COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00062898 ilii Columbia WLnibtv&ittfyi mtfjeCitpof Jletogorfe COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by / SYRINGOMYELIA AN ESSAY TO WHICH WAS AWARDED THE ALK4RENGA PRIZE OF THE COLLEGE OF PHYSICIANS OF PHILA- DELPHIA FOR THE YEAR 1895 BY GUY HINSDALE, A.M., M.D. fellow of the college of physicians of philadelphia and of the american academy of medicine; member of the American neurological association and of the Philadelphia neurological society ; member of the american climatoi.ogical association j honorary member of the pueblo county medical society of colorado j assistant physician to the orthopedic hospital and infirmary for nervous diseases ; attending physician to the pres- byterian orphanage and to the out-patient department op the pkesbytekian hospital in philadelphia, etc. PHILADELPHIA THE INTERNATIONAL MEDICAL MAGAZINE COMPANY 1897 f Copyright, 1897, BY The International Medical Magazine Co.\ TO DR. S. WEIR MITCHELL, AS A SLIGHT TRIBUTE OF RESPECT AND AS A RECOGNITION OF MANY SERVICES RENDERED TO THOSE WHO HAVE BEEN ASSOCIATED WITH HIM IN PUBLIC AND PRIVATE PRACTICE. PREFACE. The author would call attention to the extraordinary amount of litera- ture which has appeared during the last few years with reference to syringo- myelia. We place in evidence a bibliography the most complete that has thus far been collected, amounting to five hundred and fourteen references. Of these, two hundred and thirty have been reported from Germany and Austria, France has furnished one hundred and sixty-six, while eighty-five have appeared in English. We have gone to the original sources and have analyzed one hundred and eighteen cases which have been published since 1890. The essay is based on a study of these and of the two unpublished cases which we have added to the list, and particularly the publications of Bruhl and Guinon, of Paris, Hoffmann, of Heidelberg, and Schlesinger, of Vienna. The essay was originally printed in the November and Decem- ber, 189G, and January, 1897, numbers of the INTERNATIONAL Medical Magazine. [The synopsis of published cases which accompanied the essay as presented is not included in this publication.] Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/syringomyeliaOOhins TABLE OF CONTENTS. Preface v History and definition 3 Ili-tology and pathology 8 Symptomatology 17 Etiology 45 Forms of syringomyelia 47 Association with other diseases 50 Diagnosis 54 Course of the disease and prognosis . 57 Treatment 57 Two unpublished cases 57 Bibliography CO [ndex 73 SYRINGOMYELIA. THE ALVARENGA PRIZE ESSAY OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA FOR THE YEAR 1895. It is over one hundred and fifty years since Morgagni and Santorini observed and recorded the existence of an abnormal cavity in the spinal cord. Portal in the year 1800, and Rachetti in 1816, also noted this strange phenomenon, which had from time to time excited the curiosity of anatomists of the seventeenth and eighteenth centuries. The pathological condition passed without a distinctive name until, in 1837, Ollivier, of Angers, called the affection "syringomyelia," by which it has since been generally desig- nated. The word itself is from the Greek ffupiyyuat, " to become hollow,"' and [ioeXds, " marrow," a combination which clearly expresses the macro- scopic appearance when section is made of a typical specimen. The next step was the discovery in 1859, by Stilling, that the spinal cord is normally provided with a central canal which is constant throughout life. Yirchow and Leyden then looked upon all cavities in the cord as expansions of the normal central canal, and termed the condition " hydroniyelia." Ollivier is said to have attributed to the affection very little pathological significance, and certainly did not connect the condition with any clinical symptoms; thus all writers down to within twenty years or even less gave very little value to the condition other than as being merely a pathological curiosity and of little importance. It transpired, however, that in cases where these cavities were found at an autopsy the clinical histories bore a strong resem- 3 4 GUY HINSDALE, M.D. blance in some respects. Disorders of sensation had been observed ; burns and wounds received during later years had been sustained without pain; certain muscles had wasted and there had been the symptoms of muscular weakness to such an extent as to interfere with the customary avocations. It thus became evident that the cavity and the surrounding histologic change were accountable for a train of clinical symptoms which had not been heretofore attributed to a definite locality in the central nervous system. The first differentiation of these cases was made when a pathological condition, evidently congenital, was distinguished from a cavity acquired in later life as the result of accidental causes or the growth of new formations in the spinal cord. For the congenital affection it has been found conven- ient to retain the name hydromyelia; but for the cavities secondarily pro- duced, even though they may be considered as remotely due to a develop- mental defect dating as far back as intra-uterine existence, it has generally been the custom to use the term syringomyelia, as originally proposed. Fig. 1. Hydromyelia from a child two years old, with encephalocele and absence of cerebellum. (From Gowers, after Leyden.) In A, cervical region, the central canal is large, lined with epithelium, and from it a median Assure extends backward nearly to the periphery of the cord, limited by a layer of homogeneous tissue, more abundant at the posterior limit. In B, lower down, the fissure is enlarged to a cavity of considerable size, while in C it is still larger, and the posterior columns are reduced to a narrow zone between the layer of tissue which bounds the cavity and the gray substance. The definition which we adopt, and to which every author will doubtless assent, is that syringomyelia is a chronic affection of the spinal cord charac- terized anatomically by the pathological formation of cavities in its sub- stance, and clinically by peculiar disturbances of sensibility associated with trophic disorders. The seat of the primary lesion may extend as high as the medulla or as far downward as the lumbar region ; the seat of the secondary changes is peripheral, involving the muscles, the bones, the cellular tissue, the skin, etc. Two other terms have been proposed, but they have not been accepted by the profession. One is " myelite cavitaire," of Joffroy and Achard, which indicates the secondary nature of the cavity, but it is objectionable on account of the term myelitis, which, in the usual acceptation of the term, misrepresents the primary pathological condition. The other name, proposed by Sachs and Armstrong, is myelosyringosis. The term is no doubt a correct one for the condition, but it is not so euphonious as syringomyelia, and will probably never come into use. It was a distinct step in advance when it was recognized by Hallopeau, in 1869, that it was not so much the cavity per se that was the main element SYRINGOMYELIA. in the pathological condition, but rather that the cellular changes which take place in the cord constitute the primary lesion, and that the dilatation of the cavity is only secondary. Hallopeau's explanation was that a myelitis occurred with sclerosis of the periependymal tissue; as the latter gave way the central canal was thus secondarily excavated into a large cavity. This statement seemed beyond criticism until further studies revealed cavities in the cord independent of the central canal and not even communi- cating with it. Simon, of Paris, contributed much to the elucidation of the subject, which had now become greatly confused owing to the successive change of views. His studies, which were published in 1875, called attention to the coexistence of the cavity with vascular tumors, to which he gave the name of "gliomes telangiectasiques," and rightly claimed that the cavity resulted from softening of the glioma and absorption of the degenerated structure. In Simon's opinion, which is now generally adopted, hvdromyelia was reserved for " la dilatation et Vhydropisie du canal d'ependyme, affection en tout comparable a I'hydrociphalie" and to use the word syringomyelia to designate " les cavites et productions hystiques que Von pent rencontrer dans la moelle independamment du canal central" Much more attention has been directed in later years to the study of the symptomatology of syringomyelia. The train of clinical symptoms and their explanation by post-mortem studies furnish one of the most beautiful subjects for the student of clinical medicine and pathology. The statement that a diagnosis can only be made at the autopsy has been rele- gated to historv. The rigorous efforts of Morvan to establish an identity for the disease, which he described as "panaris analgesique" or " paresie analgesique a panaris des extremites super ieures" have likewise been un- successful, for the best observers are now nearly united in classifying this affection as one of the forms or types of syringomyelia and not a disease sui generis. V\<;. 2. Transverse section "f achici -Ik. win- medullary canal (T. C.) beginning u> (Prom Kolliker.) The various forms of this interesting disease, which is already the sub- ject of a vast amount of literature, 1 will be considered more particularly in succeeding chapters. Histology and Pathology. — In the development of the spinal cord of the embryo the germinal space or area in its very earliest stage takes on an 1 In the bibliography prepared by the author there are 500 references. 6 GUY HINSDALE, M.D. elongated form, a central longitudinal line called the primitive groove. The sides of this primitive furrow are composed of two longitudinal ridges of the external layer or fold (epiblast) of the blastoderm. These close in so as to form a canal constituting the fundamental cen- tral canal of the cord, the fourth ventricle (which is only partially en- closed), arid the ventricles of the brain. The walls of this canal are thinner in front and behind than at the sides, and the epithelium of the central canal is derived from the same external layer (epiblast) of the blastoderm, the nerve elements themselves being derived from the middle layer, the mesoblast, subjacent to this epithelium. The central canal is at first closed behind by only a thin layer of cells which meet across the middle line, the remnant of this fissure forming the posterior median fissure, the closure occurring from behind forward as the median parts of the posterior columns develop. The nature of the cellular constituents of the cord must be also under- stood in an explanation of the pathological changes. All the parts consist first of embryonal cells, or plasmatic cells as they are sometimes called, — embryonic cells, because they are the same in the adult as they were in the embryonic stage. Such cells easily undergo transformation, however, decaying, perhaps, or furnishing new forms that become pathological. As the embryo develops, some of the embryonal cells are transformed into the nerve-elements, the cells of the gray matter taking shape before the fibres of the white columns. Others persist, forming the neuroglia and the gelatinous gray substance continuous with it around the cord, at the posterior root fissure and around the central canal (Gowers). Fig. 3. Representing the posterior end of the spinal canal open. The anterior and lateral columns have been formed. The posterior columns en- croach on the canal. Fig. 4. Development of the cord com- plete by the growth of the posterior median column. The spinal canal is closed. It is therefore to be noted that the cells surrounding the central canal and extending to the posterior root fissure are the very cells most prone to undergo transformation. The central canal is finally located in the anterior part or middle of the gray commissure. It is barely discernible to the naked eye either as a slit extending laterally or antero-posteriorly, or circu- lar in section, or may, in exceptional cases, be normally closed by the epithelium which usually lines its wall. The development of the cord may stop at several stages short of comple- SYRINGOMYELIA. 7 tion. The central canal may remain abnormally large in proportion as the junction of the dorsal portion of the cord occurs at any position between the normal one and the hindmost limit of the posterior fissure. The boundaries of the canal may be symmetrical or, if the junction has taken place unevenly, a portion of the original posterior fissure, or an offset from it, may be thrown sideways into either the right or left posterior column, decentring the cavity and giving it an asymmetrical outline. Fig. 5. Syringomyelia. Case ol E. Asmus. < larity extends from the third cervical to the tenth dorsal segment. TIm' right posterior horn chiefly affected. The anterior horns intact. Specific history. It has been suggested also that in some cases the cord may be normally developed as far as external appearance goes, but may contain an undue amount of embryonic neuroglia, in which a hemorrhage or liquefactive de- generation may easily be determined by degrees of violence which would be insufficient to affect a normal cord. It can therefore readily be understood that in some cases of syringo- myelia we may deal with a congenital weakness if not an actual defect, a 8 GUY HINSDALE, M.D. developmental irregularity in the distribution of cellular elements; that, furthermore, the filling up of congenital or acquired spaces in the neuroglial* element with the products of some new formation, glioma for example, and the exercise of pressure from within outward, will react upon the gray matter, so that as it degenerates the intrinsic symptoms of the disease pre- sent themselves, and as later the white matter itself undergoes transforma- tion, the extrinsic symptoms are added to the list. Pathology. — On examining the cord as it lies in the vertebral canal the general appearance may be entirely normal. The meninges are apparently healthy, but upon opening the dura mater, if the case be well marked, the cord will bear a strong resemblance to a large blood-vessel filled with a moderate quantity of fluid, having walls reduced in thickness in proportion as the gray matter has been destroyed. On pressure it is found to lack resistance, being soft and fluctuating. In extreme cases it may be of ribbon-like appearance. The cervical enlargement is relatively great, or at whatever locality a glioma may be present there may be a fusiform swelling. The cervical and upper dorsal regions are the usual seats of the affection. The external appearance is not always so characteristic in cases of moderate degree. On cross-section the distinctive features of the disease are apparent to the naked eye. In successive sections of a well-marked specimen we may trace the glioma and its cavity throughout its vertical extent. Fig. 6. 1 %-.■■ . Syringomyelia.— Upper cervical region. Here the cavity extends far across the cord, almost sym- metrically on either side. The gliomatous formation extends out along the posterior horns, almost cutting off the posterior columns from the rest of the cord. The lateral tracts are much degenerated, especially the right, and the right direct pyramidal tract. Remnants of the anterior horns can be made out as narrow projections in front of the cavity (the left alone is shown in the drawing - ; they contain only a few multipolar cells degenerated. The anterior parts, especially, of the posterior columns, are degenerated. But little trace of posterior root-zone. The gliomatous tissue extends almost entirely around the cavity as a rim or circle. The cavity is usually single, but there may be several cavities inde- pendent of each other or intercommunicating. The cross-section of the cavity is generally elliptical, or merely a narrow slit with the long diameter 1 The author wishes to express his indebtedness to Dr. James Hendrie Lloyd for the use of these valuable illustrations, which were executed from photographs by Dr. William M. Gray, of the Army Medical Museum, Washington. SYRINGOMYELIA. Fig. 7. ^'•Vi ; ,»>r';-,v')' :-'-"-v.M».' ■>., ;,-' ; )■■■■ : J vvv; '•,'''■'■■' This drawing represents very well a section from the mid-dorsal region. (The image is reversed ) The cavity is to the right (left in figure), and follows out the posterior horn quite to the periphery. The right lateral tract is very much degenerated, and the left is rather more so than is shown in the draw- ing. The right anterior horn is also practically destroyed. The left anterior horn preserves its shape, and under the microscope some motor cells are visible in it. The posterior columns show degenerated fibres scattered through them. Fig. 8. Syringomyelia.— Cervical enlargement, The cavity here begins to trend towards the right side (left in the photograph), [t is lined with a glioma as of the central canal can be seen in a group of epithelial cells in front of the cavity und in our side of Its normal position. Ii pre- larly the outlines of a double canal [tdoi ir In the photograph. The ai white commi erved. The gray matter is strel ty.andonly a few multipolar cells are visible (very Indistinct In this photograph) In the anterior horns. The lateral pyramidal tract is deeply degenerated, and the direct pyramidal tract slightly bo. The posti rior horns and root-zones cannot be well distinguished. 