Spinal Diseases, the common appellation of diseases affecting the bony spinal column and the spinal cord and its membranes. The principal diseases of the spinal column are lateral curvature and angular curvature or Pott's disease, sometimes called scrofulous caries of the spine. Lateral curvature is the more common, and usually affects girls between 10 and 20 years of age and women of sedentary habits. Those who take much exercise are not often its subjects, as the symmetry of the spinal column is preserved principally by the action of the muscles. In its early stages lateral curvature is apt to escape detection, the first notice taken of it being generally the prominence of one shoulder, more frequently the right, or some elevation of the hip. The curvature is always double; that is, when a curve has taken place in the upper dorsal region, a complementary curve in the opposite direction will be found in the lumbar region, giving the spine a sigmoid appearance. Lateral curvature is also usually accompanied with more or less rotation of the spinal column, due to the action of the ribs, which are carried down on one side more than on the other. The treatment in slight cases is good diet, pure air, and well regulated exorcise, and sometimes the administration of ferruginous tonics.
When the curvature is considerable, stays, braces, and bandages will be of service; but they must not take the place of exercise, and should be regarded as expedients rather than curative agents. Posturing and great attention to the position of the body when lying in bed should be employed as the chief hygienic measures. - Angular curvature, or Pott's disease, is caused by inflammation of the bodies of the vertebrae and of the intervertebral substance, usually commencing in the latter. It is often accompanied with tubercle, and some hold that it is essentially a scrofulous disease. The immediate cause of the curvature is caries, and it most commonly shows itself during the period of bodily development, usually attacking the lower dorsal region. Recovery sometimes takes place without pus making its appearance, but "spinal abscess" is a common accompaniment, the pus pointing in the groin, and finding its way from the dorsal region beneath the fascia of the psoas muscle, under Poupart's ligament, forming what is known as " psoas abscess." The pus sometimes burrows beneath the muscles and involves the whole thigh.
The abscess sometimes appears above Poupart's ligament, and sometimes in the loin, forming in the latter case "lumbar abscess." When the cervical vertebne are affected, the abscess appears in the pharynx. Angular curvature is not difficult of diagnosis, as the ill health, suppuration, and deformity are highly indicative. The initiatory symptoms are also not obscure, the principal being the persistent local pain and difficulty in bending the back, accompanied by great general disturbance and hectic fever. After curvature has taken place recovery is always accompanied by anchylosis, from union of newly formed bony tissue. The treatment requires careful attention to the general health, including good diet and the employment of tonics and alteratives, such as iron, quinine, iodine, and cod-liver oil. The local applications of fomentations and leeches and of counter-irritants are also serviceable. Setons, moxas, and mercury, as tending to exhaust the strength, are to be avoided. On getting up, the patient's back should be supported by some kind of mechanical appliance.
The abscess should not be opened too hastily, for it may be absorbed; but when it progresses steadily a free opening should be made, under a piece of lint saturated with car-bolated oil, to prevent entrance of air. - The principal diseases of the spinal cord, that is, the pathological conditions to which it is subject, are spinal meningitis, myelitis, and spinal apoplexy. These conditions give rise to or aid in developing a variety of symptoms, which in turn are classed as diseases, such as paralysis (including paraplegia and spinal hemiplegia), general spinal paralysis, and locomotor ataxia. The diseases known as progressive muscular atrophy and infantile paralysis, although their causes are not clearly made out, are generally considered to be connected with affections of the spinal cord. - Spinal Meningitis, or inflammation of the membranes of the spinal cord, corresponds to inflammation of the corresponding membranes of the brain, and rarely occurs in the arachnoid and pia mater independently of cerebral meningitis, except in cases produced by injuries or diseases of the spinal column, or structural affections within the spinal canal.
The affection is therefore almost always cerebro-spinal. (See Brain, Diseases of the.) Fibrinous exudation, serous effusion, and generally pus follow the inflammation, the serum being often tinged with blood. The attack may be acute or chronic. When acute it extends over the whole or greater part of the membranes of the cord, but chronic meningitis is usually limited in extent, and the inflammation is accompanied by fewer pathological changes. Acute spinal meningitis is regarded by many authorities as incurable, while others assert that mild cases sometimes recover. The symptoms are pain in the spine and in the extremities, increased more by movements of the body than by pressure. There are also spasms of the muscles of the back, either persistent or convulsive, often producing that rigid bending of the body backward called opisthotonos; also tonic contraction of the thoracic muscles, and consequently difficulty of breathing. These symptoms are followed by paralysis, caused by pressure of the products of the inflammation (fibrinous exudation, effused serum, or pus). The paralysis may be confined to the lower extremities, or it may be general, and it is usually limited to motion, while there is preternatural sensibility.
