 does not possess such a means of interruption. A galvano- 
 meter, to indicate the actual strength of current passing, is 
 also very useful, since the number of cells employed affords 
 little indication of the current which actually passes through 
 the resistance of the skin, which varies much in different 
 parts. 
 
 In examining muscles and nerves we avail ourselves, 
 whenever we can, of the opposite side for comparison, and 
 when we cannot, we must, if there is any doubt, compare 
 the results obtained with those yielded by a healthy indi- 
 
 * The interrupting rheophores (containing a mechanism in the handle 
 for making and breaking contact) are less convenient than they appear. 
 In watching for the first flicker of contraction, it is essential that the 
 rheophore should be held perfectly still, and the contact cannot be made or 
 broken in the handle without causing a slight movement of the rheophore, 
 which interferes with the detection of the muscular contraction. 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPIN AT- CORD. 43 
 
 victual. Two conditions may be tested — first, the lowest 
 strength of stimulus to which the muscle or nerve will 
 respond ; and secondly, the relative degree of response to a 
 stronger current. The former is the more important, but 
 has been insisted on too exclusively, for the latter is 
 important also. If a few fibres of a nerve are healthy, and 
 the others are degenerated, contraction may occur with as 
 weak a stimulus as in the healthy nerve ; but if the current 
 be made a little stronger, the contraction in the diseased 
 part may remain the same when that on the healthy side is 
 energetic. Both irritability and power, therefore, should 
 be noted, and also the order of reaction to voltaism. 
 
 The nutrition of bones and joints also probably depends 
 on the anterior grey matter, but the influence is shown 
 chiefly by the effect of disease in retarding the growth of 
 bones. Now and then in posterior sclerosis (locomotor 
 ataxy), a painless joint affection and brittleness of bones 
 develope. When the upper dorsal cord is affected grave 
 thoracic trouble may occur in a similar insidious way. 
 Dyspnoea may lead to an examination of the chest of a 
 patient who makes no complaint, and one pleural cavity 
 may be found full of fluid. 
 
 The nutrition of the skin and subcutaneous tissues depends 
 upon nerves which have their course in the posterior, 
 sensory, roots, but whether there are special trophic fibres 
 is unknown, and the centre on which the influence depends 
 is also unknown. It is doubtful whether simple loss of the 
 function of the posterior roots leads directly to lesions of 
 nutrition. These may result indirectly in this condition ; 
 the anaesthesia deprives the patient of sensory information 
 when change of posture is required to prevent damage from 
 pressure. Occasionally, however, sloughing and vesication 
 of the skin occur with extreme readiness, on the least local 
 disturbance, and even with none. This is the case when 
 the lesion is irritative in character, especially in destruction 
 of the cord at the level from which the sensory nerves to 
 the part proceed, and sometimes in disease higher up, as 
 in some cases of acute myelitis. 
 
44 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 Micturition and Defcecation. — The spinal cord possesses 
 centres, situated in the lumbar enlargement, which preside 
 over the action of the bladder and rectum. They are pro- 
 bably complex reflex centres : that for the sphincter ani 
 is the more simple, but the system of action of each may 
 be the same. In the wall of each viscus we have muscular 
 fibres to expel the contents, and at the mouth a sphincter- 
 arrangement to prevent their continuous evacuation. Faeces 
 or air in the rectum, or urine in the bladder, excites the 
 lumbar centre, and causes two effects — contraction in the wall 
 and relaxation of the sphincter. This process may be, to a 
 considerable extent, controlled by the will, although we are 
 still ignorant of the precise mode in which the voluntary 
 influence is exerted. But if the volitional path in the cord is 
 interrupted above the lumbar centres, the will can no longer 
 control the reflex processes; as soon as fseces irritate the 
 rectum, they are expelled by the reflex mechanism ; as soon 
 as a sufficient quantity of urine accumulates in the bladder, 
 a reflex contraction of the detrusor, and relaxation of the 
 sphincter, cause its escape. The affection of the voluntary 
 path for the sphincters is not always proportioned to that 
 for the legs. If the damage to the cord involves also 
 the sensory tract, the patient is unconscious of the action of 
 the bladder or bowel. If the sensory tract is unaffected, 
 the patient is aware of the process, but cannot control 
 it. It is often said that there is permanent relaxation 
 of the sphincters, but this is true only when the lumbar 
 centres are inactive or destroyed. In this condition, 
 evacuation occurs as soon as fseces or urine enter the bowel 
 or rectum. The urine escapes continuously, instead of being 
 expelled at intervals. The condition is less obvious in the 
 case of the rectum, because there is not such continuous 
 entrance of feces into the rectum as there is of urine into the 
 bladder. "We may, however, distinguish between the two 
 states of the rectum by the introduction of the finger. If 
 the lumbar centre is inactive, there is a momentary contrac- 
 tion, due to local stimulation of the sphincter, and then 
 permanent relaxation. If, however, the reflex centre and 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL COKD. 4-J 
 
 motor nerves from it are intact, the introduction of the finger 
 is followed, first by relaxation, and then by gentle, firm, 
 tonic contraction. I have verified this by introducing an 
 india-rubber cylinder instead of the finger, and registering 
 the pressure on the cylinder by connecting it with a recording 
 apparatus, and have found that the relaxation is preceded by 
 a very slight, brief contraction, and is followed by unbroken 
 tonic contraction. ' The relaxation may also be readily pro- 
 
 FlG. 18. — DlAGEAM SHOWING PeOBABLE PlAN OF THE CeNTEE 
 FOE MlCTUEITION. 
 
 mt motor tract, ST sensory tract in the spinal cord ; ms centre, and ms motor 
 nerve for sphincter ; md centre, and md motor nerve for detrusor ; 
 s, afferent nerve from mucous membrane to s, sensory portion of centre ; 
 b, bladder. At r, the condition during rest is indicated ; the sphincter 
 centre being in action, the detrusor centre not acting. At a, the con- 
 dition during action is indicated ; the sphincter centre being inhibited, 
 the detrusor centre acting. 
 
 duced by any impression on the mucous membrane of the 
 rectum above the sphincter. 
 
 In cases of gradual disease we may often trace the 
 gradual loss of voluntary power over the process of mic- 
 turition. In some cases this loss of power appears to be 
 
46 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 manifested as an inability, not to restrain, but to excite 
 the action of the centre, and we have then a tendency to 
 retention. Many conditions can be best understood by 
 assuming that the motor centre really consists of two parts 
 — one (ms, Fig. 13) maintaining the contraction of the 
 sphincter, the other (md) exciting the contraction of the 
 detrusor fibres, and that these two parts are antagonistic : 
 when one acts the other is inhibited. 'Thus, in normal 
 rest, the sphincter centre is active, the detrusor at rest. 
 Action is produced by a conjoint afferent impulse from the 
 bladder and voluntary impulse from the brain. Then the 
 detrusor centre acts, and the sphincter centre ceases to act. 
 If voluntary power is impaired, the afferent impulse from the 
 bladder may be insufficient, and then there is retention, or 
 in other such cases the motor centre may yield too readily 
 to the afferent impulse, and there is reflex incontinence. 
 
 Sexual Functions. — The conditions of the sexual organs 
 depend on the integrity of the reflex loop to and from a 
 special centre, also situated in the lumbar enlargement, but 
 the due action of this centre depends on cerebral (psychical) 
 as well as reflex influences. Disease of the centre, or of the 
 nerves leading to or from it, abolishes sexual action. The 
 sexual reflex is, however, one of the cutaneous reflexes, and 
 it shares the condition of these rather than of the muscle- 
 reflex actions.* 
 
 The centre is probably double, and its action is impaired 
 by interference with either half. When, by disease higher 
 up, the connection with the psychical centres is interrupted, 
 the sexual act cannot be perfectly performed. If the path 
 from the controlling centre (p. 19) is unimpaired, the reflex 
 sexual processes are not in excess, may even be • diminished ; 
 but if the path from this controlling centre is also interrupted, 
 the reflex sexual processes are in excess like the other 
 superficial reflexes, and priapism results. If the reflex centre 
 is partially diseased, the sexual act is imperfectly performed. 
 
 * This is sometimes well seen in locomotor ataxy. In rare cases of that 
 disease there is satyriasis, and in such cases I have found a condition of 
 extreme irritability of the cutaneous reflex actions. 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL CORD. 4< 
 
 The sexual centre is probably near that for the eremaster 
 reflex, and from the latter we may, in some cases, gain 
 information respecting the probable condition of the sexual 
 centre, and in conjunction with the conditions just men- 
 tioned, of the sexual power. For instance, in locomotor 
 ataxy, the eremaster reflex is rarely lost* without sexual 
 power being lost or lessened also. Sexual power, may, 
 however, be lost before the eremaster reflex, perhaps because 
 more readily impaired. Again, in a patient with extensive 
 disease of the lower and middle part of the lumbar en- 
 largement, greatest on the left side, in whom the eremaster 
 reflex was present on the right side and lost on the left, 
 sexual power was partially but not wholly lost. 
 
 Vaso-motor Centres. — The centres in the cord which in- 
 fluence the sympathetic and vaso-motor system of nerves are 
 frequently affected in disease, and altered temperature, 
 vascularity, and perspiration of limb result. In disease 
 of the upper part of the cervical enlargement, especially 
 in sudden lesions, hyperpyrexia may occur. But these 
 symptoms at present are of little diagnostic importance, 
 except when the disease is in the cervical region, and the 
 vaso-motor change is conspicuous in the face. Then, if 
 one side is affected, unilateral sweating and flushing are 
 conspicuous, and are due to the fact that sympathetic fibres 
 for the head arise in, or pass through, the cervical cord. 
 In the same cases, the movements of the iris are impaired : 
 irritation of the cervical origin of the sympathetic causing 
 spasm of the radiating fibres (dilatation), paralysis of the 
 sympathetic causing their relaxation (contraction of the 
 pupil). In many degenerative diseases of the cord the 
 reflex action of the pupil to light is lost, the pupils being 
 usually, but not always, small, but (as Argyll Eobertson 
 first showed) the pupils almost always contract if an effort 
 of accommodation is made. The reflex action is lost, but 
 
 * It must be remembered that the eremaster reflex is sometimes absent, 
 in adults, apart from disease. The statement in the text applies to the 
 cases in which there was such a general absence of the superficial reflexes 
 as suggested a pathological loss. 
 
48 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 the associated action remains. When the pupils are small 
 in these cases, they do not dilate on cutaneous stimula- 
 tion, as they do in health (Erb). It is probable that these 
 phenomena do not depend directly on the disease of the 
 cord, but are due to an associated degeneration in the 
 centres for the movements of the iris in the upper part of 
 the pons. 
 
 In this survey of the more important functions of the 
 cord, and their derangement, we have passed in review the 
 chief symptoms which guide us in diagnosis. One or two 
 others, however, remain. 
 
 Pain, referred to the spine, occasionally present in 
 organic disease of the cord, is more frequent in disease 
 originating in the meninges or bones. But the frequency 
 with which spinal pain is present in abdominal, especially 
 gastric, disease, and in- neuralgic affections, lessens its 
 diagnostic value when it exists alone. It is probably no 
 exaggeration to say that of one hundred patients who com- 
 plain of spinal pain, in ninety-nine there is no spinal disease. 
 Moreover, in cases of organic disease, pain is far less 
 frequent when the disease begins in the cord, than when 
 it commences in the protecting structures. In meningitis, 
 acute or chronic, spinal pain is frequent, and in organic 
 disease of the bones of the vertebral column it is an almost 
 constant symptom, and is combined with local tenderness. 
 The same combination of local pain and tenderness is seen, 
 however, in some cases of neuralgic pain, "rachialgia." 
 The distinction between the two is, that in organic disease 
 there are indications either of displacement of the vertebrae 
 or of changes in the cord. 
 
 A still more important group of pains are those which 
 are referred to the parts to which the sensory nerves are 
 distributed, and have hence been termed " excentric or 
 irradiating pains." They are due to the irritation of the 
 posterior nerve-roots in their passage through the inter- 
 vertebral foramina, through the membranes, or through 
 the posterior columns of the cord. Other similar pains 
 are due, apparently, in some cases, to irritation of the 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL CORD. 49 
 
 sensory conducting tract higher up the cord.* They may 
 be dull pains, singularly resembling rheumatism, and con- 
 stantly mistaken for rheumatism by the patients themselves 
 and their medical attendants. The mistake is the more 
 easily made, because other symptoms suggestive of spinal 
 disease may be inconspicuous, and the rheumatoid pains, 
 in acute cases, may be accompanied by febrile symptoms, and 
 in chronic cases may be influenced by weather, being much 
 more troublesome in damp and cold than in fine and dry 
 weather. In all cases, persistent rheumatic pains in the 
 limbs should excite a suspicion of spinal disease, and watch 
 should be kept for such symptoms as local loss of power, or 
 alterations in reflex action. In other cases they are sharp 
 darting pains, " like a flash of lightning and gone again," as 
 they are often described by patients with locomotor ataxy, 
 in which they are very frequent. Sometimes there is a 
 momentary local stab, at others the pain seems to dart down 
 the limb. The position in which these various excentric 
 pains are felt — legs, trunk, or arms — depends (when the 
 nerve-roots are irritated) upon the seat of the disease — in the 
 lumbar, dorsal, or cervical region of the cord. Occasionally 
 the irritation is felt, not as a sharp pain, but as a painful 
 sense of tightness, as if a band were tied tightly around the 
 limb or trunk — the " girdle-pain," as it is called. When 
 there is transverse damage to the cord, at the lowest part of 
 the healthy region there is a state of irritation of the sensory 
 nerves, and this irritation (referred to the nerve- endings) 
 causes the girdle-pain. When the nerve-roots are irritated 
 by disease of the vertebrae, caries or cancer, the pain is 
 very intense, and is especially increased by movement 
 ("paraplegia dolorosa "). 
 
 Whenever there are excentric pains there may be increased 
 or diminished sensitiveness in the part to which the pains 
 are referred. Spontaneous sensations are also common, 
 the various feelings comprehended under the terms " numb- 
 
 * The latest physiological researches seem to show that the conducting 
 tracts in the cord are not, as is commonly taught, entirely insensitive to 
 local stimulation. 
 
50 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 ness," " pins and needles," " furriness," " formication," and 
 the like. The conditions in which they occur are various, 
 but they should never be lightly passed over. 
 