10 GUY HINSDALE, M.D. transverse (Figs. 6, 8, 9, 10). The shape of the cavity varies very largely, and its long axis may lie in almost any direction, very commonly extending obliquely in the direction of one of the posterior horns. (Fig. 7.) The dimensions of cavities vary greatly in different cases and at differ- ent levels in the same case, measuring one millimetre or less up to almost the entire thickness of the cord, and usually attaining their maximum in the cervical region. While the cervical and upper dorsal portions of the Fig. 9. Syringomyelia.— Cervical enlargement. Cervical region next below Fig. 8. Cavity trends still farther to right. (In this the image is not reversed.) The anterior horn can be well distinguished. It contains more multipolar cells than the former section, but under a high power they are seen to be de- generated. Otherwise the appearances are much the same as in section from which Fig. 8 is taken. The direct pyramidal tract on the right is more degenerated than on the left. The anterior portion, especially, of the columns of Goll are involved in gliomatosis. cord are the usual seat of cavities, they have been observed in the lumbar enlargement alone. Position. — The cavity itself always lies in the gray matter primarily. It occupies very frequently the position of the central canal in the peri- ependymal tissue. It is often observed posterior to the canal in the gray substance forming the posterior commissure, and may extend throughout one or both of the anterior or posterior horns, reaching thus to the very margin of the cord. In such cases the cavity is asymmetrical, lying chiefly in either the right or the left half. The white matter in moderate cases is SYEIXGOM YELI A . 11 unaffected, but where the cavity is large, and pressure from the glioma has become great, the white matter is in its turn involved, being crowded to the periphery and more or less unable to carry on its functions. The an- terior columns of the white substance preserve their integrity to the last. We are unable to point to a single case in which these have been affected. Since the defect is originally posterior, it is natural that the columns of Fig. 10. Syringomyelia.— Upper dorsal region. The cavity trends to the right (image not reversed). The glioinatous tissue extends down both posterior hums. All around It the white, as well as gray, matter nerated, especially in the direct and crossed pyramidal tracts (mure marked in the right). The anterior parts of the posterior columns also are affected. The gray matter is almost entirely destroyed, except the anterior horns, which are seen as mere small projections in front of the cavity. They con- tain l.ut few cells. Goll and Burdach should be the first of the white matter to undergo a change. The trophic columns of Clark, at the neck of the posterior roots (gray matter), are also often affected. The initial situation of the glioma is about the central canal, extending thence to Clark's column, and then to the anterior and posterior horns. In fifty-six cases where autopsies were made the lesion was located as follows : ( ' \-i .- | Baumler . Posterior horns 21 Left posterior 6 Anterior home 11 Right anterior 5 Right posterior 5 Lefl anterior 5 12 GUY HINSDALE, M.D. The lateral columns, and particularly the pyramidal tracts when involved, as they occasionally are, produce paraplegia. The invasion of the columns of Burdach and Goll gives rise to sensory phenomena, while the degenera- tion of Clark's column probably is accountable for the trophic changes. Fig. 11. Syringomyelia— Lumbar enlargement. The cord here presents a striking contrast to its appear- ance higher up. Its general shape and size, as well as those of its gray matter, are normal. The an- terior horns are large and well supplied with motor cells. The posterior horns and root-zones are plainly seen. In but two features does it present very marked abnormal appearances; and these, in view of the diseased state of the cord higher up, are full of interest. First, the lateral, or crossed, pyramidal tracts, which are here small and have come to the periphery, are degenerated. Second, the region of the central canal, in the posterior gray commissure, shows distinctly gliomatous change. Al- ready the central canal is obliterated, but no gliomatous cavity has yet taken the place of the normal one. Dr. Lloyd remarks that this proves very beautifully that the cavity in syringomyelia is not a mere expansion of the normal canal. On the contrary, the normal canal does not exist any longer, and its place is taken by the remains of its columnar epithelial cells, which have undergone coagulation ne- crosis with loss of their characteristic columnar appearance. This group of broken-down cells is sur- rounded by the gliomatous mass, which at this level occupies but a small space in the gray commissure. We see here, probably, an early stage of the gliomatous process at the lowest point of its downward progression in the cord. Slight degeneration is seen here in the posterior columns near the periphery. If the new formation give rise to pressure in an extreme degree there may be hemorrhages, inflammation, and evidences of degeneration. In such an event it would be the gray matter of the cord that would show the hemorrhage and inflammation, while the white columns would undergo degeneration. This latter would be, as a rule, ascending, for it is the pos- terior and lateral columns that are most frequently attacked. Inasmuch as sensory disorders constitute the corner-stone of the diagnosis of syringo- SYRINGOMYELIA. 13 rnyelia, it is quite likely that the proportion of cases in which the posterior columns are affected (sixty-two per cent, according to Wichraann) is consid- erably greater than has been recognized hitherto. In the one hundred and eighteen cases published which we have carefully examined, nine cases, or eight per cent., showed degeneration of the posterior columns, while a larger majority showed sensory changes. It should be remembered, however, that it is possible for syringomyelia to exist without any sensory disorder. In a case of Schlesinger's (VI. Monograph, 1895), there was no anaesthesia of any form, but an autopsy revealed a cavity extending nearly the entire length of the cord. Ascending degeneration was found in Lloyd's case, in which the patient's motor symptoms were more marked on the right side, and the left pyramid degenerated above the cavity. W'- Mb ^rc \ r? ' :" Ascending Degeneration in Syringomyelia. (Medulla Oblongata, Lloyd.)— Ng, nucleus funiculi gracilis; tfc, nucleus funiculi cuniati; /'.funiculus cuniatus; Sub g, substantia gelatinosa; 2Ti, acces- sory nerve ; DC, direct cerebellar tract : l', ascending root of fifth nerve; I'll, posterior born ; a. (Sowers' tract ; Ah. anterior horn ; D, decussal Ion of pyramids ; Pyr, left pyramid. The light, unshaded areas are degenerated. The central canal is surrounded wiib gliomatous ma- terial. The fibres of the accessory nerve are too diagrammatic. They are not so distinct in the section. The section shown in Fig. 12 was made at about the region of the de- cussation of the pyramids. The central canal, lined with epithelium, is seen. It is surrounded by gliomatous material, which has not yet begun to break down into a cavity, although under the microscope it is seen to be brittle and friable. The decussating fibres are seen and the remnants of the anterior horns cut off by them, lying to their outer side. It is to be noted that the fibres running towards the right are much more numerous then those running in the opposite direction ; also, that the left pyramid is degenerated. In another case, which recently died in the Philadelphia Hospital Fig. 15), ascending degeneration of the pyramidal tracts was found by Der- 14 GUY HINSDALE, M.D. cum and Spiller. In this case sections were made from the level of nearly every spinal root and from many spinal ganglia. By the microscopic examination degeneration of the crossed pyramidal tract was found as high as the substantia reticularis of the second cervical segment and of the direct pyramidal as high as the motor decussation upon the right side, and for a short distance of the crossed pyramidal upon the left. This was believed to be ascending on account of the following facts : 1. Absence of any microscopic lesion above the medulla oblongata. 2. Degeneration of the crossed and direct pyramidal tracts on the same side of the cervical cord, intense in the lower cervical region near the lesion, and diminishing gradually in intensity in the cervical segments, and finally becoming very indistinct in the upper cervical region. 3. Absence of all degeneration in the anterior pyramids. 4. Long duration of a chronic process. While certain associative fibres may be considered degenerated in these columns, the entire anterolateral column contains such fibres, and the de- generation was notably in the area occupied by the crossed and the direct pyramidal tract. This ascending sclerosis was probably in greater part due • to destruction of motor fibers deprived of their function. Degeneration of the direct cerebellar tracts and of the tracts of Gowers was traced as far as the inferior peduncles of the cerebellum. Intense pachymeningitis was noticed from the second lumbar segment to the exit of the third dorsal roots. The arthropathy of the right shoulder was not due to any special changes in the cord or spinal ganglia. The posterior roots were not affected even where the pachymeningitis was most intense ; the anterior roots at one part of the dorsal cord were degenerated. In the entire cervical region as high as the second cervical segment the cavity was limited to the right posterior horn. The gliosis extended from the extreme end of the conus terminalis to the second cervical segment. The microscopic examination explained satisfactorily the symptoms observed in life. In this case the disease dated from a strain of the back; three years later there were severe pains in the legs, a band-like pain about the lower part of the chest, weakness in the lower limbs, and a spastic gait. Com- plete paraplegia with contractures, more marked on the right side, wasting of the lower limbs, paralysis of bladder and rectum developed later. Cuta- neous sensibility was lost in the legs and upon the trunk as high as the nipple on the right side and a little above the umbilicus on the left. The sense of temperature was absolutely lost over the right arm, the right shoul- der, and the right side of the neck, and also upon the adjacent part of the right sideof the trunk above the nipple-line. There was some analgesia of the right arm. It is only in exceptional cases that pressure is exerted laterally, and, on account of interference with the functions of the crossed pyramidal tracts, that spastic phenomena develop. Marked atrophy is an indication of excavation of the anterior horns, and SYRINGOMYELIA. 15 its seat, whether in the upper or lower extremities, is an index of the ver- tical extent of the lesion. In advanced cases the lesion passes beyond the cervical cord and involves the medulla. This is made evident by difficul- ties of speech and deglutition, and even mental degeneration and other symptoms of bulbar disease arising from disturbances of innervation of the glossopharyngeal, hypoglossal, pneumogastric, and spinal accessory nerves. When the nerves themselves are affected, we may have the evidences of neuritis. 1 The contents of the cavity vary considerably in color and consistence. In some cases the liquid is clear, analogous to the cerebro-spinal fluid ; in other cases it may be described as a hyaline jelly perfectly clear or of a turbid or yellowish-brown hue. It may be bloody, thick, and viscid, or contain gelatinous flakes. It never ruptures outward, as it is not subject to any very great internal pressure. The walls of the cavity are smooth and glossy as a rule, but in ex- ceptional cases are rough, shreddy and uneven, and of a slightly yellowish color. The new formation, which is the starting point of syringomyelia, is gliomatous. This may be defined as a neoplastic hyperplasia of the gray matter, — a glioma. It has been called by Cornil and Ranvier a neuroglial' sarcoma. According to Joffroy and Achard, Hallopeau and Erckholt, after an inflammatory hyperplasia or myelitis a cavity forms from the re- traction of the sclerosed periependymal tissue from the distinctive tendency of the hyperplasia, or may arise from softening consequent on thrombosis of the inflamed vessels. Considerable stress is laid on the vascular origin of the cavity, some authors, such as Langhans, Stadelmann, and Steudener, asserting that the cavity results from periependymal oedema, or from hemorrhage with secondary absorption, or from colloid degeneration of the vessels. Joffroy and Achard's term, myUite cavitaire, is entirely reconcilable with the views held by Simon, Westphal, Roth, Blocq, and Schultze, that the syringomyelia is due to a degeneration of the elements of a neoplasm, — a glioma. The differences of opinion are rather discrepancies of terminology. It may be said briefly that the usual course of arteritis in syphilis and in disseminated sclerosis is towards a diffuse sclerosis and not to cavities. We do not meet with cavities in the system scleroses. The argument, however, that syringomyelia does not result from a myelitis or a central softening of the cord by endarteritis because we do not meet with syringomyelic cavities in the scleroses of the cord has been shown by Dr. Byroru Bramwell to be unfounded. The glioma has its seat in the gray substance, particularly the peri- ependymal region, and affects chiefly the gelatinous substance of Rolando, 1 See Alexis Thomson's case for neuritis of the suprascapular and circumflex nerves, Edinburgh Hospital Reports, 1894. 16 GUY HINSDALE, M.D. which acts as an intercellular cement on the gray matter. It is of a yellowish-brown color and of a rather firm consistence. The latest teaching of the French school is that this mass is the result principally of an agglom- eration of large cells, which are more or less crowded together, sending out ramifications which by their interlacing enclose small spaces. The cells themselves form small masses of protoplasm, which are grouped centrally or peripherally, and stain conspicuously the ordinary reagents. The trabecule are long and delicate, slightly thickened at certain points. In the net- work of filaments the granular elements are enclosed as well as free cells and fine fibres, together with numerous pigment granules, which give the growth a distinctive color. The reticular tissue is well supplied with capillaries. The cavity is in most cases lined by a thin membrane, which to the naked eye is glossy and of a yellowish hue. It consists of a delicate mem- brane of neurogliar tissue composed of branching neuroglia cells of various sizes and with small spheroidal and oval cells embraced in a net-work of fibres. These elements may be either densely packed together or loosely arranged. In other cases the cavity has no limiting membrane or we may have such a membrane present in one portion of the cavity but absent at other portions. The process of liquefaction readily takes place in the limiting membrane. Small holes are sometimes observed in the wall, — spheroidal cavities which have been evidently produced by liquefactive de- generation with disappearance of the neuroglia cells. Van Gieson shows that these changes in the glia-cells are not caused by the action of the hardening agents, since the degenerating cells are not scattered uniformly throughout the cord, but are noticeable wherever there is much hyperplasia of neurogliar tissue. In a typical case the tumor is composed of closely-packed masses of spindle-shaped and oval cells associated with filaments arranged in strands between and around numerous blood-vessels which are surrounded by a close-textured, sparingly nucleated sheath of neuroglia filaments. The cells, when isolated, comprise glia-cells, together with granular, rounded, or spindle-shaped non-branching cells, resembling the cells of sarcomata. The liquefying product will be found to consist of fluid, fibrin, hsematogenous pigment, and, in places, of disintegrated tumor cells. Liquefactive de- generation of the glia-cells, gliomatous tumors, constitutes one of the charac- teristic features of syringomyelia. In a given case we may find obliteration of the central canal ; at the same time no gliomatous cavity has taken the place of the normal one. While the canal does not exist, we find in its place the remains of its columnar epithelial cells broken down in a coagula- tion necrosis with a loss of their characteristic columnar appearance. At other levels the fully-formed cavity will be observed. It should be borne in mind that not every change visible under the microscope was actually present in life. Irregularities of outline, for exam- ple, are very often due to the manipulation of the cord in the process of SYRINGOMYELIA. 17 removal aud subsequent examination. Too much stress should, therefore, not be placed on such distortions. The case of Gyurman has been cited by Van Gieson as one of these examples of artefacts mistaken in some respects for pathological change. Dr. Byrom Bramwell * has shown by microscopic sections from two ordinary cases of myelitis that cavity-formation with a surrounding dense membrane does occur, but that specimens of central gliosis from another case, which he very carefully prepared, show that the cavity was formed by breaking down in the process of preparation. Symptomatology. — The symptomatology of syringomelia has been placed upon an established basis during only the last fifteen years. Previous to that period the clinical symptoms had not been grouped and classified and given their proper value so as to be of any service to the clinician in recog- nizing the disease. Its identity, judging it by a series of post-mortem records, has been established by a system of a posteriori reasoning, so that we are in possession of a definite train of symptoms that have enabled the clinician to declare, in turn, the pathological changes which are present in a given case, particularly if the clinical symptoms are well marked. These symptoms arrange themselves as follows : I. Intrinsic symptoms. 