The disease runs a rapid course, often terminating fatally within a week. Apnoea, or suspension of the respiratory function from involvement of the roots of the respiratory nerves, is the usual mode of death. The treatment, in cases not dependent on blood poisoning, comprises the application of cups and - leeches, setons, moxas, blisters, antimonial ointment, and croton oil, and also of belladonna and chloroform and the warm bath to relieve pain. Iodide-of potassium is often given in large doses to promote absorption of the products of inflammation. The diet should be nutritious, but some authorities interdict the use of animal food. - Epidemic Cerebrospinal Meningitis. Although there are cases of cerebro-spinal meningitis which are idiopathic, and it is therefore then to be regarded as truly a spinal disease, the vast majority of cases are of epidemic origin, and the spinal lesions are therefore secondary affections, depending upon blood poisoning. The disease is then called epidemic cerebro-spinal meningitis, a dangerous affection which has of late prevailed extensively in different parts of the United States and Europe. From the appearance of certain spots upon the skin during the course of the disease it has been proposed to call it spotted fever; but as these spots are not a constant accompaniment, the proposition has not been adopted.
The name was given to an epidemic which prevailed in New England between 1807 and 1810, which is supposed by many to be the same disease, but the identity is not established. Some have regarded epidemic cerebro-spinal meningitis as a variety of typhus, but the greater suddenness of the attack and the absence of the mulberry rash of typhus indicate a difference of origin. The disease usually begins with a chill, followed by great vertigo, violent headache, obstinate vomiting, and muscular stiffness, which soon passes into tetanus. The face is pale, the pupils contracted, the conjunctivas red, and the skin exceedingly sensitive. The head is strongly drawn back, even at the end of the first or second day, and there is delirium, which soon passes into the stupor of coma. The bodily temperature is variable-, the highest occurring in the most rapidly fatal cases. Wunderlich recognizes three forms. One, rapidly fatal, is accompanied by a high temperature, which rises toward the approach of death to 108° F., and continues to rise for some hours after death. A second form is slight, with fever of short duration and very irregular course; a third is protracted, but marked by very great variation of temperature.
The pulse at the commencement is usually not more frequent, often slower than normal, and is often intermittent. It increases with the disease, but rarely reaches more than 100 beats per minute until near the fatal termination, when it becomes very small and frequent. The urine is increased in quantity and deposits a large amount of urates, and there is sometimes haematuria. In from 20 to GO hours after the commencement a peculiar eruption usually appears upon the skin of the neck, abdomen, back, arms, legs, and face, composed of distinct dark red or purple spots, somewhat larger than a pin's head. They are not raised above the surface, and do not disappear upon pressure; sometimes they do not become visible till after death. The tongue is moist and creamy until the spasmodic stage is established, when it becomes dry, dark-colored, and covered with sordes. The duration of the disease varies from a few hours to several weeks; cases are reported as terminating fatally in three or four hours, but more than half the deaths occur between the second and fifth days. Convalesence may begin from the fifth day to the fourth week or later, and is always tedious, relapses being common and often fatal. The treatment is various.
Bloodletting has been practised, but with unfavorable results, as might be expected from the depression of the vital powders. The use of quinia is regarded with favor, and opium has its advocates; ether and chloroform have been used by inhalation as sedatives; and tincture of cantharides is said to be of service in cases marked by extreme depression. Counter-irritation, by the actual cautery applied along the spine, or by blisters, has been followed by alleviation of symptoms. The use of cold compresses to the head, and of leeches behind the ears, is also recommended. - Myelitis, or inflammation of the body of the spinal cord, is similar to cerebritis, or inflammation of brain tissue, and may terminate fatally either in the acute inflammatory stage, or by softening, by undefined suppuration, or by abscess; the most common mode being by softening, the disorganization involving the whole cord or only one column. Acute myelitis, except as a sequel to spinal meningitis, or when caused by a wound, is rare. The symptoms are similar to those of spinal meningitis, and it must be borne in mind that the two diseases are rarely unconnected, one inducing the other, the primary disease being predominant. Paralysis often comes on in a few hours, and is more pronounced than in meningitis.
It is usually confined to the lower limbs, but involves the upper extremities when the affection reaches as high as the fifth pair of cervical nerves. When the inflammation is in the upper cervical and occipital sections of the cord, death may take place almost immediately from arrest of respiration. In chronic affections the palsied limbs usually become atrophied, and induration or sclerosis of the cord ensues, caused by an abnormal growth of connective cellular tissue, accompanied by atrophy of nerve tissue. Myelitis attacks subjects of all ages, but more commonly adults, and is more frequent in the male than in the female sex. The treatment depends upon the intensity of the attack; in the majority of acute cases little more can be done than to endeavor to relieve the most urgent symptoms, such as promoting the action of the bowels and preventing retention of urine. Strychnia may be sometimes used in the earlier stages of acute mve-litis with advantage, and so may the electric current, and in chronic cases with decided benefit. - Spinal Apoplexy, or haemorrhage within the spinal canal, may be caused by injuries to the spinal membranes, or by degeneration of the cord.
Extravasations of blood derived from the membranes are chiefly formed in the lower part of the spinal canal, and the changes found in the substance of the cord, and the blood clot, are similar to those in cerebral apoplexy, as described in Brain, Diseases of the. The effusions cause irritation, pain in the back, spasm of muscles below the seat of injury, and finally paralysis. Spinal apoplexy is distinguished from other paralytic affections by observing that the attending paralysis is usually not accompanied by fever or general loss of nervous power, and other symptoms. The treatment is rest and attention to the general state of the health, with moderate counter-irritation. - Progressive Locomotor Ataxia (Gr. άταέία, want of order). This name has been given to a form of paralysis characterized by disorderly muscular movements in consequence of loss of coordinating power, which has been recognized only within the present century. Duchenne described it in 1858-'9 more fully than any previous author, and gave it its name.