 Spasm. — Muscular spasm is conspicuous in many cases 
 of disease of the spinal cord. It depends on over-action of 
 the motor centres. Primarily, perhaps, it is due to " dimin- 
 ished resistance " within them, but ultimately the func- 
 tional action (and underlying nutrition) of these centres 
 seems to be permanently altered. The motor centres are, 
 as we have seen, both parts of the reflex centres, and the 
 terminations of the path of voluntary impulse. Hence 
 spinal spasm may be excited by peripheral impressions, or by 
 attempts at voluntary motion. In some cases paroxysms 
 appear to come on without excitation, especially during sleep. 
 In sleep, however, the reflex action of the cord is very 
 readily excited, and it is difficult to exclude slight reflex 
 stimulation. As an acute symptom, spasm is almost confined 
 to meningitis, and to some very rare forms of functional 
 irritation. In meningitis the spasm is apparently reflex, 
 produced by irritation of the nerves of the meninges. In 
 chronic organic disease, spasm is usually a late symptom, of 
 gradual development, and then its reflex character may often 
 be distinctly traced. It occurs in cases in which muscle- 
 reflex action is in excess, and this, as already explained, 
 follows and indicates the occurrence of descending degene- 
 ration in the lateral columns (see p. 30). The increase in the 
 muscle-reflex action is first manifested by an excess of the 
 irritability which can be developed by tension (increased 
 knee-jerk, foot-clonus), and this may be distinct at the 
 end of a week or ten days. A further increase leads to 
 occasional " stiffness " in the legs, especially at night ; and 
 ultimately there is developed a considerable degree of spasm, 
 the condition known as " spasmodic or spastic paraplegia." 
 Any peripheral impression, superficial or deep, pinching the 
 skin, for instance, or sudden muscular tension, will then 
 excite spasm. The attempt to elicit the foot-clonus may 
 cause such muscular rigidity that no clonus can be obtained. 
 In most cases the spasm is extensor in character, and evidently 
 
PATHOLOGICAL PHYSIOLOGY OF THE SPINAL COED. 51 
 
 depends on the reflex mechanism which assists in main- 
 taining extension of the legs in the erect posture. In health, 
 when we stand, the muscles are in a state of balanced 
 contraction, largely reflex, the afferent impulses being 
 derived from muscles, possibly in part from joints. In spastic 
 paraplegia a similar but more intense extensor contraction is 
 excited by the same posture of the limb. Flexed, it may 
 be supple, but extend it passively, and as soon as it is 
 straight the muscles become rigid, and it cannot again 
 be flexed except by considerable force. It is just as 
 when a clasp-knife is opened, as soon as the blade is 
 fully extended it becomes rigid. So this has been called 
 "clasp-knife rigidity." Frequently the spasm fixes for 
 the time both legs to the pelvis, and if one leg is lifted 
 from the bed the other rises with it. The same extensor 
 spasm occurs when the patient attempts to stand, and it 
 often enables a patient to remain erect whose voluntary 
 power would be insufficient for him to do so were he not 
 aided by the spasm. 
 
 In some cases, especially during sleep, flexor spasm 
 predominates, and the hip and knee joints become 
 strongly flexed. On what the difference in the form of 
 spasm depends we do not yet know. Spasm, especially 
 flexor spasm, was formerly regarded as evidence of " chronic 
 meningitis," because acute meningitis is accompanied by 
 spasm. In many of these cases, however, there is no 
 other evidence of meningeal disease. 
 
 Occasionally spasm occurs in violent paroxysms, first 
 tonic, and then clonic, excited by slight peripheral im- 
 pressions, and in some cases apparently spontaneous — 
 the " spinal epilepsy " of Brown-Sequard. The resemblance 
 to an epileptic paroxysm, however, is not close, and the 
 quick clonic spasm depends on precisely the same conditions 
 as the foot-clonus. The peripheral impression excites violent 
 tonic spasm ; as this is passing off, the tension on the imper- 
 fectly relaxed muscle is sufficient to develope clonic contrac- 
 tions, just as does the passive tension in the ordinary method 
 of obtaining the foot- clonus, and so we have a series of quick 
 
 e 2 
 
52 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 clonic contractions succeeding tonic spasm. The effect is 
 most conspicuous in the quadriceps extensor of the knee. 
 Sometimes the initial tonic spasm is slight, and the spasm 
 appears to consist entirely of clonic spasm.* 
 
 Thus these spasmodic phenomena indicate integrity of the 
 reflex loops and functional over-activity of the retlex-centres. 
 This over-action in chronic cases is the effect of disease 
 above, in the lateral columns; the degeneration of their 
 fibres extends down to the lower centres into the grey 
 matter, and probably invades a structure in it which controls 
 the muscle reflex action (see p. 30). The gradual develop- 
 ment of the over-action indicates that it is the result, in most 
 cases, of changes consequent on this degeneration. Control 
 being thus removed, the excessive reflex action gradually 
 leads to what may be termed, if the expression is permissible, 
 a functional hypertrophy of the centres, causing persistent 
 and extreme spasm. 
 
 Simple rigidity of muscles, varying too little to be termed 
 spasm, occurs also in some forms of disease of the cord, espe- 
 cially in cases of muscular atrophy (degeneration of the 
 anterior cornua), and is due to simultaneous (or, according to 
 Charcot, preceding) degeneration in the lateral columns. Per- 
 sistent shortening (contracture) occurs also in the antagonists 
 of paralysed muscles, but now and then as a result of over- 
 action from central disease. As a consequence of this the knees 
 may become flexed or the heels drawn up. The latter form 
 of rigidity, dependent on a primary over-action, is always 
 associated with more or less general spasm in the limb — an 
 important distinction from the condition in which such 
 shortening is due to the paralysis of the opponents of the 
 contracted muscles. Persistent contracture of the gastroc- 
 nemii, as part of "spastic paraplegia," is sometimes seen 
 in adults, but is more common in children. 
 
 * It is necessary to mention that the term " spinal epilepsy " has been 
 misapplied in France to the foot-clonus. 
 
ANATOMICAL DIAGNOSIS. 53 
 
 1IL— INDICATIONS OF POSITION OF DISEASE : 
 ANATOMICAL DIAGNOSIS. 
 
 "We may now consider, briefly, how the symptoms which 
 we have studied are grouped in diseases of different regions 
 of the cord. The various symptoms, and their significance, 
 have already been considered in detail, so that it is necessary 
 only to mention them here. Some lesions of the cord affect 
 certain structures (white columns or grey matter) in a consider- 
 able vertical extent, the other structures being normal. Such 
 affections have been called " system diseases." Others, again, 
 are very limited in their vertical extent, and have been 
 termed " focal " lesions. The latter may be limited to one 
 structure, or may extend through a considerable transverse 
 extent, even through the whole thickness of the cord — " total 
 transverse lesions." The lesions which affect certain struc- 
 tures only, whether extensive system diseases or limited focal 
 diseases, are called " partial lesions," and it is convenient to 
 commence with these. 
 
 1. Antero-lateral White Columns. — Disease of the antero- 
 lateral white columns causes loss or impairment of voluntary 
 power below the lesion, descending degeneration in the 
 pyramidal tracts, and over-action of the lower centres, espe- 
 cially of those concerned in the muscle-reflex processes. This 
 over-action may be manifested only as excess of the myotatic 
 contractions, or it may increase to spasm and rigidity — spastic 
 or spasmodic paraplegia. There is no wasting unless the 
 degeneration, extending from the lateral columns, invades the 
 motor nerve-cells in the anterior cornua. Then we have a 
 combination of spasm and wasting in which, if the cornual 
 degeneration proceeds, the spasm and rigidity may lessen as the 
 nerve-cells suffer. In disease limited to these columns (at any 
 rate, when the disease is limited to the pyramidal tracts) there 
 is no loss of sensation, or inco-ordination. These symptoms of 
 " spasmodic paraplegia " may arise from a primary degenera- 
 tion in the lateral columns, limited thereto ; but such cases are 
 rare, and in the majority the disease is a focal lesion more 
 
54 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 or less extensive at some level in the dorsal or cervical cord, 
 and the degeneration in the lateral columns is secondary. 
 The evidence of the latter form is afforded (1) by the cir- 
 cumstance that the symptoms came on, in the first instance, 
 suddenly or rapidly, primary sclerosis being gradual in onset, 
 and a lesion which occurs in short time is always " focal " ; 
 (2) the evidence which may generally be discovered that 
 there has been at some time, or is in some region, damage 
 which extends beyond the lateral columns. The proof of 
 this is the implication of sensation, or the interference, at the 
 level of the lesion, with the central functions of the cord. 
 "We are only justified in suspecting a primary solerosis of the 
 lateral columns when we can find no such evidence or history 
 of a wider focal lesion, and when the affection came on very 
 gradually ; and we can only feel sure that it exists when the 
 arms become affected in the same manner as the legs, and 
 after them. We must remember also that descending lateral 
 sclerosis, with secondary spasmodic phenomena in the limbs, 
 may also result from damage to the motor tracts above 
 their decussation — in the medulla, the pons, or the motor 
 parts of the cerebral hemispheres. It occasionally results 
 from bilateral damage to the surface of the brain during 
 difficult birth. 
 
 Certain lesions may damage the motor tracts slightly, 
 and impair conduction in a peculiar way, apparently 
 rendering it unequal in different fibres. As a consequence, 
 the muscular action is disproportionate in different muscles, 
 and instead of a balanced co-ordinated movement, we have 
 an unbalanced jerky movement. This is seen especially 
 when irregular islets of sclerosis affect the cord — dissemi- 
 nated or insular sclerosis ; and according to the researches of 
 Charcot it appears that this irregular conduction is the 
 result of the unequal wasting of the medullary sheaths, the 
 axis-cylinders remaining. A precisely similar symptom may 
 result from pressure on the motor tract — as by a growth. 
 Not rarely this " disseminated " or " insular " sclerosis, in 
 one region, is combined with a system-degeneration in 
 another. An occasional combination, for instance, is the 
 
ANATOMICAL DIAGNOSIS. 00 
 
 jerking movement (from cervical insular sclerosis) in the 
 arms, and ataxic inco-ordination in the legs (from lumbar 
 posterior sclerosis). Or with the jerky inco-ordination in 
 the arms there may be weakness with spasm in the legs 
 from lumbar lateral sclerosis). In the latter case it is 
 probable that the lateral sclerosis is simply " descending," 
 the result of the damage to the pyramidal tracts higher up 
 by the insular sclerosis. It must be remembered that insular 
 sclerosis sometimes causes merely loss of power, and equal, 
 not irregular, impairment of conduction, especially when it 
 occurs in the dorsal region. In such a case we may be 
 unable to distinguish its symptoms from those of a diffuse, 
 widely-spread degeneration. 
 
 2. Posterior Columns. — In disease of the posterior columns 
 there is interference with co-ordination without loss of 
 power ; excentric pains, impaired sensation, and diminution 
 of reflex action, in consequence of the implication of the 
 sensory roots. All these symptoms depend on disease of 
 the postero-external columns (posterior root zone).* Disease 
 of the postero-median columns gives rise to no known 
 symptoms. 
 
 The posterior columns may be damaged by any patho- 
 logical process ; they are frequent seats of primary degenera- 
 tion (sclerosis), the condition which constitutes the common 
 form of locomotor ataxy. The symptoms of this disease 
 usually present the following order — loss of the myotatic con- 
 tractions, especially of the knee-jerk, pains, inco-ordination, 
 diminution of sensation, loss of sexual power, and of the 
 reflex-action from the skin (which may in the early stage 
 be increased), affection of the sphincters, and occasionally 
 interference with the nutrition of bones and joints. 
 
 There is no loss of motor power or wasting as long as the 
 
 * It is to be noted, however, that recent researches, especially those of 
 Pierret and Dejerine, have shown that there is frequently an independent 
 degeneration of the peripheral sensory nerves. The extent to which the 
 symptoms of the disease depend on this is at present undetermined. It 
 does not appear to be invariable, and the effect is probably the same, 
 whether the nerve-fibres are damaged at the periphery or in the posterior 
 columns of the cord. 
 
56 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 disease remains limited to the posterior columns. It may, 
 however, extend forwards into the anterior cornua, causing 
 muscular atrophy and weakness to be conjoined with the 
 ataxy. Or the lateral columns may be affected at the same 
 time as the posterior : we then have weakness as well as 
 ataxy, but no wasting. The disease of the lateral columns 
 causes, as I have just stated, increase of the muscle-reflex 
 action, and this increase may thus co-exist with inco-ordina- 
 tion, the damage to the posterior roots being slight, perhaps 
 absent, in these cases (see p. 36). Thus we may have the 
 anomaly of ataxy with actual loss of power, excess of the 
 knee-jerk instead of its loss, and the front-tap contraction 
 obtainable, and even the foot-clonus. 
 
 Associated with primary degeneration of the posterior 
 column are certain other symptoms due to simultaneous 
 degeneration elsewhere. Of these the most important are 
 loss of reflex action of the iris to light, which is extremely 
 common, loss of accommodation, which is rare, and optic 
 nerve atrophy, which is occasional. 
 
 An important fact to remember, regarding the posterior 
 columns, is their proneness to degenerate : they recover less 
 readily, and degenerate more readily, than any other struc- 
 ture in the cord. A lesion in one spot may set up a degene- 
 ration which ultimately involves them in their whole extent. 
 Damage affecting the whole thickness of the cord may pass 
 away from the rest, and persist in the posterior columns, and 
 even spread there. In such a case we have ataxy succeeding 
 loss of power. Movement returns, but without co-ordination. 
 
 3. Anterior Cornua. — The anterior cornua contain the 
 motor nerve-cells, which, as I have said — (1) influence the 
 nutrition of the motor nerve-fibres proceeding from them, 
 and consequently that of the muscles; (2) constitute, a 
 link in the path of the voluntary impulse from the brain to 
 the muscles ; (3) form part of the reflex loop, probably also 
 of the reflex centre, with which the muscles are connected. 
 
 Hence we have, as the result of disease of the anterior 
 cornua — (1) degeneration of the motor nerves and wasting 
 of the muscles ; (2) loss of voluntary power, i.e., paralysis 
 
ANATOMICAL DIAGNOSIS. 57 
 
 of those muscles ; (3) interference with, or arrest of, all 
 the reflex actions in which these muscles take part. 
 
 The extent of these symptoms, whether they are uni- 
 lateral or bilateral, affect many muscles or few, will depend 
 strictly on the extent of the disease in the spinal cord. 
 