1. Symptoms of anterior poliomyelitis, and motor symptoms (atrophy). 2. Symptoms of median poliomyelitis (the central gray substance of the cord). (1) Trophic disorders. (2) Deviations of the spinal column. (3) Vasomotor disturbances. (4) Disorder of the sphincters. (5) Ocular symptoms. (6) Bulbar symptoms. 3. Symptoms of posterior poliomyelitis. II. Extrinsic symptoms. 1. Sclerosis of the lateral columns. Spastic phenomena. 2. Sclerosis of the posterior columns. Tabetic phenomena. By means of this convenient classification, which we owe to the late Professor Charcot, we may study the symptoms in order. I. The intrinsic symptoms are related to the gray substance itself. 1. Degeneration of the cells of the anterior horns manifests itself by muscular atrophy. This feature of syringomyelia is rarely absent, and is almost as characteristic as disturbance of sensation. Atrophy was one of the first of the clinical symptoms that appeared prominently in a review of those cases in which an autopsy revealed syringomyelia. Indeed, many of these cases had been diagnosticated as progressive muscular atrophy. 8 1 Medico-Chirurgical Transactions, Ivlinbur^h, 18!W-(»4. 2 Examples are found in the cases of Gull, Clarke, Beevor, Westphal, Ivahler and Pick, Schultzc, Dreschfeld, and Schuppel. 18 GUY HINSDALE, M.D. The most frequent form of atrophy is of the type Aran-Duchenne. The small muscles of the hand, the interossei, the thenar and hypothenar emi- nences, appear to be the regions most frequently involved. The atrophy invades the forearm and the arm, the muscles of the shoulder-girdle and trunk, occasionally involving a portion of the tongue, almost always sparing the face. Fig. 13. A case of syringomyelia, showing atrophy. (From the Philadelphia Hospital.) Whether general or unilateral, the atrophy in these cases is always of spinal origin, and by a knowledge of spinal localization we are enabled by the initial motor symptoms and by their progress to determine very closely the seat of lesion. Valuable charts have been prepared and published by Dr. M. Allen Starr and Dr. C. K. Mills as guides in spinal localization. SYRINGOMYELIA. 19 They have been made from data drawn from studies in comparative anatomy, physiological experiment, and records of spinal-cord diseases, especially from the study of anterior poliomyelitis, transverse myelitis, and syringomyelia. The muscles of the lower extremity are not involved by any means as frequently as those of the upper limb. Paraplegia is, however, not a rare symptom. 1 The gait is frequently much disturbed. It is slow and in extreme cases so uncertain that it has been mistaken for that of intoxication. Particularly is this the case when the white matter of the cord is affected, where tabetic or spastic symptoms have supervened. If, in addition, the medulla has been involved with consequent thickness of speech it is evident that unfor- tunate mistakes of this kind would occur. Such have been recorded by Hoffmann, Raich line, F. Taylor, and Haumann. Electrical Reactions. — The atrophied muscles are prone to undergo quan- titative and qualitative changes in their electrical reactions. The opinion is now becoming more common 2 that the sign of reaction of degeneration has lost much of the diagnostic value which we have for a long time accorded it, inasmuch as it is met with in affections that are purely muscular, as, for example, pseudo-hypertrophic muscular paralysis, and as, on the other hand, we note its absence in nervous amyotrophies of advanced type. In syringo- myelia there is great diversity in this respect in different cases. In the one hundred and eighteen cases which we have analyzed the reaction of degen- eration in the atrophied muscles was recorded in twenty-one cases. While no doubt many cases were not examined in this regard, we may safely say that R. D. is not found by any means so frequently in syringomyelia as in atrophy consequent on neuritis. It is quite common, however, to find quantitative changes in syringomyelia, there being diminution and some- times total disappearance of electrical excitability. In one of Midler's cases the muscles presented a normal appearance apparently in no way atrophic, and yet there was very great diminution of faradic and galvanic excitability. Schlesinger and Frank! Ilochwart have called attention to a case which was under treatment by direct applications of the faradic current to the biceps, exhibiting a peculiar undulation in that muscle when stimulated, and which continued to show this phenomenon during the entire course of treatment. Fibrillary Tremors. — The affected muscles also present another phenom- enon, — viz., fibrillary twitching or tremor. True tremors, as observed in paralysis agitans and in hysteria, are not observed in syringomyelia, but we find frequent mention of a frequent and intense fibrillary twitching. In our analysis of one hundred and eighteen cases this feature is mentioned thirty times. 1 Cases of Westphal, Schultze, Grasset, Chabanne, and Baichline form exceptions. * See Guinon's remarks in the Traits de M6decin, vol. iii., 1894. 2 20 GUY HINSDALE, M.D. 2. Symptoms of median poliomyelitis. This important group of symptoms embraces those which we seem jus- tified in attributing to an alteration of the central gray substance of the cord. The later continental writers, including Bruhl, have adopted the classification which we give below. While in some respects questions may arise as to the localization of some of the symptoms in this group, with our present knowledge we are not able to definitely relegate them elsewhere. (1) Trophic disturbances. (2) Deviations of the spinal column. (3) Vasomotor disorders. (4) Affections of the sphincters. (5) Oculo-pupillary changes. (6) Bulbar symptoms. (1) The trophic disorders of syringomyelia affect four tissues, viz., — (a) The skin and mucous membranes. (6) The subcutaneous cellular tissue. (c) The joints. (d) The bones. (a) Trophic alterations of the skin are commonly observed in syringo- myelia, and may be of all grades, from a slight glossy condition to extensive necrosis or gangrene. These changes are usually confined to the extremi- ties affecting the atrophied structures, and are prone to occur in the anaes- thetic regions: occasionally there is a tendency to hypertrophy of the skin with formation of dense fibrous tissue (Case CXII.). 1 It is common to observe scaling, cracking, and the formation of deep fissures that are the seat of ulcers that become chronic and refuse to heal. These cracks are commonly seated in the palm of the hand, and, although the fissures them- selves are frequently painless, the chronic ulcerations are so unsightly that they are often the occasion of the patient's presenting himself for treatment. These cracks furnish a ready pathway for infection, and particularly in syringomyelia of Morvan's type they lead to actual deformity. The accom- panying plate from a case of H. Curschmann's illustrates very well this condition. The nails become striated, crack, and suppurate at the matrix. As seen'in the plate, some have fallen off, and the remaining stumps with their horny appendages present a repulsive appearance. The resemblance between the observed trophic disorders of the skin and scleroderma are not uncommonly noted by observers. Syringomyelia has been mistaken for pemphigus, on account of the spontaneous bullae or phlyctenules that are liable to occur on the hands and feet. These phenomena are liable to be persistent, and to give rise to obstinate ulcerations that are difficult to heal, and show a tendency to spread. In a case of Neuberger's there were as many as thirty separate areas of ulceration, of irregular outline and varying 1 Yerhoogen and Vandervelden's case, in which a cavity was found independent of the spinal canal. SYRINGOMYELIA. 21 size all over the body. Besides this, there were pigmented areas in places, and radiating cicatrices in other situations. In this case there was a syphi- litic history, but the autopsy showed a syringomyelia. The mucous mem- brane of the mouth had been so extensively involved that speech was disturbed, the small vesicles which appeared along the right border and tip Fig. 14. Trophic changes in syringomyelia. of the tongue ruptured and left small ulcerated areas that were extremely painful, and rendered impossible the ingestion of solid food. These patches were at first of circular outline, and covered with a yellowish de- posit and surrounded by a reddened areola, but after a time they tended to become confluent. At a later period the left border of the tongue also be- came affected. In a little while the entire organ became enormously swollen. In the intervals between the paroxysms ulceration sometimes took place in the fissures present. At the time of the attacks there were also pricking sensations in the face. Sometimes the tonsils were swollen and the seat of a yellowish deposit. The condition affecting the mucous mem- brane of the mouth and pharynx was believed to be pemphigus, non- syphilitic in character. On one occasion an eruption of vesicles was observed upon the extensor aspect of the right hand, and on another occa- sion a similar eruption on the middle toe of the left foot. Upon post-mortem examination the tongue was found swollen, fissured, and ulcerated. The epiglottis was enlarged and reddened. The entrance to the larynx was closed by intense oedema of the ventricular bands. The mucous membrane 22 GUY HINSDALE, M.D. of the larynx was thick and rugous, in places eroded, and here and there, particularly upon the arytenoid cartilages, presenting frothy, yellowish secretions, probably derived from the rupture of pre-existing vesicles. The mucous membrane of the trachea was hyperaemic, swollen, and covered with frothy secretion. (b) The subcutaneous cellular tissue undergoes well-marked trophic changes. One type of syringomyelia (that of Morvan) is distinguished by painless panaritia, whitlows, or felons. These appearances are usually associated with the palmar cutaneous fissures previously referred to. There are phlegmons and abscesses, more or less extensive, seated in the arms, the axilla?, and the palms of the hands. Perforating ulcer may also develop. In a case of Le Fort's, in which panaris had existed, and small swellings like boils had appeared on the forearm, shoulder, and abdominal walls, gangrenous areas appeared in the external and upper portion of the left forearm and on the posterior and outer part of the shoulder. All these trophic lesions of subcutaneous tissues are often serious, if not by their extent, at least by their refusal to heal. They almost always leave behind permanent cicatrices and more or less deformity or mutilation. Wherever trophic disturbances like panaris occur there is occasionally a subjective sense of cold ; in other cases the skin assumes a cyanotic hue or, on the other hand, a diffused redness of the skin with sense of burning. In these cases the surface temperature is sensibly elevated, and a surface thermometer may record from 7° to 9° C. more than when normal areas are tested. Neuropathic oedema may occur in a generalized manner or localized in a single part, as, for example, in the dorsum of the hand. In one of Ver- hoogen and Vandervelden's cases (No. 6) there was a cyanotic oedema of the ankles when the patient assumed the erect position. Roth has described cases with "tumeurs pateuses" which are examples of neuropathic oedema seated in the connective tissue. They presented pitting on pressure and were not associated with any discoloration of the skin. (c) Arthropathy. — Just as in tabes so in syringomyelia, it is not unusual to find affections of the joints. Indeed, they occur rather more frequently than in locomotor ataxia. In our analysis of one hundred and eighteen cases we find arthropathies in thirty-eight or thirty-two per cent, of cases. They may occur spontaneously without trauma, appearing suddenly without accompanying fever or pain. The shoulder- and elbow-joints are favorite sites in this respect, affording a contrast to tabetic arthropathy in which in about seventy-five per cent, of cases we find the lower extremities involved. The syringomyelic arthropathies are usually seated in the upper extremities. It is liable to occur at an early stage, and taken in connection with sensory disturbances constitutes an important and early sign of the disease. In Schlesinger's ninety-seven cases of syringomyelia with arthropathy we have the following distribution : SYRINGOMYELIA. 23 Schlesinger's Cases. Shoulder-joint 29 Elbow-joint 24 Wrist-joint 18 Thumb 2 Hip 4 Knee 7 Ankle 7 Jaw 4 Steruo-clavicular 2 Total 97 The arthropathy may consist of a simple hydrarthrosis. The joint swells and leads the patient to consult a surgeon, sometimes, rather thau a physician. It is not generally painful, and may become quite aggravated without the patient being aware of it. There may be a subsidence for a time and then an increase of deformity. After swelling of the joint and subsequent disappearance of the fluid the articulation is loosened by re- Fig. 15. Arthropathy of the shoulder in syringomyelia, I Alexis Thomson I taxation of the ligaments, and it is quite easy to produce luxation. The epiphyses become friable; spontaneous luxation may occur with the growth of enormous osteophytes. Motion at this stage is accompanied by crack- ling sounds, but the movements arc not, as a rule, painful to the patient. Tn a characteristic case which had been under observation for years in the Philadelphia Hospital, and studied by Dr. Dercum and others, the right shoulder-joint began to swell, and from rupture of the capsular lig- 24 GUY HINSDALE, M.D. ament cellulitis with redness and local heat was produced, but with little or no pain. In extension the humerus assumed the position of a subglenoid luxation. Death was due to exhaustion. At the autopsy, in 1896, the capsule of the right shoulder-joint was found much thickened and roughened on the inner surface. The head of the humerus had disappeared, the bone having been eroded to some little distance below the surgical neck. A cystic tumor was found in the axilla containing a friable fatty material. The surface of the glenoid cavity was much eroded, roughened, and porous; it was abnormally large, and exten- sive bony deposits had taken place along its edges. The coracoid process exhibited a thick and firm accretion around its entire edge. 1 Shoulder-joints have even been excised 2 without the use of an anaes- thetic, and in one instance the patient himself occasionally used to evacuate fluid from his elbow with a pair of scissors. A typical case of this kind has been recently published in full by Mons. J. B. Charcot. The patient, a female, aged fifty-seven, had furnished a characteristic picture of syrin- gomyelia, in which the left upper extremity was the seat of the dissociation symptom. The right arm and forearm retained feebly their sensation. Scoliosis and lordosis were marked. In the course of time this patient left the hospital, and three years after the publication of Critzman's account of the case it came again under observation. It transpired that in 1892 she had a fall, first striking the left atrophied shoulder and then the right shoulder, which was the better and which was only slightly disturbed as to sensation. She continued to use her arm, but not so well as before, but at the end of three weeks it had swollen considerably and movement was more difficult. The right shoulder-joint was the seat of an effusion and half a litre of fluid was drawn by aspiration. A luxation received at the time of the fall was then easily reduced, but recurred, and crackling sounds of the joint were noted. The head of the humerus became atrophied and deformed, so much so that dislocation could be produced at will in all directions. Pain had never been very noticeable in this joint ; it was present at times, especially under manipulation, but was transient and easily borne. It was particularly the crackling which disturbed and irri- tated the patient. The vast majority of subjects of syringomyelia, whether male or female, belong to the laboring classes, and in such patients repeated injury of a joint is liable to occur, especially if the sense of pain has been impaired or abolished. In many of these cases it requires only a slight accident to give rise to affections of the joints. It is not uncommonly observed that in cases of trophic disturbances of the skin a slight mechanical or thermic irritation is often followed by active vasomotor troubles and by various *For description of pathological changes in the spinal cord, see page 13. 2 Sokoloff's case and Czerny's case. SYRINGOMYELIA. 25 symptoms such as would not occur from similar exciting agents in healthy persons. 