COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD r- HX64126609 noooo .L^a Pachymeningitis spin ■***- fll ■*v*r' Jte. ~ Hfk> .*? '*~-y£~ '*£& . ^ i. -; c^va >4w3^&'.v «& ^ ■ .. '■».* ■?- *. 4 ~r &»; R£2&3_ L26" Columbia (MnitJer^ttp intljeCitpofltogork CoUegt of $f)psirians; ano burgeons; TLibxavp With the Authors' Compliments Pachymeningitis Spinalis Externa. RECOVERY COMPLETE. BY F. W. LANGDON, M.D. Professor of Nervous and Mental Diseases, Laura Memorial Woman's Medical College; Clinical Professor of Nervous Diseases, Miami Medical College ; Neurologist to the Cincinnati Hospital. AND BY ALBERT H. FREIBERG, M.D. Professor of Surgery, Laura Memorial Woman's Medical College; Orthopedic Surgeon to the Cincinnati Hospital. CINCINNATI, OHIO. REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION AUGUST 26, 1899. CHICAGO American Mkdical Association Press 1899. Pachymeningitis Spinalis Externa. RECOVERY COMPLETE. BY F. W. LANGDON, M.D. Professor of Nervous and Mental* Diseases, Laura Memorial Woman's Medical College; Clinical Professor of Nervous Diseases, Miami Medical College ; Neurologist to the Cincinnati Hospital. BY ALBERT H. FREIBERG, M.D. Professor of Surgery, Laura Memorial Woman's Medical College; Orthopedic Burgeon to the Cincinnati Hospital. CINCINNATI, OHIO. REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION AUGUST 26, 1899. CHICAGO Ameeican Medical Association Pkess 1899 PACHYMENINGITIS SPINALIS EXTEENA. RECOVERY COMPLETE. J. X., aged 19, an American of Hebrew parentage, single, a salesman and clerk, was referred to the Cin- cinnati Hospital, neurological service, by Dr. A. V. Phelps, February 28, 1898. 1 His chief complaint was "loss of power in arms and legs" of six weeks' duration. A few days before his ad- mission he developed fever and a feeling of general illness which led him to apply for admission to the hospital. Family History. — His father died of "throat con- sumption," at the age of 49, having been ill for one year following a wetting and severe cold. His mother is subject to acute rheumatic attacks. One brother died in infancy; one sister has inflammatory rheumatism; three brothers and one sister are living and well. Personal History. — He has been generally healthy and remembers no illness up to 14 years of age, when he had "sore throat," lasting two days. Syphilis can positively be excluded. He had gonorrhea eight months ago followed in two weeks. by pain and stiffness in the back of the neck, which he called "rheumatism." He recovered and returned to his business within month, and was Avell for the succeeding five months witli the exception of occasional pains in the back of the neck which did not disable him. There were no paralytic symptoms during this time. The onset of the paralysis was gradual, beginning about six weeks before his admission to the hospital and being accompanied by some pain and rigidity in back of the neck. Motor weakness began in the left arm, and i Acknowledgements are due to Drs. Victor Ray and John S. Rogtress. internes, for their careful examination and history of the case, of which the following- is an abstract, and also to our colleague, Dr. Herman H, Hoppe, for kindly permitting the use of notes made during his term of service. 306553 gradually increased until in one week the entire limb was helpless. During this period the right arm became weak and he gradually lost the use of it. The legs were affected last ; presumably simultaneously. Within a month — probably within three weeks — he was com- pletely disabled in all four extremities. At no time- previous to admission has he had any pain in his limbs,. or any bladder or rectal defect. He has had no cough ; has- had some headache and fever for two or three days before admission. Temperature shortly after admission was 101.6 — rising to 104.2 within twenty-four hours — pulse 116, respiration 30. 2 2 This pyrexia and its accompaniments are apparently due to an inter- mittent tonsillitis, so far as can be seen unconnected with his spinal lesion, and subsiding within a few days. See temperature chart appended. Present State —February 29, 1899. Height is 5 feet, 8 inches, weight 138, of medium build, dark complexion; black curly hair, dark eyes. His general nutrition is good. Part of the thorax and abdomen is covered with a growth of pityriasis versicolor, which patient states has been present for six years. His neck is rigid, its tissues apparently in- filtrated and indurated posteriorly. There is not much tenderness on pressure and manipulation. The left tonsil is swollen, its follicles being distended and filled with grayish-white secretion. The uvula and soft palate are bifid; no edema of larynx or pharynx. Patient can swallow and talk without much discomfort. His mental condition is good; speech not impaired: cranial nerves not affected. Trunk and Extremities. — Patient can not stand nor walk; quadruplegia is present, practically complete be- low elbow and knees; he can flex all fingers feebly. The paralysis is moderately rigid, almost "waxy" in type. Foot and wrist drop are marked on both sides. He can flex and extend both elbows feebly. Extension at elbows is notably stronger than 'flexion. Grasping power to dynamometric test E, 0. L, 0. Sensation. — Tactile sensibility is somewhat dimin- ished in acuity at the ends of the fingers, elsewhere ap- parently normal. Pain and temperature senses are not accurately tested at this date. Note change in cutaneous sensibility four dsys later, as shown by charts appended. Reflexes. — Organic. No defects of deglutition, defeca- tion or micturition. Tendon: Elbow-jerks present and equal; wrist-jerks present, active and equal. Knee-jerks present, exaggerated and equal; rectus and ankle-clonus present and equal on both sides. Cutaneous : Not ob- served. Vasomotor system : Patient sweating freely. Trophic: No muscular atrophy observable to ordinary examination. No trophic ulcerations. Urine. — Eeaction acid, barely; sp. g. 1030; phos- phates in excess ; albumin and sugar absent. Blood-count shows a moderate leucocytosis (16,500.) This was probably due to the intercurrent tonsillitis. July 10. — A tuberculin test, with m. xv of a 1-250 so- lution was followed in two hours by