 Of the three symptoms, the muscular wasting is incom- 
 parably the most important. Paralysis may result from 
 disease elsewhere in the motor tract, e.g., disease of the 
 lateral column higher up. Loss of reflex action may depend 
 on disease elsewhere in the reflex loop, e.g., disease of the 
 sensory fibres in or outside the cord. But muscular wasting 
 is due only to a lesion of the motor cells, or to a lesion 
 of the nerves cutting the muscles off from the influence of 
 these cells. In most cases we are able to exclude the 
 latter (by indications presently to be mentioned) : the state 
 of muscular nutrition comes thus to be of the highest 
 importance as indicative of the state of the anterior cornua 
 of the cord. To learn their condition further, we ascertain 
 the electrical excitability of the nerves and muscles, according 
 to the principles already laid down. 
 
 Whenever we find wasting, and infer that there is disease 
 of the anterior cornua, we have next to observe whether the 
 weakness and wasting are proportioned, i.e., whether the 
 weakness is only such as the affection of the grey matter 
 will account for, or whether it is in such excess as to 
 indicate other disease in the motor tract. 
 
 In acute diseases of the anterior cornua, paralysis precedes 
 wasting. The sudden interruption of the motor path causes 
 immediate loss of power. Wasting of muscles succeeds 
 the degeneration of the motor nerves, occurring a week 
 or ten days after the loss of power. In chronic diseases 
 the wasting and weakness come on together. 
 
 Chronic disease of the anterior cornua is often combined 
 with disease of the lateral (pyramidal) columns similar to 
 the descending degeneration. Charcot believes that in these 
 cases the degeneration in the lateral column is primary, 
 its symptom, muscular rigidity, preceding the symptom of 
 the cornual disease, muscular wasting, and he terms the 
 
58 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 affection "lateral amyotrophic sclerosis." It is possible, 
 however, that this position will need reconsideration, and 
 that the degeneration in the lateral columns is, sometimes 
 at least, secondary to, or simultaneous with, the disease in 
 the cornua. It often extends, however, beyond the fibres 
 related to the degenerated cornua, and so may cause weak- 
 ness and spasm in the limbs below the seat of the muscular 
 atrophy. Thus we have wasting in the arms, and weakness 
 with spasm in the legs, and even, as I have seen, wasting 
 in the shoulder muscles, and weakness without wasting 
 in the hands. 
 
 A lesion of the anterior cornua never, per se, affects 
 sensation. Acute lesions in this situation may, however, 
 disturb adjacent sensory parts (posterior cornu or sensory 
 tract), and so cause "excentric" pains, often rheumatic in 
 character. Actual loss of sensation, with, wasting, points, 
 especially if irregular in distribution, to damage to the 
 nerve-roots outside the cord, and therefore to disease of the 
 meninges rather than of the cord itself. 
 
 4. Unilateral Lesions. — These interfere with the conduction 
 of the motor impulse on the same side as the lesion, and 
 so cause weakness in one side, " henii-paraplegia " or " spinal 
 hemiplegia," and often descending unilateral sclerosis with 
 its symptoms in the affected leg. Whether there is weakness 
 of the other leg (if the lesion is strictly unilateral) will 
 depend on the number of pyramidal fibres, which in the 
 " direct pyramidal tract," have not decussated at the seat 
 of the lesion ; and this varies, as we have seen, in different 
 individuals. It must be remembered, however, that in uni- 
 lateral lesions, the opposite half of the cord is often slightly 
 damaged, and the symptoms are therefore rarely limited 
 to one leg. Sensation is affected on the opposite side to 
 motion, but not quite up to the level of the lesion, because 
 the decussation of the sensory tract is not immediate, but 
 occurs a little above the place at which the nerves enter the 
 cord. Sometimes, however, sensation is affected on the same 
 side as motion. This is often the case when the paralysis 
 affects the leg only, and probably the lesion is, in such 
 
ANATOMICAL DIAGNOSIS. 59 
 
 cases, so placed as to impair the sensory fibres before their 
 decussation. 
 
 5. Total Transverse Lesions. — A total transverse lesion of 
 the cord, at any level, however limited in vertical extent, 
 separates all parts below the lesion from the brain, and 
 hence, so far as will and perception are concerned, pro- 
 duces the same effect as if the whole of the cord below 
 the lesion were destroyed. A section across the cord in 
 the middle of the cervical enlargement, for instance, 
 paralyses all parts below the neck with the exception of the 
 diaphragm. Hence the extent of the paralysis indicates 
 only the upward limit of the lesion. This is also indicated 
 by the position of the girdle-pain and radiating pains, or 
 zone of hypersesthesia, which are due to the irritation of 
 the sensory roots in the lowest part of the upper segment — 
 an important indication when the lesion is in the dorsal 
 region, where the precise limitation of motor weakness may 
 be recognized with difficulty. 
 
 It is important, however, to know the symptoms which 
 occur in disease at different levels. These are shown in 
 the accompanying diagram and table (Fig. 14), and may 
 be understood from the following description. The indi- 
 cation of the upper level of the lesion is afforded by the loss 
 of the motor and sensory functions, shown in the first two 
 columns. The lowest nerves supply the anus and perineum. 
 The nerves which supply the skin and muscles of the leg 
 and foot arise from the 1st to the 3rd sacral nerves, and 
 are damaged by a lesion involving the lower part of the 
 lumbar enlargement. We must remember, however, that 
 the skin on the inner side of the leg is not supplied from 
 this source, and so may escape when the outer part of the 
 leg and back of the thigh have lost sensation. In the 
 middle of the lumbar enlargement, we have the nerves 
 arising which enter the lumbo-sacral cord, and these are 
 probably destined for the flexors of the knee, and for the 
 hip muscles which are supplied by the sacral plexus, the 
 glutei, the quadratus, and gemelli, and the "skin of the 
 lower part of the gluteal region. These parts then will be 
 
St. -mastoid 
 L Trapezius 
 
 Hand 
 (ulnar n. lowest) 
 
 SENSORY. 
 
 Flexors, hip 
 
 Extensors, knee 
 I Adductors " 
 
 •hip 
 Abductors 
 
 . | Extensors(?) 
 
 Flexors, knee(?) 
 
 Muscles of leg 
 moving foot 
 
 >Perineal and Anal 
 J muscles 
 
 >Neek and Scalp 
 >Neck and Shoulder 
 
 Shoulder 
 
 Arm 
 
 Hand 
 
 .Scapular 
 
 Front of Thorax 
 
 f Ensiform area 
 
 .Abdomen 
 '(Umbilicus 10th) 
 
 I Buttock, upper 
 f part 
 
 Groin and Scrotum 
 (front) 
 
 f outer side 
 
 Epigastric 
 
 > Thigh, 
 
 front 
 
 Jnner side 
 Leg, inner side 
 'Buttock, lower 
 part 
 
 >\ Back of Thigh 
 Leg 
 
 and 
 
 except 
 
 lFootJ inner P art 
 
 1 Perineum and 
 r Anus 
 
 "I Skin from coccyx 
 J to anus 
 
 "Abdominal 
 
 •Cremasteric 
 
 > Knee-jerk 
 
 ^Gluteal 
 
 Foot-clonus 
 Plantar 
 
 Fig. 14. — Diagram and Table Showing the Approximate Relation to 
 the Spinal Nerves of the Various Motor, Sensory, and Keflex 
 Functions of the Spinal Cord. {From anatomical and pathological data.) 
 
ANATOMICAL DIAGNOSIS. 61 
 
 paralysed by disease in the middle of the lumbar enlarge- 
 ment, while the muscles and skin in front of the thigh 
 are unaffected. The latter suffer when the disease affects 
 the upper part of the lumbar enlargement, the origin of 
 the anterior crural (rectus, etc.), and obturator (adductors). 
 The skin on the upper and outer parts of the thigh loses 
 sensibility, with the part adjacent to the scrotum, and in 
 the groin, only when the disease damages the highest part 
 of the lumbar enlargement, from which the first three 
 lumbar nerves arise, and then the flexors of the hip become 
 paralysed. In proportion as the disease is higher in the 
 dorsal region, we have the symptoms ascending higher up 
 the trunk, and marking accurately the height of the lesion 
 by the loss of cutaneous sensibility, and by the impairment 
 — first, of the abdominal muscles, and then of the inter- 
 costal muscles. The umbilicus corresponds to the 10th 
 dorsal nerves, and the ensiform area to the 6th and 7th. 
 When the disease reaches the lowest part of the cervical 
 enlargement (the 1st dorsal nerves), we have the first 
 symptoms in the upper extremity ; but these are not, as 
 might be expected, in the muscles moving the shoulder 
 joint, but in the hand. The first numbness is com- 
 plained of in the little finger, and the first weakness is 
 in the intrinsic muscles of the hand. Ascending higher, 
 the symptoms pass up the arm with some uniformity, and 
 without respect to nerve distribution. "When the middle 
 of the cervical enlargement is reached (the 5th, 6th, 7th 
 cervical) the shoulder muscles and the serratus magnus 
 become paralysed, and there is general loss of power and 
 sensation and anaesthesia. Above the level of the 6th 
 pair, the trapezius and sterno-mastoid become somewhat 
 weakened, for the fibres of the spinal accessory which 
 supply them undoubtedly arise in part from this region of 
 the cord. At the 4th and 5th cervical the lower part of 
 the neck becomes anaesthetic, and the diaphragm ceases to 
 act. Here our localization might cease, for total transverse 
 lesions at this spot necessarily cause death. For a little 
 time the sterno-mastoids and scaleni can still get air into 
 
62 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 the chest, but not in sufficient amount to maintain life for 
 more than a few days. But limited lesions may occur 
 higher up, and then we have complete powerlessness of the 
 muscles moving the head, upper part of trapezius and sterno- 
 mastoid, and other muscles attached to the occipital bone, 
 and interference with sensation in the neck and parts of the 
 head, which are not supplied by the 5th nerve. 
 
 The extent downwards of the lesion, its vertical extent, 
 is thus not indicated by the impairment of its conducting 
 functions, the motor or sensory paralysis ; and to learn 
 this we have to examine the functions of the cord as a 
 central organ, and to ascertain how far they are impaired 
 in the paralysed region — to examine especially muscular 
 nutrition and reflex action. The state of muscular nutri- 
 tion and irritability indicates how far the anterior cornua 
 are impaired, and the latter shows, as I have explained 
 (p. 40), whether they are involved in the primary lesion or 
 are affected secondarily. The relation of the several groups 
 of muscles to the cord is shown in the first column of 
 the table. The integrity of reflex action indicates the 
 integrity of the reflex loops, and the study of the super- 
 ficial reflexes of the trunk is especially instructive in this 
 respect. The series of reflexes, and the relation of each to 
 the cord, are shown in the third column of the table ; the 
 myotatic contractions are printed in italics in the position 
 which corresponds to the centres, the influence of which 
 is essential for their production. Excess of superficial reflex 
 action indicates withdrawal of the cerebral controlling in- 
 fluence of the reflex centres, and marked excess of the 
 muscle-reflexes suggests the existence of a descending 
 degeneration in the lateral columus. 
 
PATHOLOGICAL DIAGNOSIS. 63 
 
 IV.— INDICATIONS OF NATURE OF DISEASE: 
 PATHOLOGICAL DIAGNOSIS. 
 
 The last part of our subject remains for consideration — 
 the elements of the pathological diagnosis, by which, having 
 ascertained the seat of the lesion, we endeavour to learn 
 its nature. To do this, we attend, first, to the way the 
 symptoms come on and develope ; secondly, to the position 
 and distribution of the lesion ; thirdly, to any causal or 
 associated conditions which may be present. 
 
 We may group the primary morbid states into the fol- 
 lowing forms : — 
 
 (a) Vascular lesions ; rupture of vessels, causing haemor- 
 rhage ; occlusion of vessels, from thrombosis or embolism 
 (the latter being very rare). 
 
 (b) Inflammation ; " myelitis," acute or chronic, the 
 former causing softening. It is common to call all forms 
 of softening " myelitis " ; we do not yet know how far 
 they are originally inflammatory, or are set up, as in the 
 brain, by vascular occlusion. Some chronic inflammations 
 are not attended by softening. 
 
 (c) Degeneration and "sclerosis," in which the nerve-fibres 
 waste, and the connective tissue (neuroglia) overgrows. 
 
 The term " sclerosis " is inaccurate etymologically, since 
 the part altered by increase of connective tissue elements is 
 often softer than normal, but the term is firmly established. 
 In some cases the change appears to commence in the nerve- 
 fibres, in others in the connective tissue. Some forms of 
 degeneration pass by graduations into chronic inflammation 
 (here as elsewhere), and the term " chronic myelitis " is 
 sometimes applied to the slow degenerative forms. On the 
 other hand, the condition of " sclerosis " may result from 
 inflammation. The term is thus used in two senses, to 
 indicate a pathological process, and a pathological condition 
 which may result from more than one morbid change. Here 
 
64 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 the term will be used, when unqualified, to designate the 
 process. 
 
 It is most important to remember that degeneration and 
 sclerosis are not identical terms. Primary degeneration of 
 the nerve-fibres is followed, after weeks or months, by over- 
 growth of the interstitial tissue, which takes their place. 
 
 (d) Pressure from without, by inflammatory swelling of 
 meninges, or by displaced bones, or by growths. 
 
 (e) Growths in the cord itself. 
 
 I. We have first to consider how far these several lesions 
 can be distinguished by their onset, i.e., by the time occupied 
 in their development to a considerable degree of intensity. 
 According to this, we may divide them into five classes : 
 those in which the onset is sudden, instantaneous or nearly 
 so ; acute, occupying a few hours to a few days ; subacute, 
 developing in one to six weeks ; and lastly, the chronic 
 cases, which may be divided into those occupying six weeks 
 to six months, and those occupying six months and upwards 
 in their onset. 
 
 I have endeavoured to show the common relation of the 
 lesions to these several courses in the following table : — 
 
 Onset. 
 
 Sudden ~x 
 
 (few minutes) . I T7 i i • 
 
 . V ; > Vascular lesions. 
 
 Acute 
 
 (few hours or days) . * 
 
 -d , Subacute | 
 
 or I {one to six weeks) . { Inflammat ; on 
 
 Growths 1 C " Bomc ; ,. . f (myelitis. 
 
 v {six weeks to six months). J\ 
 
 Very Chronic \ Degeneration 
 
 {six months and upwards) I (sclerosis). 
 