1 It must not be concluded, however, from such premises that syringomy- elic arthropathies are of traumatic origin. Volkmann maintained that such was the case in tabes, but his view has not been accepted, and the pre- vailing opinion, based on clear evidence, is that they are distinctly trophic lesions. The obscure nature of the arthropathy is borne out by the various theories that have been formulated for its explanation. That they are syphilitic as Striimpell has claimed we cannot admit, nor can we concede that they are rheumatic in origin. Buzzard's theory that they are due to an invasion of the medulla oblongata because, as he claimed, they were co- incident with gastric and laryngeal crises is equally untenable. This author fortified his position by arbitrarily assigning to the medulla a trophic cen- tre for the bones and joints. Believing with Charcot, Blocq, Hoffmann, Xissen, and Marinesco that the arthropathy of syringomyelia is entirely analogous in its origin to that of tabes, we deem it entirely fair to use the same arguments in support of the explanation of the nature of syringomyelic arthropathy that have been adduced to explain that of tabes. Among the earliest investigations of this subject was that of Charcot and Joffroy in 1870 (q.v.). They examined the spinal cord of a woman who had had locomotor ataxia for ten years, with a large tabetic arthropa- thy of the left shoulder, and with complete destruction of the head of the humerus. In addition to a characteristic sclerosis of the posterior columns, there was a remarkable atrophy of the left anterior horn in the cervical region, with destruction of many cells particularly in the posterior external group. At other levels the anterior horns were normal. - In another instance Charcot and Joffroy found an atrophy of the ante- rior horn of the lumbar cord coincident with arthropathy of the knee of the same side, and they believed them to be in the relation of cause and effect. Later investigations by Pierret (1870), de Lionville (1874), and Seeligmi'd- ler seem to support this view ; but those of Bourceret (1875), Raymond (1875), Pities and Vaillard {Revue de 3Iedeeine, 1886), and Pavlides (1888) have afforded negative observations. Talamon also failed to find any lesion of the anterior horns in several autopsies in cases of spinal arthropathy. Pitres and Vaillard did find, however, in four cases of tabetic arthropathy alterations of the periarticular nerves, and even of the capsular filaments, and from these observations tiny announced the theory of the peripheral nervous origin of the affection, in which they have been supported by Siemerling. Marinesco has examined the spinal cord (Revue Neurologique, July 30, casi - of •' urgena ami Marinesco. '-' It will lie noticed in this connection that the arthropathies of syringomyelia are chiefly in the upper extremities, ami that the usual Bite ofthe central lesion 18 in the lower cervical ami upper dorsal regions. 26 GUY HINSDALE, M.D. 1894), the crural nerves, and articular filaments in a case of double tabetic arthropathy. The cord showed a system-sclerosis of the posterior columns, having its greatest intensity in the lumbar region. In this situation there remained in the posterior columns only a few scattered fibres in the cornu- Fir;. 16 Arthropathy in general paresis. (From a ease of Dr. Lloyd, in the Philadelphia Hospital.) commissural zone. There were still a few fibres scattered ihrough the other zones of the posterior columns. The zone of Lissauer was com- pletely degenerated, as well as the posterior horns. The anterior horns were normal throughout the entire lumbar region. The crural nerves on both sides showed well-marked degeneration, which appeared particularly SYRINGOMYELIA. 27 in certain bundles of fibres, — in other words, there were atrophied medul- lated nerve-fibres. The articular nerves had also degenerated. Finally, in a well-marked case of arthropathy in general paresis, studied by J. H. Lloyd, an illustration of which is presented for comparison, it could not be affirmed that a direct connection was apparent between the cord lesions and the arthropathies, but the opinion was expressed that this connection existed probably by way of the nerve-roots. The spinal cord in this case showed, first, partial posterior sclerosis, and, second, sclerosis of the motor tracts from one hemisphere, — i.e., the crossed pyramidal tract on the right side and part of the direct pyramidal tract on the left side. The multipolar cells of the anterior horns in the region examined (mid-dorsal region) did not present very marked changes. We are very much in need of a further study of the nature of syringo- myelic arthropathy. The arthropathies of syringomyelia, as well as of tabes, have been ar- ranged under two heads: first, the atrophic form, which is the rarer; and, second, the hypertrophic form, more usually seen, and which resembles in some respects the lesions of arthritis deformans. Recent investigations lead to the opinion that a lesion of the articular sensory nerves is accountable for these arthropathies. Goldscheider's ob- servations show that the articular surfaces are sensitive to mechanical and thermic irritations. Recent studies by Golgi show that numerous sensory nerve-corpuscles exist in the tendons themselves, but no one has yet de- scribed trophic nerves passing from the centre to the periphery in a manner analogous to the nerve-fibres of muscles and glands. "We may then un- derstand how, in the atrophic form of arthropathy, at least the articular surfaces of the bones, deprived of their sensory nerves by degenerative pro- cesses, are thereby unable to recognize the adverse conditions to which they may be subjected. The nutritive function being dependent on intact sen- sory innervation is, therefore, abated as the communication with the vaso- motor centres is gradually lost. The resulting impoverishment of the blood-supply results in the wasting and reabsorption of the constituents of the articulation." ' On the other hand, an ingenious theory is advanced to explain the hy- pertrophic form. " It is a recognized fact that in healthy individuals there are certain spontaneous compensations of nutrition. Applying, now, the same principles in pathologic conditions, it may be urged that in some forms of arthropathy, for example, portions of an articulation are deprived of a regular nutritive circulation because their centripetal nerve-supply ia im- paired. Thus it may occur that the neighboring portions remaining unaf- fected enjoy a compensatory increase of nutrition corresponding to what has been denied the affected regions." However this may be, hypertrophies do occur in the neighborhood of those portions of joints that have undergone 1 Marinesco. 28 GUY HINSDALE, M.D. Fig. i; impairment of innervation. The modus operandi, according to Marinesco and others, is, therefore, a mechanism which, starting in the centripetal nerves of the articulation, reacts in such a way upon the vasomotor centres, and thence again to the vasomotor fibres distributed to the articular sur- faces, that the trophic changes result. To sum up the determination of the two forms of arthropathy as ob- served in syringomyelia, tabes, etc., we may say that if there exists only an impaired action of the sensory nerves, by which they are incompetent to transmit impressions from the joint to the centre, the atrophic form of arthropathy will result. If now there is added a compensatory adjustment by which fibres remaining intact bring about an increase of nutrition to the surrounding unaffected portions of the articulation, we will have the phe- nomena of hypertrophy. Attention is drawn to the influence of pathogenic microbes in the pro- duction of arthropathies. Where innervation is impaired the tissues, par- ticularly at the extremities, are not well able to resist the invasion of microbes. Such affected areas constitute the points of least resistance, where their pene- tration is easy and their multiplication undisturbed. Those changes of infectious nature are well seen in Morvan's type of syringomyelia, and in a case of combined syringomyelia and leprosy, — such as, for instance, one reported by Souza-Martin. As in the arthropathy of hemiplegia, so in Mor- van's type of syringomyelia, the changes are due to the combined influence of a direct pathological process involving the central nervous system and, in ad- dition, the action of pathogenic mi- crobes which have been introduced from without at a vulnerable point. We have referred to the resemblance which the hypertrophic arthropathy of syringomyelia may bear to arthritis de- formans. Volkmann endeavored to make the anatomical distinction in these cases that in the latter disease the for- mation of new bone is confined to the interior of the joint capsule, while in the spinal arthropathies there may be extensive ossification of the periarticular soft parts with formation of osteophytes. Such a distinction, however, does not hold, for examples of arthritis de- formans are met with on post-mortem examination in which there were abundant bony formations outside the limits of the affected joint, and especially in the adjacent tendons and ligaments. The articular surfaces Arthropathy of Morvan's type mann's case.) (Cursch- SYRINGOMYELIA. 29 co-ossified in places may be deformed either by partial fractures or by osteophytes with which they are surrounded. Isolated bony growths, de- veloped in the tendons or aponeuroses, seem to be met with more often in syringomyelia than in tabes. 1 In the hypertrophic form the ligaments and the capsule of the joints 1 For example, in a ease of 1 1 oilman n's, of syringomyelic arthropathy, there was an osteoma of the anconeus mu 30 GUY HINSDALE, M.D. Fir;. 19. involved are relaxed or destroyed, with a consequent mobility of the adja- cent ends of the bone. Such was the condition in a patient of Dr. Alexis Thomson, of Edinburgh. (Fig. ]5.) A similar condition was also seen in Dr. Dercum's case at the Philadelphia Hospital. (Fig. 18.) Dr. Thomson calls attention to the fact that it is clearly the duty of the surgeon in all cases of unusual forms of joint-disease, repeated dislocation, or spontaneous fracture, to investigate accurately the sensibility to pain and temperature, — features which will occupy our attention later, — for otherwise this disease will continue to escape recognition in surgical practice. (d) The Bones. — Lastly, we may have serious alterations of the shafts of the bones. Fractures occasionally occur spontaneously, or by slight efforts or accidents. These fractures, like the arthropathies, are painless, and hence may escape detection for a considerable length of time. Union is delayed, and there is a great liability to vicious or redundant callus. In some cases the fracture remains ununited, and a false joint forms. One of the best illustrations of fractures of this kind is that of Schultze, . cited by Thomson and Bruhl. It occurred in a healthy man, aged twenty-four, in whom the first evidence of syringomyelia was a "spontaneous" fracture of the humerus, caused by an energetic muscular effort. Be- cause of the loss of sensibility to pain this patient only knew of his fracture by the noise of the break and by the loss of power in the limb. He subsequently fractured his left radius and fifth metacarpal, — all bones of the upper extremity. After death, at a later period, of septic meningitis, Schultze found that all the fractures had united in a satisfactory manner, and that there was no abnormal fragility of the bones, such as might have been reasonably expected. He en- deavors to explain the liability to fracture in these cases by the loss of the muscular sense and of sensibility to pain, allowiug the patient to exert more muscular effort than is required for the object in view or than the bone can stand. Lastly we may have trophic changes in the bones, particularly of the hands and fingers, that partake of the nature of acromegaly. 1 (2) Deviations of the Spinal Column. — Changes in the spinal column have been observed in so many cases of syringomyelia that they have come Scoliosis in syringomyelia. (Cursch mann's case.) 1 See cases of Marie, Holsckevnikoff, and Peterson. SYRINGOMYELIA. .°>1 to be regarded as a characteristic symptom. Lancereaux was probably the first to notice this in a case of syringomyelia, which he described in 1861 under the name of hypertrophy of the ependyma. Although the earlier observations on syringomyelia generally made no mention of the state of the spine, it is now given a prominent place in the symptomatology of the disease. In an analysis of the one hundred and eighteen cases found in the appendix, we find that deviations of the spinal column are noted in forty-four cases. Bruhl states that this frequency is about fifty per cent, and Sehlesinger gives forty per cent. The more carefully the examination is made the more likely will the percentage be found to be increased. The accompanying photograph of one of Curschmann's cases shows this deform- ity in a marked degree. In one of the cases described by the author (case of Robert Collins, see Case No. I.) 1 there is a marked deformity. Hallion, Hoffmann, and Jeffries have also published excellent examples. The usual form of deviation is scoliosis; in some cases this is associated with kyphosis. Pure kyphosis is very rare, but has been observed in the cervical region. Lordosis is uncommon, but when present may be looked for in the lumbar region. Scoliosis may involve, together with the compensatory curves, the entire length of the spinal column, but the favorite seat is the dorsal region. The convexity of the curve looks usually to the side which is affected earliest and on which the muscles are impaired. This impairment allows the stronger muscles of the opposite side to contract more effectually, with the result that a convexity on the opposite side of the spinal column is produced. This deformity, obviously, is more marked in cases where the disease is unilateral. Exceptions to this may occur, as, for instance, in a case of Kahler's in which the spine was normal, although there was a strong predominance of the disease on the left side; but in this case the muscles of the trunk were believed to be spared. In one hundred and eighteen cases analyzed in appendix, scoliosis was noted in thirty-six. Convexity to right 13 .Muscular defects began in right 10 Muscular defects began in left 2 Convexity to left 8 Muscular defects began in right 2 Muscular defects began in left 3 Although there may be considerable difference in the height of the shoulders, immobilization of the corresponding part of the spine and other evidences of deformity, there is, as a rule, no special pain or discomfort. Should pain exist in an exceptional case there is no evidence that it is due to a meningitis. There may, however, be a certain degree of pain on 'See Cases XXVII., XXXIV., MAX. 32 GUY HINSDALE, M.D. pressure with stiffness of the affected portion of the spinal column. This may vary as to the time at which it is apparent, either early or late in the history of the affection. The curvature itself may be coincident with the earliest symptoms, but ordinarily it is apparent several years after the on- set of the disease. In cases, such as one published by Bruhl, where the scoliosis was observed at the age of sixteen and a half years, but where the disease did not commence to be marked until the thirty-third year, we may fairly question the relationship of the two. It is not possible in most cases to state the exact time at which the deviation occurred, since no pain is present and as it is not ordinarily noticed until actual deformity appears. The nature of deviation of the vertebral column as observed in syringomyelia has given rise to various opinions. Roth believes that scoliosis is of muscular origin, arising from an atrophy of the "muscles transversaire epineux," which may exist early in the case. We have noted in a study of cases given in the appendix that atrophy of the trapezius (cucullaris) is rather frequently noted. The origin of this muscle embraces the entire extent of the spinal column above the first lumbar vertebra, and it can readily be understood how atrophy of it or of any considerable por- tion of its fibres may affect the direction of the spine. It is quite probable that the muscles are not alone in their influence in causing deviation of the spine in this disease. The tendency to affections of the joints and of the long bones in syringomyelia would suggest that the vertebras and their articulations may share the trophic change, which is more evident in other localities, so that we may hold, in view of the facts that have been presented, that the scolioses or the more pronounced de- formities are evidences of trophic disorder dependent on the changes in the gray matter of the cord. In this respect we see in it a strong analogy to the spinal deviation observed in Friedreich's ataxia. (3) Vasomotor Disturbances. — These changes are commonly observed and give rise in some cases to considerable distress. The superficial circulation in the affected areas is disturbed, being either inadequate to proper bodily comfort or, on the other hand, by its excess giving rise to redness, swelling, and actual elevation of the local temperature. In the first instance a sluggish circulation is naturally attended with a chilling of the part and a cyanotic appearance of the extremity involved. The surface temperature is lowered and the patient may complain of a sense of cold. Subjective sen- sations of cold in cases where no objective symptoms are apparent are com- mon, and in many cases these feelings are distributed over a large area, The patient complains of coldness of a limb or of a sense of cold water running down the back. On the other hand, the sensation may be of burn- ing or smarting and may vary very much even in the same individual. The skin itself quickly responds to external stimuli, so that a slight stroke along the skin of the back will leave a reddish line, which persists for some time after the stimulus has been applied. This feature is common in spinal disease under the name of dermographism or "homme auto- SYRINGOMYELIA. 