Its pathology and location had been pointed out by Dr. Todd, but its causes were more fully investigated by Duchenne. Romberg called the disease tales dorsalis, and it has also been called myelo-phthisis. There is not much loss of muscular power, except as general debility advances, but the diminution of sensation is more marked. The patient has a peculiar gait in walking, throwing the legs out in a jerking and uncertain manner, and when the disease is pretty well advanced throws his arms out like a man balancing on a tight rope. He seems to be somewhat in the condition of one who is walking in the dark over uneven ground. That which has been termed the "muscular sense " is impaired. The harmony of the reflex impressions by which muscular contractions are regulated and the limbs moved and adjusted is so far disordered that either too much or too little contraction is produced at each step. The foot will be thrown out and not properly brought to the ground, and as if to relieve this deficiency the patient by an effort of the will brings the foot down at the next step with too much force. A chief characteristic is the inability to walk or stand with the eves closed. It needs the assistance of sight to keep the body erect.
The walk is uncertain and reeling even with the eyes open, but if the patient shuts them he will fall. As the disease progresses, the upper extremities become affected, and it is difficult for the patient to tie his cravat or button his coat, or perform any motions requiring coordination of muscular movements. There are certain premonitory symptoms which have been relied upon, such as fugitive shooting pains in different parts of the body, of a neuralgic character; but they are often found unconnected with the disease, and often absent when the disease is present. One of the early symptoms is incontinence of urine consequent upon relaxation of the sphincter muscle, and an irritable state of the mucous membrane of the bladder;, and there is often increased . sexual activity, which however declines in the progress of the complaint, and at last ends in impotence. A characteristic feature of the disease is transient localized paralysis, such as that of the sixth pair of cranial nerves, which supply the external straight muscle of the eyeball, or the third pair, which supply the elevators of the eyelid, and the constrictor of the iris, so that there is drooping of the lid and dilatation of the pupil, one eye being usually affected more than the other, and vision is sometimes impaired or lost.
In some cases these paralytic affections are permanent. When the paralysis of the limbs begins on one side, which it frequently does, it is much oftener upon the left than the right side. Before the disease is much advanced, although the gait is irregular and jerking, the patient retains the power to walk considerable distances in spite of the great exertion which he makes. After a time the power of locomotion is lost, the patient is confined to his bed, he becomes unable to feed himself, and speech is difficult, sometimes impossible. The disease is distinguished from ordinary paraplegia, or anterior spinal paralysis, by the careful and circumspect gait of the latter; and although it has some symptoms in common with general paralysis of the insane, the totality of them will enable a diagnosis to be made. The prognosis is extremely unfavorable; very few cases ever cease progressing, and fewer still recover. The most that can be hoped for is that the disease will remain stationary or progress slowly. Sometimes it develops rapidly, but generally years elapse before the fatal termination, and in most cases death is produced by some intercurrent affection.
The most marked pathological condition is induration or sclerosis of the posterior columns of the spinal cord, involving the gray substance and the roots of the posterior nerves. The sclerosis is an abnormal development of the connective tissue, and produces atrophy and degeneration of the nerve fibres. Among the most frequent causes of progressive locomotor ataxia are exposure to wet and cold, mechanical injuries, and syphilis. Severe blows and falls, and the concussion produced by railroad collisions and similar shocks, often occasion that congested condition of the spinal cord which ends in locomotor ataxia. Excessive and continued mental exertion, and anxiety or grief, by producing a hyperaemic condition of the brain and spinal cord, sometimes bring on the disease, especially if there is a constitutional fault. Excessive indulgence in the sexual passion has been regarded as a frequent cause, but some revision of opinion will need to be made on this point. The irritable condition of the cord often produces a morbid sexual desire which has not previously been characteristic of the patient, and in which he has not inordinately indulged, and many are now inclined to believe that the cause in question has been overrated. Males are more often affected than females.
Of (50 cases analyzed by Carre, 42 were males and 18 females. It is especially a disease of middle life, between the. ages of 30 and 50, although it sometimes occurs before 30, and Trousseau reports a case in a patient 80 years old. The disease is sometimes associated with general paralysis of the insane, sometimes one and sometimes the other disease appearing first. There is no particular plan of treatment established. In Europe and in this country success has seemed to attend the employment of the interrupted galvanic current (faradization), and cases are reported as having been benefited by the continuous current of a powerful battery. (See Medical Electeicity.) Long continued and well regulated gymnastic exercises were successfully employed by Eisenmann in two out of six cases. The iodide and the bromide of potassium are beneficial. Counter-irritation with blisters, issues, and cautery has been found of no avail. Moderate exercise and a well regulated nutritious diet, to promote as much as possible the healthy assimilation of tissue, should be regarded as a main indication.
Galvanism promises to be a powerful adjunct, but time is still required to measure its importance.