 A lesion of sudden occurrence, developing symptoms in 
 the course of a few minutes, is almost always vascular ; 
 commonly haemorrhage, perhaps sometimes vascular obstruc- 
 tion. But a vascular lesion may occupy a somewhat longer 
 
PATHOLOGICAL DIAGNOSIS. 65 
 
 time in development — a few hours or days. In acute and 
 subacute inflammation the symptoms come on in the course of 
 a few hours, a few days, or a week or two. Chronic inflam- 
 mation occupies from a few weeks to a few months. 
 Degeneration, in which there is no adequate evidence of 
 any inflammatory process, occupies many months, or it 
 may be years. The symptoms produced by growths or 
 simple pressure (traumatic causes excluded) are never 
 sudden or very acute, and rarely, if ever, very chronic, 
 the time occupied by the development of the symptoms 
 varying, according to the nature of the cause, from a fort- 
 night to six months. 
 
 It is necessary to consider, however, not merely the 
 whole time occupied by the development of the disease, 
 but also the uniformity of its course. Two or more morbid 
 processes may concur. An initial myelitis, for instance, 
 may lead to a secondary degeneration ; and, on the other 
 hand, in degenerated tissues sudden vascular lesions occa- 
 sionally occur. Pressure often produces local myelitis, which 
 may be very acute in its development. Cancer of the 
 vertebrae, for instance, usually causes rapid myelitis. The 
 whole course of the disease must be ascertained before an 
 inference is drawn. 
 
 The onset and course of the symptoms thus sometimes 
 enable us to decide at once that a lesion is of a given 
 character, as that one which occurs instantly is vascular, or 
 that one which takes years for its development is degenera- 
 tive. More frequently they enable us to exclude certain 
 morbid processes, and to restrict the possible lesion to two 
 or three forms. For instance, a lesion which comes on in 
 the course of a few hours must be either vascular or inflam- 
 matory. Between these we have to decide by attention to 
 other indications. 
 
 II. In actual diagnosis it is convenient to consider next 
 the indication afforded by the position and distribution 
 of the disease. We consider what diseases occur in this 
 situation, and then which of them have the mode of onset 
 
66 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 which has been ascertained. As I said at the outset, this 
 indication is only to be employed in subordination to a 
 careful study of the mode of onset and course. 
 
 The grey matter of the cord is the most frequent seat 
 of haemorrhage. Either grey or white substance may be 
 the seat of inflammation or of degeneration. In young 
 children inflammation is much more common in the grey 
 matter than in the white. Pressure or growths usually 
 first affect the white columns, but may afterwards involve 
 the grey matter. 
 
 The affections called " system-diseases," in which one 
 system of structure is affected through a wide vertical 
 extent of the cord, are commonly degenerative in nature : 
 such are lateral sclerosis, posterior sclerosis (locomotor 
 ataxy), the change in the anterior cornua which leads to pro- 
 gressive muscular atrophy (anterior cornual degeneration). 
 These processes probably begin in the nerve elements. On 
 the other hand, lesions which have a limited vertical extent 
 — "focal lesions" — are commonly the result of processes 
 which may be either acute or chronic, but begin outside 
 the nerve elements, in the connective tissue, vessels, etc. 
 Such are haemorrhages, foci of myelitis, spots of " insular " 
 sclerosis, growths, and pressure from without. 
 
 But this distinction cannot be employed except after due 
 consideration of the mode of onset. Scattered acute focal 
 lesions, for instance, may be widely distributed in the same 
 structure, and produce symptoms limited to certain func- 
 tions, but of wide extent, and simulating — indeed, consti- 
 tuting — a " system-disease." Thus I have seen sub-acute 
 symmetrical myelitis of the anterior cornua in the lumbar 
 and cervical enlargement cause paralysis and atrophy in all 
 four extremities, the upper parts of the limbs being normal. 
 Again, a small focal lesion may be limited to one structure, 
 and cause symptoms confined to one function. Thus we may 
 have an anterior cornual myelitis, or a columnal myelitis, 
 lateral or posterior, giving rise to limited symptoms — local 
 muscular atrophy, unilateral paralysis, or local ataxy. 
 Lastly, many " focal lesions " may give rise to secondary 
 
PATHOLOGICAL DIAGNOSIS. 67 
 
 system-degenerations. A focus of myelitis in one lateral 
 column may cause descending degeneration in the whole 
 lateral column below, with its attendant spasmodic symp- 
 toms. Indeed, so true is this, that, as we have seen, lateral 
 sclerosis is more often secondary to a limited focal lesion 
 than primary. In all these cases, however, attention to the 
 mode of onset will prevent error. 
 
 The combination of mode of onset with seat of lesion 
 sometimes helps us in a more direct manner, especially in 
 the case of growths and compression. The characteristics 
 are their limited vertical extent, gradual onset, and slow 
 invasion of parts adjacent to that first affected, on the 
 same level ; one leg, for instance, is affected, and then the 
 other. 
 
 Indication of disease outside the cord, irritation of certain 
 nerve roots, causing severe local pain, often precedes the 
 symptoms of compression and is an important aid to 
 diagnosis. It shows the existence of a morbid process out- 
 side the cord before the cord is involved. But we cannot 
 use even this indication except in dependence on the mode 
 of onset. A disease, as a growth outside the cord, may 
 not only compress the cord, and cause slow loss of power; 
 it may excite inflammation and cause rapid palsy. 
 
 There is a rare form of paralysis, in which the functions 
 of the cord are progressively impaired from below upwards, 
 until, in the course of a few days, death results from inter- 
 ference with respiration. In these cases of " acute ascending 
 paralysis," as they are called, no lesion of the cord has 
 usually been discovered, and their exact nature is unknown. 
 
 III. The last element in the pathological diagnosis is 
 the detection of any influence which can be regarded as 
 the cause of the disease in the spinal cord, or any associated 
 condition which may indicate an active morbid process. 
 We have seen that the mode of onset may help us to limit 
 the disease to certain possible forms of lesion : the distri- 
 bution of the affection may render it probable that it is 
 one or other of these forms ; and the detection of a cause 
 
 f 2 
 
68 THE DIAGNOSIS OF DISEASES OF THE SPINAL COHD. 
 
 of disease of the spinal cord, and the knowledge of the 
 lesions which that cause produces, may help us to fix the 
 nature of the lesion still further. It is important, there- 
 fore, in diagnosis, to be aware of the several effects of the 
 common causes of spinal disease. 
 
 1. The Age of the Patient. — In young children acute 
 myelitis is the most frequent lesion, and the grey matter is 
 usually the chief seat of the disease. 
 
 2. The State of the Vascular System. — The conditions which 
 favour haemorrhage are of far less diagnostic value with 
 regard to the spinal cord than with regard to the brain. 
 Conditions of mechanical congestion — heart disease, emphy- 
 sema, etc. — favour degenerative changes and also, probably, 
 thrombosis. The state of the vascular system which is asso- 
 ciated with chronic kidney disease undoubtedly favours 
 degenerative changes in the cord, the occurrence of which has 
 been demonstrated by Sir William Grull and Dr. Sutton. 
 
 3. Scrofula commonly causes spinal disease by leading to 
 disease of the bones of the spinal column ; and the evidence 
 of this, local tenderness or irregularity of the vertebral 
 spines, or actual curvature, is of the highest diagnostic 
 importance, and careful and repeated examination of the 
 bones should never be neglected in cases of obscure spinal 
 disease. There is, perhaps, no error in diagnosis which is 
 more frequently made, or which results in graver errors in 
 treatment, than the non-recognition of disease of the spinal 
 bones. It is important to remember that the damage to 
 the cord may occur before the signs of bone disease are 
 distinct : hence the importance of repeated examinations. 
 
 In bone disease the cord suffers in at least four different 
 ways:— [a) By pressure from the inflammatory swelling of 
 the bone or inflammatory products without curvature. The 
 effects of the pressure may lessen as the curvature comes on. 
 (b) By pressure in consequence of the displacement, the 
 bony canal being narrowed by the angular projection of 
 the bodies over which the cord is stretched. (<?) By 
 secondary chronic inflammation, with thickening, of the 
 dura mater and tissue outside it, compressing the cord. 
 
PATHOLOGICAL DIAGNOSIS. 69 
 
 (d) By inflammation extending through the membranes 
 to the cord, or set up in the cord by the compression. 
 Hence we cannot, because we find evidence of bone disease, 
 immediately conclude that the cord is pressed upon by the 
 displaced bone. "We must investigate the mode of onset of 
 the symptoms and their character, and infer from these the 
 character of the disease of the cord according to the rules 
 now given. The most common mechanism is compression 
 by products of inflammation outside the dura mater, and 
 by the thickening of this membrane. 
 
 In recognizing bone disease it must be remembered that 
 not only may there be no angular curvature until long after 
 the cord has suffered, but there may not even be irregularity 
 of the vertebral spines. There are often pain and local deep 
 tenderness to be elicited. In the resulting paraplegia the 
 excess of the cutaneous reflexes is often an early and con- 
 spicuous symptom, and spots of anaesthesia at the level of 
 the bone disease, due to pressure on nerves, may sometimes 
 be found, and give important help in diagnosis. 
 
 4. Syphilis. — The methods by which syphilis causes 
 disease of the cord, which are universally recognized, are — 
 
 (a) The growth of syphilomata springing from the con- 
 nective tissue, the membranes, or tissue in the fissures, and 
 invading the cord. In these cases we have symptoms 
 varying in character according to the position of the growth, 
 and similar to those produced by other limited lesions, but 
 always of gradual onset. 
 
 (b) By chronic meningitis, with thickening and pressure 
 on the nerves, and sometimes on the cord also. The cha- 
 racteristic symptoms depend upon the damage to both 
 motor and sensory nerves, that of the former cutting off 
 the muscles and peripheral nerves from the influence of 
 the motor nerve-cells, and hence causing muscular atrophy, 
 very similar to that due to disease of the grey matter, 
 but differing by its association with scattered areas of 
 diminished sensitiveness of the skin. The interference 
 with the reflex loops abolishes reflex action in the part ; 
 but if the damage is confined to the upper part of the 
 
70 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 cord, and the cord itself is pressed upon, there may be an 
 excess of the reflex action on the lower part. 
 
 (c) Syphilitic disease of vessels may probably lead to 
 acute softening, similar to that in the brain. Syphilitic 
 subjects may become suddenly paraplegic, and it is possible 
 that it is by this mechanism, although the fact does not 
 at present rest on post-mortem evidence. 
 
 All the above lesions originate in the adventitial 
 structures. There is, however, a considerable mass of 
 evidence to show that (d) diseases which originate in the 
 nerve elements and neuroglia, more or less inflammatory 
 or degenerative in character, may be a late effect of 
 syphilis. I have found, for instance, disseminated foci of 
 chronic myelitis, affecting chiefly the periphery of the cord, 
 throughout the dorsal region, in a syphilitic woman, and 
 two similar cases have been observed by Pierret. It is pro- 
 bable that this form of chronic myelitis is usually syphilitic. 
 
 Symptoms of acute myelitis sometimes occur in syphilitic 
 subjects, and the myelitis has been regarded as due to the 
 syphilis, but the evidence of this is at present insufficient. 
 
 The majority of cases (about 70 per cent.) of locomotor 
 ataxy, primary posterior sclerosis, occur in individuals 
 who have had syphilis many years before.* Anterior 
 cornual degeneration (progressive muscular atrophy) some- 
 times occurs after constitutional syphilis, and so also do 
 the symptoms associated with sclerosis of the lateral columns. 
 In these cases of degenerative disease it does not appear, 
 as far as we can tell, that the anatomical process presents 
 any recognizable difference from that which occurs as a 
 result of other causes ; and it is possible that the influence 
 to syphilis, although effective, may not be direct, i.e., the 
 
 * See "Syphilitic Neuroses," "Brit. Med. Journal," March, 1879. A 
 similar statement had been expressed before by Fournier, and since has been 
 made by Vulpiari and Erb. I have given their statements in a paper on the 
 subject of " Syphilis and Locomotor Ataxy," in the " Lancet "for January, 
 1881. It is not suggested that syphilis is the cause in this proportion; in 
 some the coincidence of the two diseases may be accidental. The facts 
 seem to justify the assertion that half the patients would not suffer from 
 ataxy had they not previously suffered from syphilis. 
 
PATHOLOGICAL DIAGNOSIS. 71 
 
 disease is due, in part at least, to the preceding syphilis, 
 although it is not syphilitic in nature. One consequence 
 of syphilis may be to cause a neuropathic tendency, in which 
 these diseases are gradually developed. 
 
 Although not strictly a fact of etiology, I may mention 
 that the result of treatment often affords an important 
 corroboration of the diagnosis of syphilitic disease. If 
 symptoms, which we have reason to suppose are due to 
 syphilitic disease, improve rapidly when iodide of potassium 
 or mercury is given, the diagnosis is strongly corroborated.* 
 But the converse of this is not equally true. A disease may 
 be due to syphilis, and no improvement be obtained from 
 specific treatment. It must be remembered that as regards 
 (a), (b), and (c), the syphilitic disease causes symptoms by 
 producing changes in the nerve elements, softening, degene- 
 ration, etc., which are not in any way syphilitic, but are 
 such as would result from adjacent disease of any other 
 nature. Under some conditions (of intensity, duration, 
 etc.), the recovery of the nerve-tissue may be impossible, 
 even though the syphilitic adneural disease be completely 
 removed. Further, the diseases of the last class (d) are 
 not, except in the earliest stage, benefited to any marked 
 extent by anti- syphilitic treatment. 
 
 5. The exciting causes of disease of the spinal cord some- 
 times afford diagnostic indications. Exposure to cold may 
 cause acute symptoms, commonly due to inflammatory 
 softening — sometimes focal, sometimes diffuse ; and in the 
 latter case often accompanied by symptoms of meningitis. 
 It may also cause haemorrhage. It is especially effective 
 in women at the menstrual period. Repeated exposure 
 may lead to degeneration, especially in the grey matter. 
 
 Acute specific diseases, as typhoid fever, are occasionally 
 followed by spinal symptoms, due to changes which are 
 probably of the nature of subacute inflammation. It is 
 
 * Always provided the symptoms are not such as tend to lessen spon- 
 taneously. I do not mention this exception in the text, because, important 
 as it is, it has less application to the syphilitic diseases of the spinal cord 
 than to those of the brain. 
 
72 THE DIAGNOSIS OF DISEASES OF THE SPESTAL COTtD. 
 
 very common for a patient, after typhoid fever, to suffer for 
 a long time, sometimes permanently, from weakness of the 
 legs ; and occasionally during the course of the disease acute 
 symptoms, as those of anterior cornual myelitis, may occur. 
 
 Sexual excess is a more common cause of transient 
 functional weakness than of organic disease. 
 