33 graphique," and is therefore of diagnostic value only when taken in con- nection with other more characteristic symptoms. So also cedernas are noted in this disease and are distinctly of nervous origin. They are ob- served, when present, on the dorsum of the hand or in the lower part of the forearm. The "tumeurs pateuses" observed by Roth are doubtless of this nature. Disturbances of the secretion of sweat are quite commonly observed, excessive in some regions while suppressed in others. The excess is gen- erally observed in the anaesthetic areas. French writers, including Dejerine, Grasset, and Bruhl, and Schultze and Fiirstner and Zacher, in Germany, have made interesting observations on this point. (4) Disorder of the Sphincters. — These are rarely disturbed. In the first case summarized in our appendix, that of Abbe and Coley, there was partial loss of control of the bladder and rectum, and before death a violent cystitis ensued. In a case of Charcot's death was caused by a spontaneous perforation of the bladder following a simple ulcer. In a case of Oppenheim's also death was due to bed-sores and cystitis. Incontinence of the bowels is rare but constipation is commonly noted. In Preobrajensky's case (No. LXXIX.) there were retention of urine and incontinence of fasces; death occurred in the course of three weeks from pyelonephritis and purulent cystitis. In traumatic cases, where great violence is done to the cord with accom- panying paraplegia, we naturally look for incontinence of fasces and retention of urine. In Schlesinger's recently published case (No. XIV., Monograph, 1895) the above symptoms were present as a result of luxation of the twelfth dorsai vertebra with compression of the cord. At the autopsy, three months later, a dilatation of the central canal was found throughout the entire dor- sal cord above the point of luxation. Cystitis and pyelonephritis were also present. (5) Ocular Symptoms. — The disturbances of the eyes in syringomyelia may be properly considered under a separate heading, although they are closely related to the bulbar symptoms which will be more fully considered later. Pupils. — Inequality of the pupils is not an uncommon symptom. In the one hundred and eighteen cases found in the appendix we find this noted twenty-seven times. (Cases III., V. X., XVII., XXVL, XXVII., XXXV., XXXVI., XLI., XLU., XLIII., XLIV.,XLVL, XL1 X . LVIII., LXIII., LXIV., LXXII., LXXIII., LXXVI., XCL, C, CV. CXIII, CXVL, CXVIII.) In eighteen cases the right pupil was the larger; in six cases the left. Bruhl records tins symptom ten times in thirty-six cases and Schlesinger twenty-four times in two hundred cases in all the literature accessible. By adding the cases of inequality of the pupils due to paralysis of the sympa- thetic the proportion rises to twenty-five per cent. Paralysis of the sym- pathetic nerve may occur from lesion of the cord in the upper dorsal region; 34 GUY HINSDALE, M.D. it is generally unilateral, but bilateral paralyses have been recorded by Schlesinger, who remarks that it is one of the initial symptoms of syringo- myelia, particularly of the cervical type and those that are accompanied by marked muscular atrophy. The pupils in almost every case observed re- acted to both light and accommodation. In case No. LXXII. which we report convergence to light was absent. Immobility of the pupils with inequality is noted in a very few cases of syringomyelia as well as tumors of the spinal cord. The case of Oppenheim (G. P. 1 ) is an example, and other cases have been recorded by Glaser, Schultze, Homen (q. v.), Brut- tan, and Tornow. Nystagmus is not an unusual symptom. We find that it is noted fifteen times in one hundred and eighteen cases, and is usually horizontal, but may be vertical or diagonal. It is one of the earlier symptoms, and is indicative of lack of muscular tone and co-ordination of the motor apparatus of the eye. In this respect it is entirely comparable with the nystagmus of Friedreich's disease. The visual fields are occasionally narrowed. This was noted in the case of two men in a total of seventy-three men, and in five women in a total of thirty-eight women. French authors believe that this symptom is confined to cases complicated with hysteria, but this statement may fairly be ques- tioned. The two cases which have been reported by Eskridge have been Fig. 20. 280 260 280 ' 260 Contraction of the color-fields in a case of syringomyelia. very carefully studied in this respect, and both showed narrowing of the visual fields. Neither of these could be construed as hysterical. Espe- cially in the case of one of them (George S.) was this considered and ruled out. On roughly testing the eyes there was " an apparent approach to left lateral homonymous hemianopsia," but by repeated careful tests with the 1 Archiv fur Psychiatrie, 1893, p. 324. SYRINGOMYELIA. 35 aid of the perimeter (see accompanying figure) it will be seen that while all fields are lessened, the left eye showing the greatest contraction, there is not a condition of hemianopsia. Two examinations were made thirty- nine days apart. Schlesinger cites twenty cases occurring in more hys- terical subjects where there was narrowing of the visual fields and sixty- seven cases where the fields were definitely known to be normal. When narrowing does occur it is found chiefly in the color fields, particularly green. Scotoma has not been observed. The condition of the external ocular muscles is not commented on excepting in very few cases. In these convergent strabismus from early childhood was noted six times. (Cases XXXIIL, XL., LIV., LXVIL, LXXX., CXI.) The ophthalmoscopic appearances when mentioned are usually negative. In Eskridge's second case, that of Jesse C. (No. XVIII.), the disk of the right eye was of a grayish-white color, with a central physiological cup ; its edge was sharp ; the sclerotic ring was seen around the disk rather more clearly on the temporal than on the nasal side. Two small pigmeut deposits were seen in the upper inner quadrant of the fundus about the diameter of the disk from its margin. The fundus of the left eye presented very much the same picture as that of the right, both having the appearance of com- mencing gray atrophy. The color-fields of these eyes are published in " International Clinics," 3d Series, vol. iv. p. 135. In rare cases amblyopia or even amaurosis from atrophy of the optic nerves has been recorded. 1 (6) Bulbar Symptoms. — The invasion of the medulla oblongata by the glioma or by the formation of a cavity gives rise to a distinct train of symp- toms. Among these laryngeal palsies assume a prominent place. Sensory paralysis of the larynx is somewhat uncommon, but motor paralysis is the form more frequently observed. The motor derangement consists more frequently in interference with phonation than in disturbances of respiration. Unilateral paralysis of the recurrent laryngeal branch of the pneumogastric is the commonest form observed. The paralysis is usually unilateral but in exceptional cases may be bilateral. Where bulbar involvement is marked we have more extended paralysis of motion. The muscles of the pharynx, the tongue, the lips, and even the facial muscles may be involved. It thus happens in a well-marked case that the expression of the face is altered, owing to paralysis of motor branches of the trigeminus. The lips are unable to perform the act of suc- tion, prehension ; the patient is unable to whistle. Mastication is interfered with and solid food requires to be washed down with water; saliva becomes unmanageable owing to the difficulty in swallowing it. The motions of the tongue are impaired and its structure undergoes atrophy on one or both sides, — speech is thick. 1 See casts recorded by Simon, Schultze, Westphal, Furatner and Zacher, Eick- holt, Glaser, and Schuele. 3 36 GUY HINSDALE, M.D. Sensory changes, if sought for, will be found, in a typical case, to be present within the mouth, the throat, and the larynx, as well as the external portions of the body. In a case carefully studied by S. Solis-Cohen all the foregoing symptoms were found, and extensive sensory changes as well. While tactile sensation was almost perfectly preserved, it was found that at times there were places on the face, lips, and within the throat where it seemed blunted. The temperature sense was found to be both blunted and perverted on the right side of the face, while at the base of the tongue, in the oesophagus and the larynx, it was blunted but not lost. Taste was absent from the anterior portion of the tongue in the distribution of the gustatory branch of the nerve. Other bulbar symptoms, such as vertigo, attacks of transient blindness, etc., may be noted, as has been recorded in the case referred to. Laryngeal symptoms are generally gradual in their onset and pursue a chronic course. Should, however, bulbar manifestations occur suddenly by apoplectiform attacks they would probably be of a hemorrhagic nature, and would be accompanied by vertigo, clouding of the mind, and even complete loss of consciousness, possibly with vomiting. This symptom might mark the extension of the glioma into the brain if accompanied with severe head- ache. Disturbances of hearing, of central origin, and the occasional appear- ance of polyuria may be added to this group of symptoms. 1 3. Symptoms of Posterior Poliomyelitis. — Degeneration or excavation of the posterior horns of the cord gives rise to the most characteristic symp- toms of syringomyelia. Disturbances of sensation are among the earliest features which can be traced in the history of most cases, and careful inquiry will almost always reveal incidents depending on the loss of pain sense or heat sense that antedate by several years the symptoms which lead a pa- tient to consult a physician. But sensory disturbances are not always ap- parent. There are exceptional cases in which such unusual variations from the classical type have been present that the most accomplished clinicians have been led into error. It was just in this respect that Raymond was led into a mistaken diagnosis of a case, for it was only during the last fifteen months of the patient's life that any sensory changes were found although carefully searched for. Rare cases of this kind, in which during the entire course of the disease no sensory changes have been noted, are recorded by Schuele, Schiiltze, Krauss, Striimpell, Bernhardt, and Par- men tier. In a case recently reported by Schlesinger (Case VI., Monograph, 1895), a woman, aged thirty-nine years, presented no loss of sensation in any form. 1 See articles by Herman F. MUller, A. Raichline, S. Solis-Cohen, H. Schlesinger, Klebs, Krauss, Grasset, and Adolf Schmidt. The author would also call attention to the extraordinary statement by Dr. Fred- erick I. Roberts (Theory and Practice of Medicine, Ninth Edition, 1894, p. 1108) that there is no bulbar involvement in syringomyelia. SYRINGOMYELIA. 37 The pressure sense, localization sense, pain sense, and temperature sense, for both warm and cold, were normal ; there was, however, hyperesthesia and hyperalgesia. The clinical diagnosis of syringomyelia was made by both Schlesinger and Ewald on the strength of other symptoms. Death followed a surgical operation, and a cavity extending from the lumbar region throughout the entire dorsal and cervical regions was demonstrated at the autopsy. The forms of anaesthesia which require investigation in a suspected case of syringomyelia are as follows: Thermo-anaesthesia (almost invariably present). Analgesia (generally present). Tactile anaesthesia (rarely present). Loss of muscular sense (rare). Loss of pressure sense (rare). Loss of localization sense (rare). It is quite unusual to find present in any given case thermo-anaesthesia, analgesia, and tactile anaesthesia, a condition conveniently expressed as triple anaesthesia. The symptom complex, which is considered almost pathognomonic of the disease, is a combination of thermo-anaesthesia and analgesia with preservation of tactile sensation. This constitutes the famous " dissociation symptom," as Charcot has designated it. This dissociation of sensibility is not confined, however, to syringo- myelia ; it is found in the case of several affections of the nerve-centres, very frequently, for example, in cervical pachymeningitis; occasionallv in neuritis, hysteria, alcoholic neuritis, traumatic neuritis, leprosy, haemato- myelia, locomotor ataxia, and extramedullary tumor of the cord ; and in mixed cases where there is injury both to the cord and to the nerve-roots. Two cases illustrative of the latter condition, in which the dissociation symptom was well marked, have been recently published by Lloyd, under the title of "Traumatic Affections of the Spinal Cord simulating Syringo- myelia." ' In the first of these cases a man, in falling from a scaffold, struck the back of his neck, and was believed to have sustained a fracture of the spinal column. The entire body, including both arms and legs, was paralyzed. He recovered from this, and eight years later he fell again and struck the back of his head and spine between the shoulders. Partial re- covery took place, but an examination ten years afterwards revealed to some extent the dissociation symptom. There was anaesthesia to cold ; cold objects in the affected area, as shown in the charts (Figs. 2 and 3, loc. cit.), were called hot. Analgesia of the right side was present, while tactile sensi- bility was everywhere good. In a second case a laborer, at the age of thirty, injured his cervical and dorsal spine by having fallen into a canal and being jammed be- tween two canal-boats, and was unable to resume work for three months. Journal of Nervous and Mental Disease, June, 1894. 38 GUY HINSDALE, M.D. At the age of fifty-seven he was severely injured by a fall of a bank of earth. After twenty-four hours' unconsciousness he was found to be paral- yzed in the left arm and leg. Three years later an examination showed, in addition to angular deformity of the spine, atrophy and fibrillary con- tractions of the left shoulder girdle muscles, a noteworthy disorder of sen- sation. (See Figs. 5 and 6, loc. cit.) The patient was unable to distinguish heat fronfcold or to recognize either in the region marked on the chart. The Fig. 21. Aricsst/iesta Thermo Ancestkesca. Aricpsthesca. T/zer/nc Syringomyelia.— Showing segmental distribution of sensory symptoms. thermo-amesthesia was on the right side, the side opposite the paralysis of motion. There was an area of tactile anaesthesia (not portrayed on the chart) involving the right leg. It may be possible that in these cases where trauma has played such a conspicuous part the conditions may be explained by the subsequent dis- covery of hsematomyelia and consequent excavation, the" myelite cavitaire" of French authors. However this may be, this author did not feel justified in making a diagnosis of syringomyelia, in these cases at least, in the present SYRINGOMYELIA. 39 stage of their clinical manifestations. On the other hand, it is quite likely that in less careful hands a positive diagnosis would be claimed. 1 Thermo- Ansesthesia. — Loss of power to recognize heat and cold is prob- ably one of the earliest symptoms ; it is a prominent feature all through the Fig. 22. Ancesthesca Anesthesia. Thermo Ancesh'iestci . Syringomyelia.— Showing segmental distribution of sensory symptoms. history of the majority of cases, although varying considerably in its extent and in its degree in individual instances. It is most commonly found in the hands and fingers of one side, or it may extend throughout one or both upper extremities, or be in a measure present throughout almost the entire area of the body. Thermo-ansesthesia is commonly limited by the median line of the body, and in these cases where both upper and lower quadrants are involved is sometimes described as hemiplegic thermo-ansesthesia. The line of demarcation between the normal and abnormal area is gen- 1 See, also, u publication by R. Verhoogen, entitled " Dissociation de la Sensi- bility dans un Cas de Lesion des Nerfs du Plexus brachial." Brussels, L894. 40 GUY HINSDALE, M.D. erally quite sharply drawn ; particularly is this the case on crossing the median line from the affected to the unaffected side. In its distribution, thermo-ansesthesia sometimes involves the face (as- cending branch of the fifth nerve); more often it affects the sides and back of the neck and is likely to be limited by the hair of the scalp behind (distribution of the occipitalis major and minor). It is obviously more likely to be discovered in the exposed areas of the skin, but on careful exploration areas on the thorax, horizontal belts in the abdomen, or possibly areas in the outer aspects of the thighs maybe discovered. Charcot asso- ciates its distribution rather oddly with the names of garments for the various localities ; thus he makes out the " forme de gant, de manchette, de manche, de bas, de culotte, de jambe de pantelon, de petite veste," etc. The distribution is sometimes symmetrical ; it is usually progressive in character. To elicit information in a suspected case of thermo-ansesthesia it is cus- tomary to use two test-tubes of precisely similar form and appearance, one containing hot water and the other cold. It is preferable to use a small object like a test-tube instead of a more bulky bottle, for the reason that normal skin areas adjacent to the affected regions may be sensible to radia- tion of heat from a larger mass. The wide difference of temperature present in the tubes at the start tends to grow smaller as the examination progresses unless precautions are taken. It is therefore desirable to know, by using a thermometer, the exact temperatures of the testing apparatus. Charcot used a surface thermometer, the bulb of which was inclosed in a metallic cylinder filled with copper filings. By these means the temperature acquired on placing the instrument over an alcohol-lamp may be maintained for a considerable time. (See also article by Leegaard.) Glass balls pro- vided with a perforated cork for the passage of a thermometer and half filled with water may be used. The glass ball can readily be heated in an alcohol flame as far as 212° F. Great care should be used in tests with temperatures above 180° F., as too long a contact might produce burns, the healing of which would be trouble- some. Thermo-ansesthesia may be said to be complete when the patient fails to recognize either ice when placed on the skin or an object heated to near the boiling point. Such extreme loss of temperature sense is not commonly met with, and the recognition of intermediate grades becomes necessary in most cases. Any one who fails to distinguish differences of 5° C. or 9° F. may be gaid to have thermo-ansesthesia (Roth). There is need in difficult or doubtful cases to make numerous examinations with relatively slight differences of temperature, especially in the moderate ranges between 80° and 140° F. Normal individuals vary very greatly in their acuity of perception, and the time reaction varies in different cases. So also allowances must be made for the natural variations of acuteness of sensation in various parts of the SYRINGOMYELIA. 