headache, and chill and sweating in twenty-six hours- Two days after ad- mission the acnte tonsillar inflammation subsided, the temperature dropped to normal, and for the next four weeks fluctuated between 98 (a. m.) and 100 (p. m.), only once during this time rising 2 degrees above the '100 mark. After the two weeks following this period, the temperature varied between 98.4 (morning) and 99. -L- (evening). (See chart appended.) Be-examination four and five days after admission. (See chart No. 1.) Motion. — Quadruplegia, of waxy, rigid type is still present. The pectorals, deltoids, supinators, small thenar muscles, and short extensors of toes seem abso- lutely powerless on both sides. Elsewhere the muscular power is barely sufficient to flex and extend joints, ex- tension seeming rather stronger than flexion at the elbows. The tongue protrudes in the median line, is longitud- inally fissured, and a general fibrillary tremor of the en- tire organ is present. Sensory defects of a "dissociation type" have appeared as per Chart No. 2. These consist practically of diminu- tion and loss of appreciation of heat and — to a less de- gree — of cold, with preservation of tact and pain over thorax, abdomen and upper arm anteriorly, and on fore- arm and hands anteriorly and posteriorly. (See Chart 2.) Tests were made in the ordinary manner with test-tubes of decided warm and cold water for tempera- ture, cotton and pin for tact and pain. A week later (see Chart 3) these sensory defects were increased by addition of an area of analgesia over the thorax anter- iorly. At this date power in legs has apparently in- creased, so that he can move both feet and legs with considerable freedom as he lies in bed. Reflexes. — Pupils are moderately dilated when at rest, respond well to accommodation and contract to light, but do not dilate farther when light is excluded. Or- ganic : Has to be catheterized for a day or two. Vaso- motor: "Well marked "tache" over thorax and abdomen. Trophic : jSTo "bedsores" or other ulceration. March 17. — Electrical tests now and later showed partial E. D. in muscles of hypothenar group of right hand, as evidenced by very sluggish contraction to gal- vanism and nearly equal responses to both poles, though K. C. is slightly greater than A. C. Muscles elsewhere react normally to galvanic and faradic currents. There is slight improvement in power of legs and arms. Twelve days later the motor symptoms were practi- cally unchanged, the defects of heat and cold sense were somewhat diminished in area, but persisted on thorax and a longitudinal strip along the inner surface of the right arm ; forearm and hand; also over left forearm and hand posteriorly. (See Chart 4.) March 29. — About this time I asked my colleague, Dr. Freiberg, orthopedic surgeon to the hospital, to see the patient, and it was decided by his advice to make extension on the entire vertebral column in the hope of relieving the pressure which was presumed to exist on the upper cervical cord. The effect of the extension and counterextension on the sensory symptoms was startling. Twenty-four Lours after application of the apparatus, it was difficult to detect any sensory loss over thorax or abdomen, and when found it was in such ^<5L, Chort3.-JX ■fcua oX-servt ' - r/jutt defiecTTire. 1 1 <■' Co IcL cIx'^CcIlvtj -Tact-nc/rrn.at irregularly scattered patches as to make its accurate chart- ing impracticable. By April 10 — twelve days after ap- plication of extension — the only remaining defects were a loss of temperature — heat and cold — sense over right hand, palmar and dorsal surfaces; and over the left hand, dorsal surface only. The case was now trans- ferred to the care of Dr. Freiberg, who furnishes the following : SURGICAL HISTOEY. On March 2S I examined the patient whose condition has been accurately described by Dr. Langdon. I found present, exclusive of the nerve symptoms already de- scribed, a considerable, firm, diffuse swelling immediately below the occiput and extending downward to the fourth cervical spine. Without any distinct boss it was suffi- cient to render indistinct to the touch the vertebral spine. There was considerable tenderness on pressure com- juained of in tin.: whole swollen area. There was no torticollis whatever, but the patient was unable to rotate the head with freedom. Likewise it was impossible for him to bend the cervical spine backward to the normal e aont. There was some interference with the power of approximating the head toward either shoulder. The nodding motion was not interfered with. Examination of the pharynx failed to show anything abnormal. The diagnosis of tubercular disease of the upper cer- vical spine was made with some reserve, especially with regard to its exact localization. The treatment con- sisted in the application of weight and pulley extension to the head, the weight of the body serving as counter- extension. The weights were increased gradually from three to twelve pounds. The change in the patient's condition has been spoken of by Dr. Langdon as startling; this is by no means an exaggeration. Tbe improvement was, however, steadily progressive from this time forward. June 4. — The appetite is good; no fever; no pain; less rigidity. He can move his neck with considerable freedom; also all joints of extremities. Grasp: dyna- mometer E. 50, L. 46; knee-jerks exaggerated; E. and L. ankle-clonus present E. and L. The patient was kept in bed with the same weight at- tached until Aug. 4, 1898. At this time an examination showed an apparently complete return to the normal in every regard save one — the power to rotate the head laterally. The extension was therefore removed and a Sayre jury mast applied. On August 22 the patient ex- pressed a desire to leave the hospital and was permitted to do so, wearing no apparatus, and he walked out of the 10 hospital without assistance. About six weeks ago I had an opportunity of examining the patient, and his con- dition remains 1he same. A very slight interference with rotation of the head and the induration about the upper spinous process, which has never disappeared en- tirely, are all that remained of the conditions found upon the first physical examination of the neck. The patient AaL,