 Traumatic influences are frequent causes of cord disease. 
 The cord may be directly pressed upon and damaged by 
 displacement or fracture of the vertebrae, or a severe con- 
 cussion may be followed by slow paralysis at an interval 
 of a few days or weeks. In such a case, occurring after a 
 railway accident, I have found numerous minute foci of 
 chronic inflammation, most abundant in the grey matter. 
 Sometimes a still longer interval elapses between the 
 injury and the paralysis. In such cases a growth or 
 patch of sclerosis appears to be set up by the injury, 
 although years may pass before the symptoms reach a 
 considerable degree of intensity.* 
 
 These, then, are the chief etiological facts, which, taken 
 in conjunction with mode of onset and distribution, enable 
 us to form an opinion regarding the nature of the lesion. 
 
 To sum up : In examining a case of disease of the 
 spinal cord, the method should be briefly as follows : — 
 First, endeavour to ascertain the exact seat of the lesion ; 
 note how far the several conducting functions of the cord 
 are impaired, and the highest level of the impairment ; 
 then ascertain the condition of the central functions, espe- 
 cially muscular nutrition and irritability, and reflex action, 
 first in the part below the level at which conduction is 
 impaired, and secondly at the supposed level of the lesion ; 
 and in this way you may infer, without much difficulty, 
 what is the extent of the lesion transversely and vertically. 
 In the next place endeavour to ascertain its nature by con- 
 
 * An instructive instance of the way in which the results of an injury of 
 the head may cause both growths and arterial disease, and, years later, 
 both chronic and acute symptoms, will be found recorded in the author's 
 " Medical Ophthalmoscopy," Case 4, p. 248. 
 
PATHOLOGICAL DIAGNOSIS. 73 
 
 sidering — first, how the symptoms came on and developed ; 
 secondly, which of the lesions having this mode of onset 
 and development occur in the region affected ; and thirdly, 
 which of them are produced by the cause or causes to 
 which the disease is apparently due. 
 
 This process of diagnosis may seem somewhat elaborate, 
 and, no doubt, a practised observer does not always con- 
 sciously go through it. But, in most cases, if he wish to 
 avoid error, he goes through it unconsciously, and no step 
 can be with safety dispensed with. We may thus, in 
 almost all cases, arrive at an exact diagnosis of the seat 
 of the disease, and, in a large number of cases, of its nature 
 also. There are, however, some cases with respect to which the 
 diagnosis of the nature of the lesion .can be approximate only, 
 although we can always limit it to one or two possibilities. 
 
 It will be observed that I have said nothing of " ana?mia 
 of the cord," of " hypersemia of the cord," or of " reflex 
 paralysis." In current descriptions of the symptoms of these 
 conditions, I cannot help thinking that a vigorous scientific 
 imagination has contributed much more than .observation has 
 supplied. The only practical knowledge of the effects of 
 anaemia and hypersemia of the cord, is, that they seem capable 
 of causing such disturbance of the sensory structures as reveals 
 itself in subjective sensations of tingling, pins and needles, 
 and the like, and perhaps also some impairment of motor con- 
 duction. A large number of authorities here and abroad are 
 sceptical as to the existence of such a condition as "reflex 
 paralysis," i.e., a paralysis due to the effect on the centre of 
 some peripheral irritation, disappearing when this was re- 
 moved. Although our modern knowledge of the various 
 phenomena of inhibition and reflex action renders such a 
 paralysis a priori even probable, it is certain that the theory 
 has been extensively misapplied. 
 
 Spinal Meningitis. — The object of this lecture has been to 
 explain the principles of the diagnosis of diseases of the cord 
 itself. But it may be well to allude briefly to the diagnosis 
 
74 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 of spinal meningitis. Of acute meningitis I need say little. 
 The acute symptoms, spinal pain, and severe spasms, are well 
 known. Chronic spinal meningitis, however, is a disease re- 
 garding which current opinion has curiously changed during 
 the last fifteen years. A large number of symptoms were 
 assigned to chronic meningitis which we now know have 
 nothing to do with that pathological state. I have mentioned 
 that to it the symptoms of weakness with chronic spasm, 
 " spasmodic paraplegia," were ascribed. But we now know 
 that these are due to alterations within the cord, and are 
 independent of any meningitis. The only symptoms which 
 are usually due to this condition are those which result from 
 the involvement of the nerve-roots in their passage through 
 the diseased membranes. The roots are irritated by the ad- 
 jacent inflammation. The meninges frequently become much 
 thickened, and by this thickening the nerve-roots are often 
 greatly damaged. The irritation affects first the sensory 
 roots, causing " excentric " pains and hypersesthesia, to which 
 are often added areas of anaesthesia here and there, due to 
 the greater damage of some nerve-roots. The affection of 
 the motor roots causes symptoms similar to those of disease of 
 the anterior cornua, but very irregular in distribution. The 
 peripheral motor nerve-fibres, cut off from their motor cells, 
 degenerate, and the muscular fibres waste, and present elec- 
 trical reactions which vary according to the rapidity of the 
 morbid process. Sometimes the nutrition of the skin suffers. 
 There is frequently, in addition, pain in the back, from the 
 lumbar to the cervical region, sometimes severe between the 
 shoulders, and accompanied sometimes with rigidity of the 
 vertebral muscles. 
 
 The chief conditions with which chronic spinal meningitis 
 may be confounded are posterior sclerosis (locomotor ataxy) 
 in which the sensory nerve-roots are implicated, and anterior 
 cornual degeneration (progressive muscular atrophy). From 
 the former it is distinguished by the absence of ataxy, from 
 the latter by the irregular distribution of the symptoms, and 
 from both by the existence of limited areas of anaesthesia, 
 and of extensive spinal pain. It must be remembered that 
 
PATHOLOGICAL DIAGNOSIS. 75 
 
 inflammation often affects the substance of the cord as well 
 as the meninges, or the cord may be pressed upon by the 
 thickened membranes, and so mixed symptoms may result. 
 
 A word on the subject of the nomenclature of diseases of 
 the spinal cord. If we wish to obtain clear ideas, it is essen- 
 tial to use terms, where we can, which shall be pathological, 
 and which shall be at once simple and descriptive. To obtain 
 these, we must avoid the error, too common, of striving after 
 extreme brevity. Names of morbid states, the meaning 
 of which is obvious, are, even if somewhat longer, to be 
 preferred to shorter expressions, the meaning of which is 
 obscure. We are apt to associate with brief obscure names 
 the idea of definite diseases. But if we would gain and 
 convey exact ideas of the diseases of the spinal cord, we 
 must endeavour to substitute the idea of morbid processes 
 for that of definite diseases. 
 
 A simple and convenient system of terminology lies 
 close to hand. We have in the spinal cord, the two cornua 
 of grey matter and the three columns, lateral, anterior, 
 and posterior. In each of these situations the various 
 morbid processes already described may occur, and we 
 have only to combine the terms indicating the place and 
 the lesion to have a system of terminology already partly 
 in use, and which will altogether suffice for our present 
 needs. Thus we may have a columnal or a cornual 
 myelitis, haemorrhage, sclerosis, degeneration, or growth. 
 We may have, for instance, an " anterior cornual myelitis," 
 or, for shortness (since we cannot yet diagnose posterior 
 cornual diseases), a "cornual myelitis;" or we may have 
 a cornual degeneration. For anterior cornual myelitis, the 
 term " tephro-myelitis " has been proposed by Charcot, 
 and " anterior polio-myelitis " by Kussmaul. The latter 
 term has obtained wide currency, but its meaning is much 
 less obvious than that of "anterior cornual myelitis." The 
 simpler system of nomenclature I have employed throughout 
 this lecture, and it has probably been readily intelligible, 
 although unexplained. 
 
76 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 V.— TEE DISTINCTION OF FUNCTIONAL AND 
 ORGANIC DISEASE. 
 
 No term is more loosely used in medical writings than 
 " functional disease." It is commonly employed, in regard 
 to the nervous system, as a designation for those affections 
 in which no morbid changes have been hitherto discovered, 
 even with the microscope, and from which recovery is possible. 
 Unfortunately, we have no other general term for these cases, 
 and it is to be regretted that we are compelled to make a 
 positive term connote negative characteristics. Strictly speak- 
 ing, a functional disease is one which consists in a disorder 
 of function without any preceding alteration of nutrition. 
 The affections of the nervous system which can be included 
 under this definition are very few. Most of the examples 
 of purely functional disturbance of one part are the result 
 of disease in some other part of the nervous system. In 
 most cases of so-called functional disease, we must assume 
 changes in nutrition. In some, these changes are probably 
 primary ; in others they may be secondary to the disturbance 
 of function. 
 
 Hysteria is the most frequent cause of symptoms that 
 are within the range of the spinal functions, and not due 
 to organic disease. Hysterical symptoms of spinal type 
 usually have the form of loss of power in the legs, "hys- 
 terical paraplegia ; " and one of the most frequent problems 
 in diagnosis is the distinction of this from organic disease. 
 But more than one morbid condition is included under the 
 term " hysterical paraplegia." In the most characteristic 
 form of the disease there is not any affection, even func- 
 tional, of the spinal cord. There is loss of power over the legs, 
 because there is in relation to the legs the peculiar ungeared 
 state of the volitional centres, which is at the root of all pure 
 hysteric palsy. There is no disturbance of the central 
 functions of the cord. Reflex action from the skin, and 
 myotatic irritability, are normal. The muscles do not 
 
FUNCTIONAL AND ORGANIC DISEASE. 77 
 
 waste, although they may become somewhat flabby from 
 disuse. Eetention of urine may occur, but there is never 
 incontinence, nor is there any affection of the sphincter ani. 
 Sensation on the legs is almost always normal. Thus, all 
 objective indications of an affection of the cord are absent. It 
 is necessary to establish this negative fact before any weight 
 can be allowed to the positive indications of the hysterical 
 nature of the case. These are rather suggestive indications 
 than positive symptoms. One of them is the presence or 
 history of other unequivocal symptoms of hysteria, globus, 
 loss of voice, hysteroid convulsions, and the like. Another 
 is the mode of onset. Hysterical paraplegia is often excited 
 by some emotional shock, such as an alarm. But it rarely 
 comes on instantly, or reaches a high degree in an hour or 
 two, except when it immediately follows a severe emotional 
 shock. Usually its development occupies several days or 
 weeks, and it is often preceded by occasional attacks of 
 momentary weakness in the legs. When a considerable 
 degree of weakness comes on quite suddenly there have been 
 usually such preceding transient attacks of slighter loss of 
 power. A third indication is derived from the character 
 of the weakness. It is very rarely absolute. Some power 
 usually remains. The patient can move the legs, but 
 cannot stand. Moreover, there are two peculiarities in the 
 manner in which the legs are moved which are, perhaps, 
 more significant than any other positive symptom. But the 
 full power which can be exerted is not put forth at once. 
 By continued effort and repeated urging much more force 
 can be evoked ultimately than at first. Thus the patient, 
 lying in bed, is told to raise the foot. She does so, slowly, 
 for about six inches, and says she cannot get it any higher. 
 Nevertheless she holds it there, and if urged ultimately raises 
 it higher, a foot or eighteen inches from the couch. The 
 second is that if the patient tries to exert force with a given 
 group of muscles, the opponents of those muscles are put in 
 action at the same time and in undue degree. Thus, if the 
 knee is flexed, and the patient is told to try to extend it, the 
 flexors are put in action, as well as the extensors, and prevent 
 
78 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 the movement. Resistance to passive movement is often 
 hesitating and jerky. Occasionally a movement, at first 
 steady, becomes modified, in a few minutes, by tremor, usually 
 quick but variable, now fine, now coarser, and with quick 
 sudden jerks. It has been mistaken for the spasm of dissem- 
 inated sclerosis, but differs in not being uniformly wild and 
 irregular. The tendency -to contract other muscles than those 
 which effect the desired movement, is often associated with an 
 inability to relax the muscles voluntarily. This may prevent 
 the knee-jerk being obtained. The flexors of the knee con- 
 tract and prevent any movement when the patellar tendon 
 is struck. I believe that it is this, and this alone, which 
 has led to the assertion that the knee-jerk is sometimes lost 
 in hysterical paraplegia, or that it varies, and can be 
 obtained at one time and not at another. There is rarely 
 anaesthesia. These several indications are separately of 
 little significance ; they derive value from their combi- 
 nation. 
 
 In another class of cases there is, in addition to the above 
 symptoms, distinct indication of slight disturbance of the 
 functions of the spinal cord itself. There is spinal tender- 
 ness, apparently due to a neuralgic state of the spinal 
 membranes or ligaments. Pain in and about the spine is 
 often complained of, and is increased by movement, but 
 it is never unilateral, passing round one half of the trunk, 
 as in organic disease. There is a slight increase of 
 myotatic irritability in the legs. The knee-jerk is excessive ; 
 the rectus contraction can readily be produced by tapping 
 the depressed patella. The front-tap contraction in the 
 gastrocnemius may be obtained, and a " spurious foot- 
 clonus" may occur when the ankle is passively flexed. 
 This spurious clonus results, as already described (p. 32) 
 from a voluntary and variable contraction in the calf 
 muscles. There is never a regular persistent clonus, except 
 when there is persistent hysterical contracture (to be -pre- 
 sently described), a much rarer condition in hysterical 
 paraplegia than in hysterical hemiplegia. 
 
 This morbid state of the central functions of the cord is 
 
FUNCTIONAL AND ORGANIC DISEASE. 79 
 
 probably, in some cases at least, the result of the complex 
 combination of neuropathic tendencies, which is called 
 hysteria. The clinical history of this disease affords many 
 examples of the affection of lower centres, excited by 
 emotional causes, but running a course to a considerable 
 extent independent. Nutritional changes doubtless follow 
 the disturbed function, and one case recorded by Charcot 
 suggests that, after years, the changes in nutrition may 
 attain the degree of visible structural alterations. But in 
 many cases of hysterical paraplegia the change in nutrition is 
 to a large extent, often altogether, removable by judicious 
 treatment directed to the strengthening of the will, improve- 
 ment of physical health, and the removal of the irritable 
 state of the spinal cord. 
 
 In other cases the disturbance of the cord has an indepen- 
 dent origin. Many weakly women, who are not hysterical, 
 suffer from symptoms which indicate slight impaired action 
 of the cord. They are bad walkers, soon tire, and when 
 tired suffer pain in the spine. The muscles of the legs are 
 flabby, sometimes very thin ; the knee-jerk is excessive. 
 This condition is often left after prostrating diseases, such as 
 typhoid fever, repeated child-bearing, prolonged anemia from 
 any cause, and may be permanent. If such women are, or 
 become, the subjects of hysteria, the spinal weakness deter- 
 mines the direction in which symptoms develope that are of 
 ideal origin. It is often difficult to distinguish these cases 
 from those last described. I believe, however, that those in 
 which the disturbance of the central function of the cord is 
 secondary to hysteria are far less common than those in 
 which slight spinal weakness or pain in the back precedes 
 the hysterical disturbance and determines it, and may endure 
 after the volitional defect is removed. Often both may be 
 due to a common cause, which impairs general health and 
 lowers nervous tone. 
 