41 body. According to Weber and Nothnagel, .40° C. can be distinguished at the finger-tips in favorable subjects; such fine differentiation is wholly impossible without the most delicate and reliable instruments, and would fail in persons whose perceptive powers are normally more sluggish. It is also shown that at extreme temperatures at either end of the scale slight differences are not so readily recognized as at the more moderate ranges. High temperatures may be recognized simply as painful if test is made in Fig. 23. yjt \Analge5fa. Syringomyelia. — Showing segmental distribution of sensory symptoms. the back, the thorax, etc., while at certain sensitive points, as, for instance, the finger-tips, they may be recognized in their true character. In other cases the sense is perverted, giving rise to hyperesthesia or complete reversal of the sense of heat and cold. In one of Bruhl's cases the skin of the right half of the thorax was sensitive to thermic impression in an exagger- ated manner. The application of tests of various degrees of cold is not quite so easy 42 GUY HINSDALE, M.D. on account of the difficulty in securing a series of different temperatures below that of the surrounding air. On this account abnormalities in the sense of cold are doubtless frequently overlooked. Error in the estimation of the degree of thermo-anaesthesia is liable to happen by reason of daily, and, it has been suggested, by hourly variations in the areas of distribution Fig. 24. e$t Syringomyelia.— Showing segmental distribution of sensory symptoms. and in the intensity of sensation. Such cases are recorded, and serve to explain discrepancies which arise in clinical studies. In general the same regions that are insensitive to heat are also insensitive to cold, but one area is not always exactly superimposed upon the other, and this fact had led to the belief in the probability of the existence of special nerve elements for the transmission of the sensations of heat and of cold. Cases are cited in which warm objects are recognized over certain areas, while cold objects are not recognized in the same location. It should be mentioned in connection with thermo-ansesthesia that the SYRINGOMYELIA. 43 mucous membrane occasionally is involved as well as the cutaneous sur- face. Analgesia. — Loss of the sense of pain in certain areas is one of the cardinal symptoms of syringomyelia. In its distribution it occurs in general in the same areas as in the case of thermo-anaesthesia. (Figs. 23 and 24.) It may be of various degrees from partial to absolute loss of pain sense. The prick of a pin is not recognized as painful. So profound is the anal- gesia in some cases that abscesses have been opened and even fingers ampu- tated and joints excised without a particle of pain. As we have previously mentioned, fractures may occur without any pain being felt. On the other hand, in exceptional cases hyperesthesia has been recorded in place of anal- gesia. Charcot explains this by conceiving that the period of destruction of the nerve elements is preceded in some way by a period of irritation. Hyperesthesia, when present, is more likely to be found in the lower ex- tremities. In estimating the degree of analgesia it should be borne in mind that individuals of the same class at different times vary greatly in this regard, and still more noteworthy is the difference between different classes of sub- jects. The subject of dermal pain has been investigated by Mr. Griffing, of Columbia College, New York. He shows that in kilogrammes the required amount just causing pain was as follows: 1 Kilogrammes. For boys 4.8 For college students 5.1 For law students 7.8 For women 3.6 II. Extrinsic Symptoms. — Symptoms due to 1. Sclerosis of the lateral columns. 2. Sclerosis of the posterior columns. These symptoms are due to alteration of the white substance of the cord, and have been termed by Charcot " symptomes leucomyeliques." They are naturally late in their manifestation, and indicate that the glioma has passed, in its influence, beyond the bounds of the gray matter, and that it or the resulting cavity intrenches on the lateral or posterior or other columns by pressure or actual degeneration. 1. Lateral sclerosis is recognized by well-known motor symptoms. Symptoms of spastic paralysis may be of all grades from moderate paresis with some stiffness to the complete stage where contracture supervenes. An early indication of this change is an exaggerated knee-jerk, and in an advanced case the addition of ankle-clonus. In sixty-one cases out of one hundred and eighteen the knee-jerk was plus. Spastic symptoms were noted in our list of one hundred and eighteen cases in eighteen instances. 1 Transactions of tin- A.merican Psychological Association, December, 1894. 44 GUY HINSDALE, M.D. 2. Symptoms due to sclerosis of the posterior columns or tabetic symp- toms are thought to be more common than the spastic symptoms. The well-known distinguishing signs are motor incoordination, defective station with eyes open or closed, lancinating pains, and loss of knee-jerk. We have noted tabetic symptoms in nine cases out of one hundred and eighteen. In a later chapter on the forms of syringomyelia we will refer to this sub- ject again. In one hundred and eighteen cases the knee-jerk was absent in six, diminished in four, normal in twelve. Tactile Sensibility. — This is, as a rule, preserved in syringomyelia, and constitutes, by its presence and by the absence of pain and temperature sense, the well-known "dissociation symptom." In some analgesic areas there is occasionally observed a lowering of the tactile sense, — hyposesthesia. This is tested by noting whether there is any deviation or disappearance of the appreciation of ordinary contact, of tactile pressure, of simultaneous tactile pressures, of the appreciation of outline (relief), and of the tactile perception of liquids. Absolute tactile ansesthesia is altogether exceptional, but, of course, where complications are present involving the white matter of the posterior columns, we naturally would expect disturbances of tactile sensation. The allied forms of sensation, the muscular sense, pressure sense, localization sense, etc., are almost always preserved in syringomyelia. It has been claimed that in some cases the sensation of skin pressure was entirely absent or at least very much diminished, while the deeper pressure sensation was normally preserved. The Paths of Sensory Impressions. — This subject opens a very interesting field for investigation, and one where many discoveries are yet to be made. Investigations that are purely anatomical and physiological bearing upon this subject have received considerable aid from the clinical study of syrin- gomyelia. It is a subject that also interests the psychologist. There seems to be a geueral agreement that the nerve fibres for the conduction of pain and temperature run in different tracts from those that conduct ordinary tactile sensation. Professor SchifF has always maintained that the gray matter conducted thermal and painful sensations, while the posterior col- umns conducted the tactile and muscular sense. Brown-Sequard differen- tiates this further, declaring that the central part of the gray matter serves for the conduction of the sense of temperature, its posterior and lateral parts for that of pain, while the posterior columns of the cord convey tactile sen- sibility, all three forms previously decussating in the median line. Gowers says that after decussation in the posterior commissure, the fibres subserving sensibility to pain pass upward on the antero-lateral ascending tract, and that those subserving temperature probably pass up in their immediate vicinity. Gowers quotes a case of injury to the cord in the upper cervical region involving the lateral column and gray matter, as the result of which there was an entire loss of sensibility to pain on the side of the body oppo- site to the lesion without any loss of tactile sensibility. "Experiments SYRINGOMYELIA. 45 seem to show that tactile sensibility is conducted by the posterior columns, and the integrity of these latter, especially in the earlier stages of the dis- ease, would account for its retention in some cases." ETIOLOGY. Sex. — Males are far more liable to syringomyelia than females. Out of one hundred and ninety cases, one hundred and thirty-three were in males and fifty-seven in females, or seventy per cent, and thirty per cent, respectively. The explanation of this is no doubt the influence of trauma in developing an innate tendency to the disease, or in producing directlv pathological conditions in the spinal cord, which are followed by glioma and cavity formation. Age. — The influence of age is probably active in great measure, as per- mitting occupations and exposure to accident, etc., which act directly. The following table shows the frequency in the different decades of life as col- lected by Schlesinger : Age. Male. Female. Total. 1 to 10 4 1 5 11 to 20 36 8 44 21 to 30 53 25 78 31 to 40 30 12 42 41 to 50 4 7 11 51to60 3 3 6 61+ 3 1 4 133 57 190 The decade in which the disease is most frequently observed is that of twenty-one to thirty years. There is a tendency to a somewhat later de- velopment of the disease in women than in men. One case of Schlesinger's (Obs. xvi.) occurred in a woman aged seventy-eight years. Occupation. — The vast majority of cases occur in those who live by manual labor. Overwork is frequently noted. Trauma. — A large number of cases are apparently the result of injury, particularly to the back. We may mention particularly cases of Oppen- heira, Strumpell, Sinkler, Stadelman, Minor, SokolofF, Silcock, Harcken, Bikeles, Alexis Thomson, and Eskridge. It may be said in this connection that Eickhorst found in experiments on animals in which the cord had been divided or injured that cavities formed frequently in the posterior columns, and sometimes extended into the central canal. In cases in which the syndrome in syringomyelia becomes suddenly present, especially when we have a history of a recent trauma, we may naturally suspect the existence of bsematomyelia, since hemorrhages of the spinal cord principally affect the central portion, — i.e., the gray Bubstance. The production of glioma in consequence of trauma requires a consid- erably longer time. It is quite likely that traumatic hemorrhages of the 46 GUY HINSDALE, M.D. Fig. 25. medulla may evolve hemorrhagic cysts, which would then have compact surrounding capsules of connective tissue, and might form the starting-point for central gliomatous degeneration. Such a pathogenic process may also occur when the central hemorrhage is not induced by trauma. In four cases, in which the organic lesion of the spinal cord undoubtedly resulted from trauma, Minor found many symptoms closely resembling those occur- ring in syringomyelia : for instance, the characteristic dissociation of sensi- bility. As the patients in question are still living, the diagnosis has not been confirmed. In a fifth case of traumatic haeniatomyelia death occurred after several days. The autopsy revealed a tubular hemorrhage throughout the entire gray axis of the spinal column. 1 The accompanying figure shows the arterial circulation for the cervical (0), dorsal (D), and lumbar (L) regions of the cord. How far excess in alcohol and exposure to cold and dampness are fac- tors in the production of the disease we cannot say. These influences are probably of small moment. It has been noted by Verhoogen and Vandervelden. Infectious Diseases. — These have a distinct predisposing influence. The following diseases have been observed in the previous history of subjects of syringomyelia : Syphilis (cases of Simon, Schuele, Neuhaus (Obs. i. and v.), Tornow) ; rheumatism, arthritis deformans (Klemm) ; typhoid fever (Bruhl, Bern- hardt, Freund, Westphal, Schiippel, Sokoloff, Schultze, Remak) ; tetanus (Knoppek and Meyer) ; variola ; erysipelas of the head ; chronic chorea (Duchenne and Hoffmann) ; Basedow's disease (Joffroy and Achard) ; pachymeningitis chronica (Rosenblath, Schmaus, Francotte) ; myelitis (Leyden) ; anterior poliomyelitis (Kah- ler and Pick) ; Friedreich's disease (Friedreich and Dejerine, Letulle). Heredity. — In two instances syringomyelia seems to have assumed a family type. Verhoogen and Vandervelden report the disease occurring in In an autopsy on one of these cases the anterior and posterior horns were found intact; the central canal, of an oval form with the long exis transverse, was found with its aperture closed and the cavity full of granular exudate and cells with gray nuclei and with cellular debris. In the mid-dorsal region there was sclerosis of the ex- ternal part of the lateral column and of the columns of Burdach and Goll. The canal was the same as in the cervical enlargement. In the lumbar Arterial circulation in the spinal cord. (Brissaud.) two sisters and a brother. Arcbiv fur Psychiatrie, vol. xxiv. SYRINGOMYELIA. 47 region there was sclerosis of the postero-internal part of the anterior column, and in the whole extent of the lateral column and the anterior portion of the column of Burdach alteration of the canal, most marked in the upper portion. Dr. Andrea Ferrannini has recently described four cases in one family, including two brothers, Nicola and Francesca, their sister Martaand mother Benedetta. At different times all four have sought medical advice for the same affection. Panaris, paresthesia, and special forms of dysesthesia, limited to a single upper extremity or abscess, developed without any ap- parent cause ; felons developed in the left thumb of the two brothers, in the right thumb in the mother, and in the right index-finger of the sister Marta. In Nicola, Benedetta, and Marta the swelling was followed by necrosis and complete destruction of the last phalanx in each case. In the fourth patient there was no necrosis. In all four patients the incision of the swelling by the physician at different times gave exit to a very small quantity of pus or sometimes only to blood. Marta felt neither the incision nor the extraction of the dead bone, much to the wonderment of onlookers. These manifestations occurred in two of the cases, Nicola and Marta, be- tween the thirtieth and thirty-fifth years, and in the others at about the fiftieth year. Panaritia were observed in all four patients, and the ulceration with acute oedema or pseudophlegmon of the forearm were noted in Nicola. There were marked vasomotor changes. Appearance of erythromelalgia in Francesca's left hand. These appearances would subside at times and the hand would suddenly become white and cold as though dead, then painful at times, constituting an acrodynia and an acroparesthesia, hyperesthetic rather than anesthetic. Disordered sensation to temperature. Heat was recognized as cold and vice versa. Formication in the calves of the legs, ankles, sole of the foot or shoulder, chiefly on the left side of the body. Burning, or a sense of cold, in the first three fingers of the left hand or in only one, particularly the ungual phalanx of the thumb. Frequently at times a painful sensation as from many pins pricking, or stings of bees. Also a curious sensation in the ball of the thumb. These sensations pre- cede an attack of erythromelalgia. The sensations were likened to the action of a file or the gnawing of an animal ; the pain was deep and either intermittent or intensifying towards a crisis. The pains were like those of syphilis except that there was no nocturnal exacerbation and no increased pain on pressure. A little ice in contact with the thumb gave the sensation of intense heat; a temperature of 5° C. was felt as hot; at other points of the body gave the sensation of contact only. On the other hand, there was complete loss of heat sense, even when tested to 100° C. Fibrillary twitchings present. Varieties. — The great diversity of forms of syringomyelia renders a classification desirable. We may have types as follows: 4 48 GUY HINSDALE, M.D. 1. Atrophic or anteropoliomyelitic. 2. Spastic and amyotrophic lateral sclerosis. 3. Sensory (posterior and median poliomyelitic). 4. Type M or van. 5. Lumbar type. 6. Unilateral type. 7. Bulbar type. 8. Anterior leucomyelitic or posterior leucomyelitic. 9. Latent form. 10. Non-typical cases. Clinically, we may say that there is a gliomatous form beginning early, — between the ages of fifteen and twenty-five. At quite an early period cicatrices from painless burns are found, marking the early appearance of thermo-ansesthesia. In other cases amyotrophy is one of the earlier signs. The early stage is long, but steadily progresses. In the myelitic form the onset is later in life; it has less tendency to progress, and may remain completely stationary. For example, in a case of Charcot's, the early symptoms, appearing at the age of forty years, as- sumed a paraplegic form, with cervical location, with amyotrophy, and with sensory and trophic disorders. These developed rapidly at first, and then remained stationary. Type 31orvan. — Morvau and Dejerine still claim for this affection a dis- tinct identity, but most authorities classify it as a type only of syringomye- lia. An argument for its identity is found in the apparent tendency of the disease to occur frequently in certain localities. This has been taken to indicate a toxic origin. Gombault's case, in which he found in a patient with Morvan's disease a peripheral neuritis with slight sclerosis of the cervical cord, lends some probability to this theory ; but it has lately been shown that peripheral neuritis may occur in syringomyelia as well as Morvan's disease, and that cavities in the spinal cord may occur in well-marked cases of the latter affection. 1 (Joffroy and Achard.) Thus Morvan's disease is held to be only a special clinical form of syringomyelia characterized by predominance of panaris. Unilateral Gliomatosis. — It is not unusual for the gliomatosis to be con- fined to the entire gray matter, or to a single half of the spinal cord. Such irregularities naturally give rise to difficulty of diagnosis. (See Fig. 26.) (The author is indebted to Dr. Charles K. Mills for the use of this figure, taken from his work on " Nervous Diseases," in press.) (Cases of Oppenheim, Rossolimo, and of Dejerine and Sottas and Wein- traud are of this variety.) The bulbar type has already been considered. Tabetic Type. — This type arises from a combination of tabes with syrin- 1 Soc. Med. des Hopitaux, 1890 and 1891. SYRINGOMYELIA. 49 gomyelia, or by an extension of the gliosis to the posterior columns. Such cases are not unusual, and have been recorded, among others, by Redlich, Eisenlohr, Nonne, Senator, Mann, Rosenblath, Jegorow, Schiippel, Schle- singer (Obs. xii.). Fig. 26. Unilateral glioinatois. In a recently published case of Oppenheim's (Arehiv fur Psychiatrie, vol. xxv.) a man, aged forty, had for a long time an affection characterized for the most part with signs of tabes (unsteadiness of gait, and, with eyes closed, increased sway). The knee-jerk was absent on the left side. There were troubles of sensation, with dissociation of tactile sensibility and ther- mic and pain sense, and scars on different portions of the skin. The sub- ject, who had kypho-scoliosis, was weak-minded, and had ideas of grandeur, etc. Dementia paralytica. Death ensued, and at the autopsy diffused glioma of the spinal cord and gray degeneration of the posterior columns were found. Chronic cerebral pachy- and leptomeningitis were found, dila- tation of the ventricles, atrophy, and gray degeneration of the nerves and optic fibres (bandelettes). Central gliomatosis of the cord and posterior fascicular degeneration. Glioma of the lower cervical enlargement extending through the dorsal cord to the lumbar enlargement. In the mid-dorsal region the entire gray substance was involved. In the lower part and in the lumbar region the gliomatous product was con- fined to the left half of the cord. In Oppenheim's case Clark's column was atrophied on the lef'f by com- pression and atrophied on the right by degeneration. In the lower part of 50 GUY HINSDALE, M.D. the dorsal cord the columns of Goll were degenerated. Lower down the degeneration is diffused throughout the two posterior fasciculi, and dimin- ished from above downward to the lumbar region. The degeneration ot Clark's column occupied in the same extent the right side, while the left column (the side of the lesion) had retained its normal character. At the seat of the lower portion of the glioma the degeneration of the posterior right column was still active. 1 The latent form of syringomyelia referred to by some authors includes those cases where no manifestations of the disease were noted during life, but where the true diagnosis was established at the autopsy. It is quite likely that if these unrecognized cases had been more closely studied during life, sensory disorders and other symptoms would have been given their proper weight. It would seem, therefore, that this class of cases would be likely to play a less conspicuous part in the classification of the various forms of the disease. It has been claimed that in the latent form the lesion may exist in the periependymal region, and yet there be no disturbance of the functions of the white or gray matter of the cord. A lesion localized on one side may not necessarily be revealed in any objective symptoms referable to that locality, for, although we are not able to say just how far compensation may exist or what the channels of commissural innervation may be, it is reason- able to believe that the function of one side may be more or less completely performed by corresponding nerve-cells of the opposite side by means of commissural communications, which physiologists teach us have an exist- ence. We are not in a position as yet to state just how these commis- sures act. SYRINGOMYELIA ASSOCIATED WITH OTHER DISEASES. Hysteria. — A few of the reported cases present hysterical symptoms. An excellent example is that reported recently by Dr. Agostiui, of Perugia. The woman was thirty-five years old, and gave a family history of alco- holism, phthisis, and nervous derangements. Her present illness began four years ago with neuralgic pains in the left scapular region, and with formication and a feeling of weight and debility in the arms, first affecting the pectoral region, then the arms, forearms, and, lastly, the hands. At the same time she developed hysteria, paraplegia, and aphasia, and later on the classical convulsions of hysteria major. These symptoms persisted for two years, and were finally treated successfully by hypnotism. Muscular force of right hand, thirty ; of left, five. Marked atrophy of the muscles of the forearm, of the interossei, and of the thenar and hypo- theuar eminences. Tactile sensibility is generally preserved, sas T e on the posterior part of Archiv fiir Psychiatrie, 1893, vol. xxv. p. 315. SYRINGOMYELIA. 51 the left upper arm, where hyperesthesia is present. Sensation of heat and cold and of pain are abolished from the neck to the ninth intercostal space and in the left arm. Muscular sense is intact, likewise sense of taste, sight, and hearing. Visual fields concentrically contracted. Pupils do not react. Exaggeration of the muscle and tendon reflexes. Reaction of degenera- tion in the muscles of the thenar and hypothenar eminences. Agostini concludes as follows : 1. Syringomyelia may be associated with hysteria, and confusion may arise when the difference pertains to sensibility alone. 2. The presence of progressive muscular atrophy, accompanied by di- minished electrical excitability, persistence of the muscular sense, point to a syringomyelic affection rather than an hysterical. 3. The best diagnostic criterion in this and other neuropathic affections is hypnosis, in which muscles with anatomical lesions do not pass into the cataleptic state. Cases of syringomyelia and hysteria have been recorded by Charcot and Asmus. Syphilis of the Central Nervous System. — This has been observed in con- nection with syringomyelia by Eisenlohr, Nonne, Jegorow, Beevor, Sou- ques (339), Sinkler (333), Rosen blath (303). It is liable to give rise to difficulties in diagnosis. Lepra. — A vigorous controversy has arisen as to the relation of this disease to cases reported as syringomyelia, particularly of the type Morvan. Zambaco and others have maintained that Morvan's disease, so called, is nothing more than anesthetic leprosy. There is no doubt that a strong analogy does exist in some cases between the symptoms of these affections and, to a less extent, scleroderma, ainhum, the tropho-neuroses, morphoea, and symmetrical gangrene. In discussing this subject before the Sociedade das Sciencias Medicas of Lisbon, Dr. Falcao expressed the opinion that Morvan's disease and syringomyelia are in reality anesthetic leprosy, but he believes that the other affections cannot be classed with this disease. Dr. Falcao was consulted by a patient from Para who presented the fol- lowing symptoms : Atrophy of the thenar and hypothenar eminences, in- terossei, and some muscles of the forearm, anesthesia, bent fingers, and thickening of the ulnar nerve. Dr. Falcao made the diagnosis of lepra anesthetica, which was justified not only by the symptoms present, but by the fact that the patient came from a country where leprosy is a common disease. Subsequently this patient went to Paris to consult Professor Charcot, from whom, it is said, he received a written statement to the effect that the disease in question was syringomyelia. The Gazcta Medica da Bahia relates the celebrated case of a French- man named Mares, who for more than seven years appeared in the hospitals of Paris as a case of Morvan's disease. Professor Hayem and Monod con- firmed this diagnosis, and the latter amputated several fingers of Mares, and published in the Archives de Midecine et de Chirurgie his observation- i 52 GUY HINSDALE, M.D. this case, which he regarded as a typical one of Morvan's disease. Later on, Broca confirmed the previous diagnosis and amputated two fingers of this patient. Again Hay em took charge of him, and amputated another finger. Several months later Mares was admitted to the Saltpetriere, where Professor Charcot had him photographed, and for eleven months exhibited him to physicians and students as a case of Morvan's disease. Later on, Charcot diagnosed Mares's case as syringomyelia, type Morvan. Finally, this patient was admitted to the Hospital de Bicetre, where Dejerine did not agree with Charcot as to the identity of these two affections, and stated that Mares had simply Morvan's disease. Gombault, who had made several histological examinations of the amputated fingers of Mares, admitted the diagnosis of Dejerine, — Morvan's disease. Dr. Zambaco procured the address of Mares, and, after examining him at his residence, he was convinced that he had before him a case of leprosy. In this it is reported that he was sustained by Vidal, Besnier, Tournier, Hallopeau, Quinquaud, Du Castel, aud Tenneson. 1 A genuine case of syringomyelia associated with leprosy, confirmed by both a bacteriological examination and an autopsy, has been recorded by Souza-Martin and L. da Camara Pestana. (See case, Semaine Medicate, No. 20, 1894.) The autopsy revealed in the cervical region a cavity in- volving the gray and white substance. The cavity was filled with a brown, diffluent mass. In preparations of this substance stained by immersion for six minutes in the carbolized fuchsine of Ziehl, then decolorized by nitric acid, he was able to find a great number of bacilli disposed iu groups of the length of four /*, presenting clear spaces separated by strongly colored granulations which were found usually at the extremity of the bacillus. These characters are those of the bacillus of Hansen (lepra). In this instance a case of syringomyelia diagnosticated two years before death has confirmed, for the first time, the ideas enunciated by Zambaco. While it is not possible to conclude from this one case the etiologic unity of syringomyelia and leprosy, it leads us to recognize that the syringomyelic affection of the type Morvan may afford an easy entrance for the bacillus of lepra. In leprosy with nervous disturbance the disease seems to depend on a neuritis, — i.e., that tactile sensibility is involved as well as the other forms of sensibility. In very rare cases, — e.g., that of Rosenbach, — we find at the seat of the macules preservation of tactile sense with alteration of temperature and pain sense. The distinguishing features are as follows : Syringomyelia. — Disassociation of sensory disturbances; integrity of superficial muscles of the face; absence of discolorations on the skin ; hair unaffected ; deviations of the spine. 1 See article by Dr. Alvarez, of Hawaii, Pacific Medical Journal, January, 1895. Also Semaine Mtklicale, 1893, pp. 289, 295. SYRINGOMYELIA. 53 Anoesthetic Leprosy. — Abolition of tactile sense; atrophy and paresis of the superficial muscles of the face; thickening and nodulous swellings of nerves; discolorations (painless) upon the body. Zones of anaesthesia and thermo-anaesthesia irregularly distributed in the shape of plaques with sharp transition from the affected to the normal areas. These spots or islets of anesthesia are circumscribed by a reddish line a little raised and very irregular. In syringomyelia, on the contrary, the anesthetic zones of thermo- anesthesia occupy large areas limited by regular lines. Souza-Martin goes to the extreme in denying that syringomyelia is a nosological entity, and affirms that it is merely a condition that confronts us and not a disease per se. He attempts to claim that it is similar in a certain sense to cavernous affections in the lungs, which he says we might just as well call syringopneumia ; in other words, the condition known as syringo- myelia may be present in various diseases, among which he reckons leprosy. It is needless to say that we dissent entirely from his views. As to the relationship of lepra and syringomyelia we believe that an individual who may exhibit symptoms of syringomyelia or Morvan's disease may have, in addition, leprosy. For example, this was recently observed by Pitres and Sabrazes in what they report as a case of systematic nervous leprosy of syringomyelic type. It required a bacteriological examination to determine its real nature. To accomplish this it was necessary in one case to excise a portion of the neuritic nerve from the living subject. The bacillus was found in large numbers, limited, however, to the nerve-fasciculus itself, none being found in the perineurium, the intrafascicular tissue, or in the vessels. In three other cases where the bacillus was searched for and not found the conclusion was reached that leprosy and syringomyelia are distinct effec- tions, both as to etiology and nature, notwithstanding that certain analogies are present in their symptoms. The weight of authority is in favor of the duality of the diseases, Zambaco being the principal claimant for their identity. Syringomyelia and Chronic Hydrocephalus. — This combination points to the developmental origin of syringomyelia. Out of one hundred and thirty reported cases examined Rupfer berg found fifteen in which a syringo- myelia or hydroinyelia accompanied a chronic idiopathic hydrocephalus. The cases of syringomyelia were those of Langhans (4), Westphal, Kiewlicz (1), Chiari (2), to which we add those of Voughl and Schlesinger (Obs. 13). The latter has also recorded a case of hydrocephalus, idiocy, and syringomyelia combined. (Obs. 29.) Spina Bifida. — This affection furnished the cases in which some of the earliest observations of syringomyelia were made. It is more distinctly related, however, to hydroinyelia. (See cases of Pagenstecher.) 54 GUY HINSDALE, M.D. Tumors of the pons, cerebellum, and cerebrum have been found in cases reported by Gowers, Harris, Kronthal, Hoffmann, and Schultze. Cervical Hypertrophic Pachymeningitis. — In Rosenblath's case this was believed to be the primary condition and the syringomyelia to have developed later. Other cases have been reported by Raymond and Critz- man. Acromegaly and Cheiromegaly. — Marie exhibited about a year ago before the Medical Society of the Hospitals of Paris a case of this character. The patient was a young man of twenty-one, having syringomyelia. His right hand and left foot had for some years been much increased in size. Charcot and Brissaud have also described a form of trophic affection of the bone under the name of cheiromegaly, which, as the name implies, is an increase in the size of the hands and fingers analogous to acromegaly. Holschevnikoff and Recklinghausen have described cases of syringomyelia with acromegaly; it is quite likely that the latter is only a trophic disturb- ance entirely secondary or a part of the primary syringomyelia. Hoffmann (Obs. 12) and Karg have published similar cases. (See Frederick Peter- son's case.) Amyotrophic Lateral Sclerosis. — Lloyd's case. (See Figs. 8, 9, 10, and 13.) Friedreich's Ataxia. — This disease is probably closely related to syringo- myelia. The motor symptoms, the spinal curvature, the trophic and vaso- motor symptoms, to a slight extent the sensory disorders, the bulbar symp- toms, and particularly the nystagmus, all point to the intimate relationship of the two affections. Further than this, in three out of the twelve autopsies in cases of Friedreich's ataxia collected by Griffith cavities have been found. Among other diseases which have been noted in connection with syrin- gomyelia we have Basedow's disease (Joffroy and Achard), pellagra (Pel- lizi), Friedreich's disease (Friedreich, Dejerine, Letulle), general paralysis and dementia (Fiirstner and Zacher, Kanasugi, Hoffmann, Czerny), chronic chorea (Duchenne and Hoffmann), idiocy (Arndt), melancholia (Schuele, Meyer), mania (Defoix), and cancer of the stomach (Jeffries). The mental state is, as a rule, undisturbed unless bulbar involvement ensues. DIAGNOSIS. So much has been said in the foregoing chapter on the relation of this to other diseases that a full discussion would involve much useless repeti- tion. It may be said in general that the diagnosis of syringomyelia now rests upon a firm foundation, and, in a classical case, ought to present no difficulty in forming a correct opinion during life. In fact, the diagnosis is repeatedly made intra vitam and corroborated at the autopsy, and that too in cases that depart in some degree from the typical form. It naturally happens that where trophic changes assume prominence, or in cases of amy- SYRINGOMYELIA. 