 These cases, in which volitional defect is combined with 
 slight over-action of the spinal centres, give rise to consider- 
 able diagnostic difficulty, unless the complexity of the 
 pathological condition is duly recognized. 
 
80 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 In cases in which there is rigidity of the legs, the question 
 arises whether there is true spasm or hysterical contracture. 
 The problem is the more difficult, because in each condition 
 the limbs are usually extended, and in each there may be a 
 distinct foot-clonus. This may be developed in hysterical 
 contracture, as it is in health when the calf-muscles are long 
 contracted. But in the vast majority of cases attention to 
 the following points will decide without difficulty the nature 
 of the case. In hysterical contracture the muscular spasm is 
 greatest at the extremity of the limb. The ankle-joint is 
 extended, so that the dorsum of the foot is in the line of the 
 tibia, and the foot is usually inverted. Any attempt to alter 
 the position is resisted, and if the contracture is partially 
 overcome the rigidity continues. It can be ultimately over- 
 come, but considerable pain is produced. The contraction is 
 constant. In spastic paraplegia the spasm is equal through- 
 out the limb, or even greater at the proximal extremity. The 
 effect is to fix both legs to the pelvis, so that if one is lifted 
 the other is moved with it. The spasm is variable ; at times 
 it is slight, at others violent. It is excited by peripheral 
 irritation. It is not only extensor in character, but is almost 
 exclusively extensor. When the limbs are flexed they are 
 supple, but as soon as they are extended they become rigid. 
 If the ankle-joint is in extension, it is in consequence of actual 
 shortening of the calf-muscles, which cannot be overcome. 
 A clonus is usually obtained without difficulty, and is uniform. 
 It is best obtained when the spasm is least. In hysterical 
 contracture the clonus is usually variable, and best marked 
 when the contracture is greatest. The attacks of so-called 
 " spinal epilepsy," first tonic and then clonic spasm, excited 
 by peripheral impressions, occur only in organic disease. 
 
 Hysterical symptoms are notoriously greatest when the 
 patient is under examination. The patient walks best when 
 she is unaware that she is being watched. The more atten- 
 tion is paid to a given symptom, by the patient or others, 
 the greater it is. Under the influence of a strong motive, 
 actions can be performed that cannot be effected by a simple 
 volitional effort. Strong faradization, for instance, may 
 
ILLUSTRATIONS OF DIAGNOSIS. 81 
 
 make an hysterical patient move her leg when she cannot 
 be made to move it by a voluntary effort. Care must be 
 taken, however, not to mistake a reflex for a voluntary 
 movement. Such a mistake frequently leads to error in 
 diagnosis. In many cases of paraplegia, from disease of 
 the dorsal cord, with entire loss of voluntary movement, a 
 painful cutaneous impression will cause a flexion of the hip- 
 joint, by which the leg is drawn up, closely resembling a 
 voluntary movement. The observer must satisfy himself 
 as to the character of the movement before he allows it to 
 influence his diagnosis. 
 
 Other forms of so-called "functional paraplegia" are 
 rare. Their most frequent causes are sexual excess and some 
 morbid blood state, especially chronic alcoholism and gout. 
 The loss of power is never absolute, rarely such as to prevent 
 the patient walking, and varies from time to time. The legs 
 "feel heavy;" they are readily fatigued, and are often 
 the seat of abnormal sensations, tingling, formication, and 
 the like. Sensation, reflex action, and myotatic irritability 
 are all normal. The symptoms occur chiefly in adults and 
 in males. The absence of indications of organic disease, 
 the variations in the symptoms, and the recognition of the 
 cause, usually render an accurate diagnosis practicable. 
 
 VL— ILLUSTRATIONS OF DIAGNOSIS. 
 
 The following illustrations may render clearer the appli- 
 cation of the methods of diagnosis. I will take, first, 
 two cases in which the pathological diagnosis presented 
 no difficulty, since both were cases of fractured spine, and 
 complete paralysis of the legs occurred immediately on the 
 accident, indicating direct damage to the cord by the dis- 
 placed bone. 
 
 (1.) In the one case, that of a sailor, there was no irregu- 
 larity of the spines to guide us as to the position of the 
 injury, but this was clear enough from the symptoms. The 
 
 G 
 
82 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 legs were completely paralysed, and all the muscles, when 
 the patient came under observation, some months after 
 the injury, were greatly wasted, faradaic irritability being 
 extinct. This proved complete degeneration of the motor 
 nerves arising from the lumbar enlargement. Sores had 
 formed on the limbs and sacrum, indicating damage to the 
 nerves which influence the nutrition of the skin. Sensa- 
 tion was at first lost, but afterwards returned as hyperses- 
 thesia — suggesting initial damage and partial recovery of 
 the nerves or tracts conveying sensation. The sphincters 
 were powerless, and their condition was such as to indicate 
 damage to, or separation from, their centres in the cord 
 (see p. 44). From these symptoms we inferred damage by 
 compression of the lower part of the lumbar enlargement, 
 and of the nerves passing it. But what was the state of the 
 dorsal region of the cord ? Sensation above the groins was 
 normal, but this does not exclude slight damage to the cord, 
 since the impairment of sensation caused by slight damage 
 may soon pass away. Here it was that the superficial 
 trunk reflexes assisted us. We found that the epigastric 
 reflex and the abdominal reflex were perfectly natural on 
 each side, even in the lower part of the abdomen. The 
 cremasteric reflex, however, was active on the right side, 
 absent on the left ; so that we had evidence that the dorsal 
 cord was normal, and that the damage commenced at the 
 1st lumbar nerve, where the reflex loops were damaged 
 on the left side and normal on the right, and that 
 just below this point the damage was great. The patient 
 died, and the autopsy revealed exactly the condition which 
 had been diagnosed. The dorsal cord was uninjured, and 
 so was the highest part of the lumbar enlargement ; while 
 its lower portion was split in two by a fracture, with 
 displacement, of the 1st lumbar vertebra, which had also 
 compressed the nerve-roots. Microscopical examination 
 revealed, also, slighter mischief in the cord, extending as 
 far as the upper part of the lumbar enlargement. 
 
 (2.) The other case is that of a girl, a patient in 
 
ILLUSTRATIONS OF DIAGNOSIS. 8-'> 
 
 University College Hospital under the care of Mr. Heath. 
 She fell off a house-top and became at once paraplegic. 
 There were indications of damage to the bones about the 
 10th dorsal vertebra. The legs were completely paralysed ; 
 but there was only slight wasting, the faradaic irrita- 
 bility of the muscles being preserved, although lowered ; and 
 reflex action was preserved. Hence it was inferred that the 
 motor nerves were undegenerated, that the lumbar anterior 
 cornua were not directly damaged, that the reflex loops 
 were entire ; in short, that the damage to the cord was at 
 or above the highest part of the lumbar enlargement. There 
 was loss of sensibility to pain in the legs, that to touch 
 being perfect. Hence we inferred that the destruction of 
 the cord was incomplete. This loss extended as high as the 
 epigastrium — evidence of some damage to the cord as high 
 as the origin of the 8th dorsal nerves. This was corro- 
 borated by the condition of the superficial reflexes of the 
 trunk : the abdominal was lost on both sides ; the epigastric 
 was lost on the right side, but present on the left, indicating 
 clearly the highest level of damage. Thus there was evi- 
 dence of affection of the cord from the origin of the 8th 
 to that of the 11th dorsal pairs; but the symptoms did 
 not show whether the damage was equal throughout this 
 region. This information was, however, supplied by an 
 examination of the faradaic irritability of the abdominal 
 muscles. Above the umbilicus there was normal irritability ; 
 below the umbilicus it was gone — i.e., the motor fibres of 
 the 9th pair were undegenerated, their anterior cornua 
 were undamaged, the fibres of the 10th pair, perhaps also 
 the 11th pair, were degenerated, and the corresponding 
 cornua probably damaged. As the lumbar enlargement 
 was not directly damaged, we were able thus to limit with 
 precision the considerable damage to the cord to the origin 
 of the 10th, or 10th and 11th pairs. The loss of the epigas- 
 tric reflex on the right side indicated that the damage to the 
 cord on that side was greater than on the left. The sub- 
 sequent progress of the case showed the significance of these 
 indications. A month later the epigastric reflex returned 
 
84 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 on the right side, an indication of commencing recovery 
 in the upper part of the damaged region. A few weeks 
 later she gained some power of moving the left leg, but 
 the reflex action became excessive in both legs, and the 
 foot- clonus could be obtained. Now, four months after 
 the injury, the abdominal reflexes are returning ; a slight 
 reflex can be obtained just above the groin, and above the 
 umbilicus ; none at or just below the umbilicus.* 
 
 In both these cases, thus, the information conveyed by 
 the trunk reflexes was most important. 
 
 (3.) A man, aged twenty-eight, had suffered from weak- 
 ness of the legs for more than two years. He was able 
 to walk leaning forwards upon his sticks. His arms were 
 unaffected. He could just flex the hips and extend the 
 knees, but could not flex the knees, and scarcely the 
 ankles. The right leg was the weaker. The legs were 
 well nourished. Even as he entered the room, the clonic 
 spasm at the ankle-joint, as the calf -muscles were put on 
 the stretch, was conspicuous, and it was found that the 
 knee-jerk was in great excess, and the foot-clonus 
 could be obtained by the slightest pressure against the 
 soles. A slight peripheral impression caused rigid sjjasm 
 succeeded by clonic contraction as the stronger spasm 
 passed lessened (spinal epilepsy, see p. 51). Thus the 
 loss of power showed interruption to the motor path some- 
 where below the cervical enlargement. The preservation 
 of the myotatic contractions, and the absence of wasting 
 in the legs, showed the integrity of the lumbar reflex 
 loops and grey matter, while the intensification of these 
 contractions pointed to such over-action of the reflex centres 
 as accompanies descending degeneration in the lateral 
 columns. 
 
 The next point was to search for any evidence of mis- 
 chief beyond the motor tract. This was found in the fact 
 
 * Fifteen months after the accident, the left leg has regained considerable 
 power : the right remains paralysed. The muscle-reflex irritability has 
 increased to spasm. 
 
ILLUSTRATIONS OF DIAGNOSIS. 85 
 
 that sensation to pain in the legs was perverted : the pain 
 of a prick was felt, but in an abnormal manner. Sensation 
 to touch was normal. Thus it was evident that somewhere 
 the sensory tract also was interfered with to a slight 
 degree. The same fact was indicated by a sense of con- 
 striction around the abdomen. The two symptoms pointed 
 to a lesion extending beyond the motor tracts, i.e., to a. 
 focal lesion, and the fact that the sense of constriction was 
 around the lower part of the abdomen made it probable 
 that the lesion was in the lower part of the dorsal region. 
 The cutaneous reflexes of the trunk were then examined. 
 On the left side the epigastric reflex and the abdominal 
 reflex above the umbilicus were very active. Just below 
 the level of the umbilicus the abdominal reflex was much 
 lessened, and midway between the umbilicus and groin 
 could not be obtained. On approaching Poupart's ligament 
 it was again produced, and an impression here caused reflex 
 flexion of the hip. Behind, the left dorsal reflex was 
 active, the lumbar absent. On the right side, however, the 
 abdominal reflex was extremely slight throughout, and the 
 epigastric reflex could not be produced (although so active 
 on the left side), and no lower dorsal or lumbar reflex 
 was obtainable. Thus the reflex phenomena pointed to a 
 very limited lesion on the left side, at the level of origin 
 of the 11th dorsal nerve, while on the right side the more 
 extensive loss indicated more extensive mischief in the 
 right half of the lower dorsal cord, corresponding to the 
 greater weakness of the right leg. This affection of the 
 reflex in the left side corresponded to the position of the 
 constricting band around the lower part of the abdomen. 
 What was the nature of the lesion ? Its onset was very 
 gradual ; the commencement was by a sensation of 
 " numbness," followed, eight months later, by weakness. 
 This extreme slowness pointed to degenerative changes 
 — local " sclerosis." There was no bone disease, no history 
 of syphilis ; but the patient had been much exposed to 
 wet two months before the onset, and we have seen that 
 degenerative changes sometimes result from this cause. 
 
86 THE DIAGNOSIS OF DISEASES OF THE SPINAL COED. 
 
 (4.) A man, aged forty-eight, came under treatment for 
 weakness of the right leg, chiefly marked in the movements 
 of the foot. The corresponding arm was unaffected. Thus 
 there was impairment of the motor conducting tract (lateral 
 column) on the right side, somewhere below the cervical 
 enlargement. Sensation was unimpaired ; the sensory tract, 
 therefore, undamaged. The nutrition of the legs was good ; 
 the plantar reflex ready and equal; the knee-jerk excessive 
 in each leg ; the foot-clonus and front-tap contraction ob- 
 tainable in each. Hence the reflex loops and grey matter of 
 the chief part of the lumbar enlargement were intact ; the 
 excess showed that there was probably lateral sclerosis 
 descending from a lesion above, and that this existed on the 
 left side as well as on the right. The lesion was thus 
 evidently somewhere in the dorsal region of the cord. To 
 learn its seat further, the higher superficial reflexes were 
 examined. The cremaster reflex was distinct on the left side, 
 not to be obtained on the right. The abdominal reflex 
 was normal on the left side, but on the right it could not 
 be obtained except just below the edge of the ribs. The 
 epigastric reflex, excited from the side of the chest, was dis- 
 tinct on each side — as readily excited on the right side as on 
 the left. Hence we had evidence, from the impairment of 
 the reflex loops, that the cord was damaged on the right side, 
 from the 8th dorsal nerve to the 1st lumbar. The excess of 
 the myotatic irritability in the left leg suggests that the mis- 
 chief had implicated slightly the left half of the cord, so as to 
 lead to some descending degeneration, although not to any 
 loss of the cutaneous reflexes. It is possible, however, that 
 the descending degeneration in the left side of the lumbar 
 enlargement, may have been due to the damage of fibres of 
 the direct pyramidal tract on the right side, before their 
 decussation to the left side. 
 