00 otrophy or amyotrophic lateral sclerosis, or those cases in which the disease is said to be latent, difficulties will arise. But, whatever the predomi- nating form, we must depend for our diagnosis and lay great stress on the more characteristic signs of the disease, particularly sensory troubles and the dissociation symptom. This is not, however, an infallible guide. Fig. 27. Syringomyelia.— Showing analgesia (vertical lines), thermoanesthesia (oblique lines), tactile anses* thesia (horizontal lines). This case was associated with amyotrophic lateral sclerosis. Clinical observations prove that the dissociation of sensibility exists in circumscribed neuritis or polyneuritis as well as in the neuritis of leprosy (Leloir, Babinski, Thibierge, Pitres and Sabrazes, ChafTard, Rosenbach, Ziehl, Nothnagel, Ferrannini), in alcoholic neuritis (Lancereaux, Lemoine), in neuritis with tabetic symptoms (Joffroy and Du Cazal and Parmentier), and in the neuritis following trauma, as in a case of Charcot's. In this instance a gunshot wound of the neck produced an injury to the nerve-roots with the occurrence of thermo-ainesthesia. 1 Lloyd's cases of traumatic affections of the spinal cord are also cases in point. As a rule, the dissociation symptom is observed in all reported cases, but there are a few in which this symptom is not stated to have been ob- served, but where other important disorders of the nervous system have existed, and at the autopsy a syringomyelia was found (Schuele, Striimpell, Schultze, Schlesinger, Obs. 6). Unless one makes a practice of exam- ining in a careful manner the state of the various kinds of sensibility in all cases of nervous disease, it will be quite likely that cases of syringomyelia will be allowed to pass as hypochondriac, neurasthenic, or as suffering from 1 Clinique des Maladies du Systeme'nerveux, Paris, 1892, p, 56 GUY HINSDALE, M.D. neuritis, arthritis, etc. Cases of unusual joint-disease should always excite our suspicions, and should be tested for therrno-anaBsthesia and analgesia. So also in any case of spontaneous fracture or repeated dislocation in a case of arthropathy. On the other hand, a diagnosis of syringomyelia may be erroneously made in instances of syphilitic tumors of the spinal cord. Such a case has been recorded by Dr. Beevor, of London. A gardener, aged fifty years, after two days' exposure to wet in July, 1892, began to drag the left leg. In a few hours he had weakness of the left arm and numbness of the right knee. "He noticed the weakness of the left limbs for a fortnight before admission, as well as wasting of the left arm." On the right side the numb- ness spread up to the groin, and during the last fortnight to the nipple. He had no pain till a week after the onset of the symptoms, when he began to have pain in the left shoulder, elbow, and wrist, and numbness in the left thumb and radial border of the forearm. There was no affection of the sphincters, and no history of gonorrhoea or syphilis. On admission into the National Hospital for the Paralyzed and Epileptic, in September, 1892, he had wasting of both the upper limbs, especially the left, with marked wasting and loss of power in the left serratus magnus, supinator longus, muscles of the forearm, and intrinsic muscles of the left hand, as well as weakness of the left lower limb, so that he could only just raise the leg off the bed. Sensation was lost to pain, heat, and cold of the whole of the right leg and the right half of the trunk up to the fourth rib, while tactile perception was normal. The knee-jerk was excessive on the left side, and left ankle-clonus was present. Later, the loss of painful sensation spread up to the right arm (ulnar border) and left forearm, involving the radial border. There was loss of electrical reactions in the intrinsic muscles of the hand. Later, he had paralysis of the sixth nerve of the right side, and he gradually became worse, and died on November 14. On examination post mortem, two syphilitic tumors were found on either side of the brachial enlargement of the cord, the left one passing nearer the cord than the right, but the cord was too soft for accurate examination. The following statement of the similarity of symptoms and of points of divergence will be useful in distinguishing syringomyelia from atrophic paralyses : Progressive Mus- Amyotrophic cular Atrophy. Lateral Sclerosis. Syringomyelia. Age 25 to 35. 25 to 35. 20 to 45. Sex Male. Male. Male. Onset Gradual. Gradual. Gradual. Course Progressive. Progressive. Progressive with remission. Muscular atrophy Marked. Marked. Marked in the arms. Tactile sense Intact. Intact. Intact. Pain sense Normal. Normal. Lost. Temperature sense Normal. Normal. Lost. Tendon reflexes Diminished or 0. SYRINGOMYELIA. 57 COURSE AND PROGNOSIS. The disease is essentially a chronic, afebrile one, lasting generally for a considerable length of time. Patients have been known to live forty years after the onset of the symptoms. Remissions are liable to occur in the course of the disease, and at least two patients, one of Bruhl and one of Schlesinger, have died at the age of seventy-three years. Harcken, how- ever, believed that he saw it take an acute course in one instance. The prognosis is unfavorable. Death may come gradually by progress of the disease, producing cachexia, emaciation, bed-sores, etc., or, particularly, by the aggravation of certain symptoms of the disease, such as trophic dis- turbances, panaris, phlegmon, or vesical disorders. Intercurrent affections, such as tuberculosis, etc., are common terminations. TREATMENT. Medical. — Pain very commonly demands relief. Owing to the chronic nature of the malady it is better to rely on preparations like antipyrin, acetanilid, or phenacetin than to begin the use of opium. Bromides and chloral will also be occasionally required. Lukewarm baths are often of considerable use. Revulsive applications of hot and cold water along the spine are sometimes useful, but care has to be taken on account of the lia- bility to trophic disorders of the skin. On this account the cautery would be liable to give trouble. Tonics, such as iron and arsenic, phosphide of zinc, nitrate of silver, and iodide of potassium, have all been used to palliate the condition. Surgical. — Local treatment for panaris or ulcers on the extremities, for cracks or slowly-healing sores the result of unfelt burns, and for boils will be demanded. It is for the relief of these affections that patients commonly consult a physician or surgeon. It is important to secure the healing of obstinate cracks and fissures so as to prevent septic infection. The analgesic skin should be protected from injury. It will be necessary to avoid hard labor, and, to counteract atrophy, it will be useful to use massage and electri- cal stimulation. In cases where arthropathy with fluid develops, a surgeon may be needed either to aspirate the affected joint or for the removal of inconvenient osteo- phytes or for the closing of a persistent sinus. In an extreme case resection of the joint has been required. Surgical operations, however, arc attended with more risk in these cases than in ordinary subjects. CASES. CASE I. — Robert C, colored, aged thirty-one, bom in the United Slates ; weight one hundred and eighty pounds, height medium; previous occupation, boot-black. Father drowned ; mother, alive; three sisters died <»(' phthisis. He'gives a history of" erysipelas" in infancy ; otherwise the patient has always been healthy, but has been an extensive masturbator. He denied syphilis or gonor- rhoea. At the age of ten he was run over by a heavy wagon, his right leg being severely injured. 58 GUY HINSDALE, M.D. Fig. 28. The present disease began when sixteen years of age. He says that his right shoulder began to fall and that this was accompanied by a feeling of excessive weak- ness in the left side. About six months after this he began to limp in walking as though he had stubbed his toe. A year later he noticed a feeling of weight in his left side. This gradually grew worse so that when blackening boots he had great difficulty in polishing the left side, and his brush would continually fall from his left hand. This continued for about five years. During this time he was compelled to use a cane. His right hand did not seem to be affected at this time. About four years ago he noticed a tendency to flexion of the fingers of the left hand, — a claw-like con- tracture, — main-en -griffe. Two years later the right hand became similarly effected. He has never had any pain in his lower limbs. Sensory disturbances began three years ago. S. P. — The patient is a well-nourished, rather intelligent, light-colored negro. As seen in the accompanying photograph, taken at the Philadelphia Hospital, and furnished together with the following notes through the kindness of Dr. Dercum, he sits in a rolling chair during the day, since he is unable to walk or to move his arms. He has very limited motion of the fingers, particularly those of the left hand. The fingers of both hands are strongly contracted, as seen in the photograph, presenting the typical contracture of main- en- griffe. There is atrophy of both upper extremities, but more on the left side. The extensors of the forearm are wasted more than the flexors. The thenar and hypothenar eminences and the interossei muscles are mark- edly atrophied. The man is quite helpless and is unable to move from side to side when placed on his back. There is an aggravated scoliosis with convexity to the left. The tongue is protruded straight, but shows a slight atrophy to the right side with fibrillary twitching. He is unable to swallow perfectly, and has more difficulty with solid food. Reflexes. Right. Plantar Present. Ankle-clonus -f Knee-jerk -j- Cremasteric Present. Muscle-jerk -f- Epigastric Abdominal Contralateral reflex of adductors.... Present. Left. Slight. Eye examination, January 23, 1895. Pupils normal ; no paralysis of external ocular muscles; fundus normal; optic disks normal. The sensory changes are well seen in the accompanying charts. SYRINGOMYELIA. 59 There is partial analgesia over the entire surface of the body, excepting in the posterior aspect of the left forearm, and in a smaller area in the right lumbar region, limited by the lumbar spine, the tenth rib, and the right iliac crest. In these regions the pain sense is normal. Analgesia is complete in the right hand and wrist, posterior aspect of the left hand and left arm and right leg, and in the anterior aspect of the left lower extremity. (See Fig. 29.) Fig. 29. Sensory changes in Case I., Robert Collins.— Tliermo-ancesthesia, oblique lines ; confusion of sensation, circles ; analgesia, vertical lines. There is total thermo-amesthesia in the right arm and hand [and right side of the posterior thorax, in the left neck and shoulder posteriorly, and over the right anterior side of the waist nearly to the middle line. It will be noticed that this area is not quite superimposed upon an area of analgesia at about the same situa- tion. Over the anterior surface of the left forearm there is confusion of the thermic sense (represented by small circles in the figures), heat being designated cold, and cold, heat. Case II. — Joseph Shiselbaer, aged fifty-two, German tailor. Father died at sixty-five years of a paralytic stroke. Mother died of senility at sixty-seven. Drinks a little; syphilis denied. In the summer of 1890 lost his appe- tite, became costive, and felt unwell. In December, 1891, he gradually lost feeling in the right hand and arm and could not do his work. He never lost power. Later he losl power of feeling in the left hand. Sensation of pins and needles in both hands and arms, also in the legs. Arms and legs also cold. He never had severe pain. Since December, 1891, was lmrned many times on the hands and arms without feeling it. Is very emotional. S. P. — A well-built man. No atrophy. Pain on pressure in both axillae. No pain over the median or ulnar nerves. Spine straight; no pain on flexion of spine or on pressure. Scars from burns on index finger and thumb of the right hand. The right metacarpophalangeal joint of the thumb is enlarged and not painful. Reflexes. — Elbow-jerk gone on both sides. Knee-jerk. No true clonus. 60 GUY HIKSDALE, M.D. Eyes. — Pupils equal ; small, react to light and accommodation. No change in form fields. Dynamometer: Right 76 ; left 100. No palsy in arms. Some trouble in touching the fingers and nose. Fibrillary twitchings of muscles of right forearm. Heat and cold sense on the right side not distinguished on the tips of the fingers, but he can distinguish at base of fingers on the palmar aspect. The patient distinguished heat and cold well on the anterior surface of the arm, not so well on the posterior surface. Left hand same as right. At the base of the fingers feels heat only. In the anterior aspect of the fingers can recognize both heat and cold. Thermo-anaesthesia. In little finger (dorsal surface of left side) hot is called cold. Cold always felt and judged correctly, even in anaesthetic areas. Confusion of sensation of heat and cold on palmar surfaces of both hands. Hot invariably called cold on the palmar surface of the left hand, and sometimes called warm and sometimes cold on the right side. Hot is called cold on right side over the areas of anaesthesia ; not so on the left side. Can distinguish between hot and cold test-tube if time be given and the difference great. Almost always answers correctly as to cold ; often does not feel heat at all, and sometimes calls heat cold, but never cold heat. Heat and cold sense normal on other parts of the body. Tactile sense on right arm diminished on the back of the arm and radial region of the forearm, lost on the back of the hand and tips of the fingers. On left arm can distinguish between sharp and dull points except on back of hand and first two fingers. Tactile sense normal on the left little finger. Sensation to pain diminished in proportion to the area of tactile anaesthesia. The position of the arm is noted well. Muscular sense normal. BIBLIOGRAPHY. 1. Abbe, Robert, and Coley, W. B. — Syringomyelia; Operation, Exploration of the Cord; Withdrawal of Fluid, Joum. Nerv. and Ment. Pis., 1892, p. 512. 2. Achard, Ch. — Syringomyelic avec Amyotrophic du Type Aran-Duchenne et Anesthesie dissociee en Band Zosteroide, Gaz. hebdom., April 16, 1896. Syringomyelic, Type Morvan, Gas. des Hopit., 1891, No. 82. 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Dimitroff, Stephan (of Adrianople, Turkey). — Archiv fur Psychiatrie und Nervenlcranhheiten, xxviii. Bd. 2 Heft and xxix. Bd. 1 Heft, Berlin, 1896, 82 pp. This essay contains a valuable synopsis of 297 cases hitherto published, classi- fied in four groups. 388. Saxer, F. (of Marburg). — Beitrage zur pathologischen Anatomie und zur allege- meinen Pathologie, xx. Bd. 2 Heft, Jena, 1896, 66 pp. Total References, 514. NDEX. 1 Acrodynia, 47. Acromegaly, 54. Agostini, 50. Alcohol a cause, 40. Amblyopia, 35. Analgesia, 43. Aran-Duchenne, 18. Arterial circulation, 4(3. Arthritis deformans, 28. Arthropathy, 22-29. Aspiration of joint, 24. Atrophies, 18. Bulbar symptoms, 35. Cancer, 54. Cavity, 8. Cervical pachymeningitis, 54. Cheiromegaly, 54. Circulation in the spinal cord, 46. Clark's column, 12, 49, Cold, sense of, 32, 47, 59. Cystitis, 33. Definition, 4. Derivation, 3. Dermographism, 32. Development, 6. Diagnosis, 52, 54. Dissociation symptom, 37, 55. Kffusion into joint, 24. Electrical reactions, 19. Embryology, 5. Embryonal cells, G. Erythromelalgia, 47. Etiology, 45. Excision of shoulder, 24. Eyes, 3:;. Ferrannini, 47. Fibrillary tremors, 19. Formication, 47. Fracture, 30. Friedreich's ataxia, 54. Gait, 19. Gangrene, 20, 22. Glioma, 15. Heredity, 46 Histology, 5. Hydromyelia, 4. Hyperesthesia, 51. Hypnotism, 50. Hysteria, 50. Infection, 20, 57. Infectious disease a cause, 46. Knee-jerk, 44, 56, 58. Laryngeal palsy, 36 Latent form, 50. Lateral sclerosis, 43. Leprosy, 51. Lloyd, 8, 12, 27, 37. Macroscopic appearances, 8. Marinesco, 25, 27. Melancholia, 54. Meninges, 31. Mesoblast, G. Morgagni, 3. Morvan's type, 48. Mouth, 21. Myelite cavitaire, 4, 15, 38. Myelosyringosis, 4. Nerve-supply of articulations, 21 Neuritis, 15. (Edema, 21, :'.::. Ollivier, 8. < teteoma, 29. Fain, dermal, 18. Pathoiogy, 8. Pemphigus, 20, 21. Portal, 3. 1 For authors' name-, see Bibliography. 7;; 74 INDEX. Position of cavity. 10. Posterior sclerosis, 13, 44, 48. Pupils, 33. immobility of, 34. Rachetti, 3. Reaction of degeneration, 19. Santorini, 3. Scoliosis, 31. Sensory symptoms absent, 3G. Souza-Martin, 52, 53. Spastic symptoms, 43. Sphincters, 33. Spinal column, 30, 53. Spinal fluid, 15. Stilling, 3. Symptom atology, 17. Syphilis, 46, 51, 56. Temperature, surface, 22. Thermo-ana3sthesia, 39. Tongue, 21. Trauma a cause, 45. Trophic changes, 20. Ulcerations, 20. Varieties of syringomyelia, 47 Vasomotor disturbances, 32. Visual fields, 34. H insdale S ^ingongrelia, R C^06.S9 1897