 So much for the anatomical diagnosis. The affection had 
 come on acutely. In nine hours from the first symptom the 
 leg was powerless, and it was five months before it recovered. 
 The " acute " onset points to either a vascular lesion or 
 inflammation. Causal indications were obscure. The man 
 
ILLUSTRATIONS OF DIAGNOSIS. 87 
 
 attributed his symptoms to a severe strain three days before, 
 which he stated also caused " ulcerated bowels." The wide 
 extent of the lesion in the right side of the cord, and its 
 acute but not instantaneous onset, suggests the probability 
 of a myelitis, not severe in degree, although acute in onset, 
 rather than of haemorrhage. 
 
 (5.) A young man, aged twenty-two, presented bimself 
 with weakness, wasting, and deformity of the left forearm. 
 The muscles of the shoulder were normal. The upper arm 
 muscles were rather smaller than those of the right side, bat 
 were of fair size and nutrition. The muscles of the forearm 
 were greatly wasted, except the radial extensor of the wrist ; 
 the muscles of the thumb and little finger were much wasted, 
 the interossei only slightly. The wasted muscles had lost 
 faradaic and voltaic irritability, the condition being of long 
 standing, and the muscular fibres probably totally degenerated. 
 Sensation was perfect. The leg was not quite so strong as 
 the other ; nutrition normal ; the myotatic irritability ex- 
 cessive in each leg ; knee-jerk increased, and foot-clonus 
 and front-tap contraction obtainable. Thus we had evidence, 
 from the muscular wasting, of a limited lesion in the left 
 anterior cornu in the lower part of the cervical enlargement ; 
 from the impaired power in the leg, of slight damage to the 
 motor tract for the leg ; and from the excess of the myotatic 
 contractions, of degeneration in the pyramidal tracts de- 
 scending from above. 
 
 Wbat was the nature of the lesion ? Its onset was sudden, 
 nine years before. One morning he suddenly felt a pain in 
 the back of his neck, then be found his arms and legs be- 
 coming weak, and this increased so rapidly, that in half an 
 hour or so he was unable to move any limb, but there was 
 no noticeable loss of sensation. Thus he lay for three weeks, 
 and then the right arm began to regain power, next the right 
 leg, and then the left leg, so that in two months he could walk. 
 The wasting in the muscles of the left arm was very rapid. 
 There was no causal indication. Thus there was a lesion of 
 sudden onset, and therefore primarily vascular — thrombosis 
 
OO THE DIAGNOSIS OF DISEASES OE THE SPINAL CORD. 
 
 or haemorrhage — at first affecting a wide transverse area of 
 the cord, and impairing all its functions at the spot, ex- 
 cept conduction of sensation. The part slightly damaged 
 soon recovered, but there remained an area of considerable 
 damage in the left anterior cornu, and of slighter damage in 
 the adjacent conducting tract to the leg. The focus of disease 
 was no doubt the seat of the primary lesion ; probably a local 
 extravasation interfering with the opposite side of the cord 
 by pressure. 
 
 (6.) The following case is somewhat complex in its indi- 
 cations, but is instructive as affording an illustration of the 
 diagnosis of chronic meningitis. For an opportunity of seeing 
 the patient, I am indebted to Dr. Russell, of Birmingham. 
 
 A man, aged forty-seven, complained of weakness of the 
 legs, which was found, on examination, to be of irregular dis- 
 tribution. In both legs the muscles moving the hip- joint 
 possessed good power. The flexors and extensors of the knee- 
 joint were strong in the right, but very weak in the left leg. 
 The flexors of the ankle in the left leg were rather weak, in 
 the right were powerless ; the extensors of the ankle were 
 weak in both legs, but much weaker in the right than in the 
 left. The muscles were wasted, and had lost faraclaic irrita- 
 bility in proportion to their weakness, the voltaic irritability 
 being preserved. The wasting was greatest in the extensors 
 of the left knee, and flexors of the right ankle. In the latter 
 faradaic irritability was gone. Sensation was noimal, except 
 in an area in the front of the left leg, where it was absolutely 
 lost to both touch and pain. Plantar reflex normal ; no 
 foot-clonus; knee-jerk slight in the right leg, absent in 
 the left. 
 
 The affection of nutrition and electrical irritability indi- 
 cated disease in the anterior cornua, or in the motor nerves 
 springing from them. By this the impairment of the knee- 
 jerk was also explained. The weakness was in proportion 
 to the wasting ; hence there was no reason to infer other 
 disease than that interfering with nutrition. The diagnosis 
 thus lay between a primary cornual disease, and damage 
 
ILLUSTRATIONS OF DIAGNOSIS. 8!) 
 
 to the nerve-roots by meningeal changes. The patch of 
 anaesthesia in the left leg was in favour of the latter. It 
 is rare that anterior cornual disease impairs sensation. 
 
 The mode of onset was then investigated to ascertain what 
 light the order of the symptoms would throw on the seat, and 
 their rapidity of development on the nature of the disease. 
 The first symptoms commenced nine months before, and 
 were sensory ; soreness in the left leg, followed by shooting 
 pains, sometimes in the big toe, sometimes in the calf, but 
 confined to the left leg ; these lasted for two months, and 
 during that time the leg gradually got weak. After this 
 similar pains were felt in the right leg, and this also 
 became weak. 
 
 Pains of this darting character are usually due to irri- 
 tation of the sensory nerve-roots ; they are similar to those 
 met with in locomotor ataxy, and are almost unknown in 
 affections of the anterior cornua. These pains, in con- 
 junction with the patch of anaesthesia, rendered it highly 
 probable that the mischief was outside the cord in the 
 meninges — chronic meningitis with thickening, the nerve- 
 roots being irregularly damaged by irritation and com- 
 pression. Hence a careful search was made to ascertain 
 if there were any trunk symptoms, throwing light on the 
 disease. Inquiry elicited a history of shooting pains on the 
 right side of the trunk, at the level of the epigastrium, 
 with a unilateral sense of constriction. Some local hyper- 
 esthesia was found, but no anaesthesia. This also pointed 
 to local irritation of the posterior nerve-roots, higher up 
 — to irregular meningeal irritation. 
 
 The causal influences were then ascertained. No imme- 
 diate cause could be ascribed except general bad health. 
 Chronic meningitis is most frequently due to bone disease 
 or syphilis. There was no evidence of bone disease, but 
 the patient had had a chancre twenty years before. 
 
 Thus the motor symptoms indicated either cornual or 
 meningeal disease ; the sensory symptoms pointed strongly 
 to the latter, and the causal conditions, as far as they 
 went, harmonized with the view. (The patient had had 
 
90 THE DIAGNOSIS OF DISEASES OF THE SPINAL CORD. 
 
 some sugar in the urine, which, except for rendering the 
 prognosis worse, had little apparent hearing on the case.) 
 He had taken iodide for a time, but without improve- 
 ment. This did not, however, militate against the diag- 
 nosis for the following reason : — The meningeal change, 
 though probably syphilitic, had caused damage to the nerves, 
 which, descending as degeneration, had led to secondary 
 changes in the muscles. The removal of the syphilitic 
 change in the membranes would not at once restore the 
 nerves. Their regeneration, if still possible, would be, of 
 necessity, a work of time, perhaps of more time than 
 had yet been allowed. Hence the patient was urged to 
 persevere with the iodide, and mercury was added to 
 it, and he was advised to continue the use of a voltaic 
 battery to the muscles. A month later there was slight 
 but distinct increase of power in the left thigh. I did 
 not see him again, but a year later he was seen, inci- 
 dentally, by Dr. Russell, who has been good enough to 
 inform me that the man then said he was, and appeared 
 to be, perfectly well. The result thus affords a strong con- 
 firmation of the diagnosis. 
 
DESCRIPTION OF PLATE. 
 
 The figures represent some of the more important lesions of the 
 spinal cord. Although semi-diagrammatic, they have, with one excep- 
 tion, been drawn, with care, from actual sections. The exception is 
 Fig. 2, which is after Charcot. It may be well to state, for the 
 information of those unfamiliar with the process of microscopical 
 examination of the nerve-centres, that when a section of the spinal 
 cord is stained with carmine, the tint assumed by the different parts 
 varies, and conveys important information. The grey substance 
 stains much more deeply than the white, and the nerve-cells more 
 deeply than the inter-cellular grey substance. Hence the grey matter 
 appears like an H -shaped rose-coloured area, in which the nerve-cells 
 appear of a much deeper red. The white substance of the nerve- 
 fibres does not stain, and although the axis-cylinders stain, they are 
 not sufficient in bulk to give much colour to the white columns. 
 Connective tissue, however, stains very deeply, and the edge of the 
 section (pia mater) is thus deep red, and so are the trabecule of connec- 
 tive tissue which extend into the white substance. Since the process of 
 sclerosis consists in an atrophy of the nerve-fibres, and an increase in 
 the connective tissue, areas so affected stain deeply in proportion to 
 the intensity of the change, and its existence and degree may thus be 
 rendered conspicuous even to the naked eye. The relative tint of the 
 figures is nearly that of the sections from which they were drawn, all 
 of which were stained with carmine. The letters indicating corre- 
 sponding parts are the same in all the figures. 
 
 Fig. 1. Descending Degeneration, unilateral. — Section of spinal cord, 
 cervical region, from a case of left hemiplegia due to disease of the 
 right cerebral hemisphere. The two pyramidal tracts are degenerated, 
 viz., the small "anterior pyramidal tract" (a), close to the anterior 
 median fissure, on the right side of the cord; and the "lateral 
 pyramidal tract" (b) in the opposite lateral column. This degenerated 
 tract is seen not to extend up to the surface, being bounded by the 
 so-called "cerebellar tract." (See p. 10.) 
 
 Fig. 2. Descending Degeneration, bilateral. — Section of spinal cord, 
 dorsal region, below a point damaged by compression. Both, lateral 
 pyramidal tracts (bb) are degenerated. There is no degeneration 
 in the anterior pyramidal tracts, which had probably ceased (by 
 decussation) above the level of the section, or may have been absent. 
 
 Fig. 3. Ascending Degeneration. — Section of spinal cord in dorsal 
 region, from a case in which the lower extremitv of the cord was crushed 
 
92 DESCRIPTION OF PLATE. 
 
 by a fracture of the spine. The postero-median columns (c) are densely 
 sclerosed. The postero-external columns (d) are quite free from 
 sclerosis. The pyramidal tracts in the lateral columns are seen to he 
 also free from disease (compare Figs. 2 and 3), hut just in front of 
 each is a symmetrical area of slight degeneration (e). (See p. 12.) 
 
 Fig. 4. Posterior Sclerosis, Locomotor Ataxy. — Section at the level 
 of the first lumbar nerves. The posterior columns are densely sclerosed 
 throughout their entire extent. The remaining white columns and 
 anterior cornua are healthy. 
 
 Fig. 5. Sclerosis of Postero-external Column (posterior root-zone), 
 Locomotor Ataxy (from a section prepared by Prof. Pierret, of Lyons). — ■ 
 A dense band of sclerosis occupies the postero-external column (d), 
 through which the posterior nerve-roots pass. The postero-median 
 columns (c) are free from sclerosis. The bands of sclerosis are narrow, 
 probably from the contraction of the tissue, since, from the position 
 of the limiting septum, they appear to occupy the entire width of this 
 column. The patient suffered from well-marked locomotor ataxy. 
 
 Fig. 6. Syphilitic Growth in Posterior Column. — Section through the 
 spinal cord, cervical region, of a man who died from syphilitic disease 
 of the brain. A growth (/) occupies the right postero-external 
 column, and has enlarged it to three times the normal size, displacing 
 the posterior median septum to the left. The growth has invaded the 
 right posterior cornu, and extended a little way beyond it into the 
 lateral column. It caused inco-ordination, and partial loss of sensi- 
 bility, in the right arm. 
 
 Fig. 7. Anterior Cornual Degeneration.- — Section of spinal cord, 
 cervical region, from a patient suffering from progressive muscular 
 atrophy. The grey substance of the anterior cornua is degenerated 
 and irregularly translucent, the nerve-cells having disappeared (compare 
 also Figs. 9 and 10). The lateral columns (pyramidal tracts) are also 
 sclerosed. The posterior columns are healthy. 
 
 Fig. 8. Anterior Cornual Myelitis {Infantile Paralysis). — Section of 
 spinal cord, lumbar enlargement, from a case of old infantile paralysis 
 of the left leg. The whole left half of the cord is smaller than 
 the right. The left anterior cornu is shrunken, and presents evidence 
 of previous inflammation. The tissue is degenerated and translucent, 
 containing large vessels. All the motor nerve-cells, so conspicuous 
 on the other side, have disappeared. 
 
 Fig. 9. — Normal anterior cornu, cervical region, showing numerous 
 multipolar nerve-cells. 
 
 Fig. 10. — Anterior cornu, same position, from a case of progressive 
 muscular atrophy. All the nerve-cells have disappeared ; minute 
 shrunken corpuscles here and there are probably their remains. The 
 grey matrix, instead of being uniform, is irregular, translucent at some 
 spots, unduly dense, from sclerosis, at others, especially near the edge of 
 the cornu. 
 
 Pardon & Sons, Printers, Paternoster Bow, London. 
 
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 October, 1883 
 
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12 
 
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INDEX. 
 
 Acton's Reproductive Organs, 14 
 Adams (W.) on Clubfoot, n 
 
 Contraction of the Fingers, 11 
 
 Curvature of the Spine, 11 
 
 Allan on Fever Nursing, 7 
 
 Allingham on Diseases of the Rectum, 13 
 
 Anatomical Remembrancer, 4 
 
 Anderson (McC.) on Eczema, 13 
 
 Aveling on the Chamberlens and Midwifery Forceps, 6 
 
 on the Influence of Posture on Women, 6 
 
 Balfour's Diseases of the Heart and Aorta, 9 
 Balkwill's Mechanical Dentistry, 13 
 
 Barnes on Obstetric Operations, 5 
 
 on Diseases of Women, 5 
 
 Beale's Microscope in Medicine, 8 
 
 Slight Ailments, 8 
 
 Bellamy's Surgical Anatomy, 3 
 
 Bennet (J. H.) on the Mediterranean, 10 
 
 on Pulmonary Consumption, 10 
 
 . on Nutrition, 10 
 
 Bentley and Trimen's Medicinal Plants, 7 
 Bentley's Manual of Botany, 7 
 
 Students' Guide to Botany, 7 
 
 Bigg (H. H.) on Orthopraxy, n 
 
 Bigg (R. H.) on the Orthopragms of Spine, n 
 Binz's Elements of Therapeutics, 7 
 Black on the Urinary Organs, 14 
 Braune's Topographical Anatomy, 3 
 Brodhurst's Anchylosis, 11 
 
 Curvatures, &c, of the Spine, n 
 
 Orthopaedic Surgery, 11 
 
 Bryant's Practice of Surgery, 11 
 
 Bucknill and Tuke's Psychological Medicine, 5 
 
 Bulkley on Diseases of the Skin, 13 
 
 on Eczema, 13 
 
 Burdett's Cottage Hospitals, 5 
 
 Pay Hospitals, 5 
 
 Burnett on the Ear, 12 
 
 Burton's Midwifery for Midwives, 5 
 
 Butlin's Sarcoma and Carcinoma, 13 
 
 Buzzard's Diseases of the Nervous System, 9 
 
 Carpenter's Human Physiology, 4 
 
 Carter (H. V.) on Spirillum Fever, 8 
 
 Carter (W.) on Renal and Urinary Diseases, 14 
 
 Cayley's Typhoid Fever, 9 
 
 Charteris' Practice of Medicine, 8. 
 
 Clark's Outlines of Surgery, 10 
 
 Clay's (C.) Obstetric Surgery, 6 
 
 Cobbold on Parasites, 14 
 
 Coles' Dental Mechanics, 13 
 
 —Deformities of the Mouth, 13 
 
 Cormack's Clinical Studies, 8 
 Coulson on Diseases of the Bladder, 14 
 
 on Stone in the Bladder, 14 
 
 on Syphilis, 14 
 
 Courty's Diseases of the Uterus, Ovaries, &c, 5 
 Cripps' Cancer of the Rectum, 14 
 Cullingworth's Manual of Nursing, 7 
 Curling's Diseases of the Testis, 13 
 Daguenet's Manual of Ophthalmoscopy, 12 
 Dalby's Diseases and Injuries of the Ear, 12 
 Dalton's Human Physiology, 4 
 Day on Diseases of Children, 6 
 
 on Headaches, 10 
 
 De Chaumont's Sanitary Assurance, 4 
 Dobell's Lectures on Winter Cough, 8 
 
 Loss of Weight, &c, 8 
 
 Mont Dore Cure, 8 
 
 Domville's Manual for Nurses, 6 
 Druitt's Surgeon's Vade-Mecum, n 
 Duncan on the Female Perineum, 5 
 
 on Diseases of Women, 5 
 
 Dunglison's Medical Dictionary, 14 
 Eade on Diphtheria, 12 
 
 Ellis's Manual for Mothers, 6 
 
 ■ — — — of the Diseases of Children, 6 
 
 Emmet's Gynaecology, 5 
 
 Fayrer's Climate and Fevers of India, 7 
 
 Observations in India, 7 
 
 Tropical Dysentery and Diarrhoea, 7 
 
 Fenwick's Chronic Atrophy of the Stomach, 8 
 
 Medical Diagnosis, 8 
 
 Outlines of Medical Treatment, 8 
 
 Fergusson's Practical Surgery, 10 
 Flint on Clinical Medicine, 8 
 
 on Phthisis, 8 
 
 Flower's Diagrams of the Nerves, 4 
 
 Foster's Clinical Medicine, 8 
 
 Fox's (C. B.) Examinations of Water, Air, and Food, 4 
 
 Fox's (G. H.) Photographs of Cutaneous Syphilis, 14 
 
 ■ Skin Diseases, 13 
 
 Fox's (T.) Atlas of Skin Diseases, 13 
 
 Frey's Histology and Histo-Chemistry, 4 
 
 Fulton's Text-Book of Physiology, 4 
 
 Galabin's Diseases of Women, 6 
 
 Gamgee's Treatment of Wounds and Fractures, 1 1 
 
 Gaskoin on Psoriasis or Lepra, 13 
 
 Gay on Hajmorrhoidal Disorder, 13 
 
 Gill on Indigestion, 10 
 
 Glenn's Laws affecting Medical Men, 14 
 
 Godlee's Atlas of Human Anatomy, 3 
 
 Gowers' Diseases of the Spinal Cord, 9 
 
 Epilepsy, 9 
 
 Medical Ophthalmoscopy, 9 
 
 ; — Pseudo-Hypertrophic Muscular Paralysis, 9 
 
 Granville on Nerve Vibration and Excitation, 9 
 Habershon's Diseases of the Abdomen, 9 
 
 — Stomach, g 
 
 Pneumogastric Nerve, 9 
 
 Hamilton's Nervous Diseases, 9 
 
 Hardwicke's Medical Education, 14 
 
 Harley on Diseases of the Liver, 9 
 
 Harris on Lithotomy, 14 
 
 Harrison's Surgical Disorders of the Urinary Organs, 1 
 
 Lithotomy, Lithotrity, &c, 14 
 
 Prevention of Stricture, 14 
 
 Heath's Minor Surgery and Bandaging, 10 
 
 Operative Surgery, 10 
 
 Practical Anatomy, 3 
 
 Surgical Diagnosis, 10 
 
 Higgens' Ophthalmic Out-patient Practice, n 
 Hillis' Leprosy in British Guiana, 13 
 Hogg's Indian Notes, 7 
 Holden's Dissections, 3 
 
 Human Osteology, 3 
 
 — — Landmarks, 3 
 
 Holmes' (G.) Guide to Use of Laryngoscope, 12 
 
 Vocal Physiology and Hygiene, 12 
 
 Hood on Gout, Rheumatism, &c. , 9 
 Hooper's Physicians' Vade-Mecum, 8 
 Horton's Tropical Diseases, 8 
 Hutchinson's Clinical Surgery, n 
 
 Rare Diseases of the Skin, 13 
 
 Huth's Marriage of Near Kin, 4 
 
 Hyde's Diseases of the Skin, 13 
 
 Ireland's Idiocy and Imbecility, 5 
 
 Irvine's Relapse of Typhoid Fever, 9 
 
 James (P.) on Sore Throat, 12 
 
 Jones' (C. H.) Functional Nervous Disorders, 9 
 
 Jones (C. H.)and Sieveking's Pathological Anatomy, 4 
 
 Jones' (H. McN.) Aural Surgery, 12 
 
 ■ Atlas of Diseases of Membrana Tympani, 72 
 
 Jones' (T. W.) Ophthalmic Medicine and Surgery, 12 
 
 Jordan's Surgical Enquiries, n 
 
 Lancereaux's Atlas of Pathological Anatomy, 4 
 
 Lane's Lectures on Syphilis, 14 
 
 Lee (H.) on Syphilis, 14 
 
 Leared on Imperfect Digestion, 9 
 
 Lewis (Bevan) on the Human Brain, 4 
 
 Liebreich's Atlas of Ophthalmoscopy, 1 1 
 
 Liveing's Megrim, Sick Headache, &c. , 10 
 
 Lucas's Indian Hygiene, 7 
 
 Macdonald's (A.) Chronic Disease of the Heart, 6 
 
 Macdonald's (J. D.) Examination of Water and Air, 4 
 
 Macewen's Osteotomy: Knock-knee, Bow-leg, &c, n 
 
 Mackenzie on Diphtheria, 12 
 
 on Diseases of the Throat and Nose, 12 
 
 Maclise's Dislocations and Fractures, n 
 
 Surgical Anatomy, 3 
 
 MacMunn's Spectroscope in Medicine, 8 
 Macnab's Medical Account Books, 14 
 Macnamara's Diseases of Bones and Joints, n 
 
 Diseases of the Eye, 12 
 
 Madden's Principal Health-Resorts, 10 
 Marcet's Southern and Swiss Health- Resorts, 10 
 Marsden's Certain Forms of Cancer, 13 
 Martin's Military and State Medicine, 5 
 Mason on Hare-Lip and Cleft Palate, 12 
 
 on Surgery of the Face, 12 
 
 Mayne's Medical Vocabulary, 14 
 
 Notes oh Poisons, 7 
 
 Therapeutical Remembrancer, 7 
 
 Mitchell (R.) on Cancer Life, 13 
 
 Mitchell's (S. Weir) Nervous System in Women, 6 
 \C0uti7i1ted on the next pa°e. 
 
Moore's Family Medicine for India, 7 
 
 Health- Resorts for Tropical Invalids, 7 
 
 Morris' (H. ) Anatomy of the Joints, 3 
 
 Mouat and Snell on Hospitals, 5 
 
 Nettleship's Diseases of the Eye, 12 
 
 Nunn's Cancer of the Breast, 13 
 
 Ogston's Medical Jurisprudence, 4 
 
 Oppert's Hospitals, Infirmaries, Dispensaries, &c, 5 
 
 Osborn on Diseases of the Testis, 13 
 
 on Hydrocele, 13 
 
 Owen's Materia Medica, 7 
 Page's Injuries of the Spine, 11 
 Parkes' Practical Hygiene, 5 
 Pavy on Diabetes, 10 
 
 on Food and Dietetics, 10 
 
 Peacock's Diseases of the Heart, g 
 
 Pharmacopoeia of the London Hospital, 7 
 
 Phillips' Materia Medica and Therapeutics, 7 
 
 Pirrie's Principles and Practice of Surgery, 11 
 
 Pollock on Rheumatism, 9 
 
 Pridham on Asthma, 8 
 
 Purcell on Cancer, 13 
 
 Radford's Caesarean Section, 5 
 
 Ralfe's Morbid Conditions of the Urine, 14 
 
 Ramsbotham's Obstetrics, 6 
 
 Reynolds' (J. J.) Diseases of Women, 6 
 
 Notes on Midwifery, 6 
 
 Reynolds' (J. R.) Clinical Electricity, 10 
 Roberts' (C.) Manual of Anthropometry, 5 
 Roberts' (D. Lloyd) Practice of Midwifery, 5 
 Ross's Diseases of the Nervous System, 9 
 Roth on Dress : Its Sanitary Aspect, 4 
 Roussel's Transfusion of Blood, 8 
 Routh's Infant Feeding, 6 
 Royle and Harley's Materia Medica, 7 
 Sanderson's Physiological Handbook 
 Sansom's Diseases of the Heart, 9 
 
 Antiseptic System, 9 
 
 Savage on the Female Pelvic Organs, 6 
 Sayre's Orthopaedic Surgery, 11 
 Schroeder's Manual of Midwifery, 6 
 Sewill's Dental Anatomy, 12 
 Sheppard on Madness, 5 
 
 Sibson's Medical Anatomy, 3 
 Sieveking's Life Assurance, 14 
 Smith's (E.) Clinical Studies, 6 
 
 Wasting Diseases of Children, 6 
 
 Smith's (Henry) Surgery of the Rectum, 14 
 Smith's (Heywood) Dysmenorrhea, 6 
 
 Gynaecology, 6 
 
 Smith (Priestley) on Glaucoma, 12 
 
 Snell's Electro-Magnet in Ophthalmic Surgery, 12 
 
 Southam's Regional Surgery, 10 
 
 Sparks on the R'viera, 10 
 
 Squire's Companion to the Pharmacopoeia, 7 
 
 continued. 
 
 Squire's Pharmacopoeias of London Hospitals, 7 
 
 Starkweather on the Law of Sex, 4 
 
 Stille and Maisch's National Dispensatory, 7 
 
 Stimson on Fractures, n 
 
 Stocken's Dental Materia Medica and Therapeutics, 12 
 
 Sullivan's Tropical Diseases, 7 
 
 Swain's Surgical Emergencies, 10 
 
 Swayne's Obstetric Aphorisms, 6 
 
 Taft's Operative Dentistry, 12 
 
 Taylor's Medical Jurisprudence, 4 
 
 Poisons in relation to Medical Jurisprudence, 4 
 
 Teale's Dangers to Health, 5 
 Thompson's (SirH.) Calculous Disease, 13 
 
 Diseases of the Prostate, 13 
 
 Diseases of the Urinary Organs, 13 
 
 Lithotomy and Li thotrity, 13 
 
 Thompson's (Dr. H.) Clinical Lectures, 8 
 Thorowgood on Asthma, 8 
 
 on Materia Medica and Therapeutics, 7 
 
 Thudichum's Pathology of the Urine, 14 
 Tibbits' Medical and Surgical Electricity, 10 
 
 — ; Map of Motor Points, 10 
 
 Tidy and Woodman's Forensic Medicine, 4 
 Tilt's Change of Life, 6 
 
 Uterine Therapeutics, 6 
 
 Tomes' (C. S.) Dental Anatomy, 12 
 Tomes' (J. & C. S.) Dental Surgery, 12 
 Van Buren on the Genito-Urinary Organs, 14 
 Vintras on the Mineral Waters, &c, of France, 10 
 Virchow's Post-mortem Examinations, 4 
 Wagstaffe's Human Osteology, 3 
 
 Walker's Ophthalmology, 12 
 Waring's Indian Bazaar Medicines, 7 
 
 Practical Therapeutics, 7 
 
 Warner's Guide to Medical Case-Taking, 8 
 Waters' (A. T. H.) Diseases of the Chest, 8 
 Waters (J. H.) on Fits, 9 
 
 Wells (Spencer) on Ovarian and Uterine Tumours, 6 
 West and Duncan's Diseases of Women, 5 
 West (S.) How to Examine the Chest, 8 
 Whistler's Syphilis of the Larynx, 12 
 Whitehead's (J L.) Climate of the Undercliff, 10 
 Whittaker's Primer on the Urine, 14 
 Wilks' Diseases of the Nervous System, 9 
 Wilks and Moxon's Pathological Anatomy, 4 
 Wilson's (Sir E.) Anatomists' Vade-Mecum, 3 
 
 Lectures on Dermatology, 13 
 
 Wilson's (G.) Handbook of Hygiene, 5 
 
 Healthy Life and Dwellings, 5 
 
 Wilson's (W. S.) Ocean as a Health-Resort, 10 
 Wise's Davos Platz, 10 
 
 Wolfe's Diseases and Injuries of the Eye, 11 
 Yeo's Contagiousness of Pulmonary Consumption, 8 
 Zander Institute Mechanical Exercises, 10 
 
 The following Catalogues issued by J. & A. Churchill will be forwarded 
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 A. J. & A. Churchill's General List of about 650 works on Anatomy, 
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 N.B.—This List includes B, C, & D. 
 
 B. Selection from J. & A. Churchill's General List, comprising all recent 
 Works published by them on the Art and Science of Medicine. 
 
 C. J. & A. Churchill's Catalogue of Text Books specially arranged for Students. 
 
 D. A selected and descriptive List of J. & A. ChurchiWs Works on 
 Chetnistry, Materia Medica, Pharinacy, Botany, Photography, Zoology, the 
 Microscope, and other branches of Science. 
 
 E. The Half-yearly List of New Works and New Editions published by 
 J. & A. Churchill during the previous six months, together with Particulars of 
 the Periodicals issued from their House. 
 
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