of Rokitansky, that, when hemorrhage occurs in the spinal cord, it is in the cervical portion. The product of inflammatory action most commonly discovered in the spinal cord is ramollissement, a condition which, however, like its analogue in the brain, is equally attributable to other pathological states, each of which may be recognized by the naked eye, and the aid of the microscope. The degree of softening varies from a slight diminution of consistency, as compared with surrounding parts, to a state of pulpy diffluence; the extent of cord affected differs equally. In paralysis, we very frequently meet with no other trace of disease but a trifling softening in the lumbar, dorsal, or cervical regions, manifestly the result of a slow inflammatory process. The microscopic products of inflammation, the inflammation corpuscles and granules, spoken of in considering the similar conditions of the brain, are also found in the present instance; and where any doubt prevails as to the nature of the softening, these microscopic appearances will aid our judgment. MM. Rilliet and Barthez have invariably found that, in children, the softening of the white matter of the cord coexisted with inflammation of the membranes, and that the extent of the former was in the exact ratio of the amount of the latter. The softening affects the gray matter, and especially that belonging to the lumbar and brachial swellings more than any other part; and a case is given by Ollivier, in which the entire gray substance of the cord was converted into a pulpy mass, leaving the white matter in a comparatively healthy state. We meet with diffused suppuration in the cord as in the brain; circumscribed abscess is also, though very rarely, found within the medullary matter. Dr. Abercrombie' gives a case of this which occurred in a woman aged fifty-six, who was affected with sudden loss of power of the limbs of the left side, followed by death in a week. The brain was sound, but in the centre of the right column of the spinal. cord, in the middle of the cervical portion, there was a cavity three inches long, and two or three lines in diameter; it was full of a soft matter, like pus, which became more consistent towards the parietes of the cavity. It appears that the softening invariably proceeds from the gray to the white matter in myelitis. It is probable that where the process is a result of exhaustion, mal-nutrition, or degeneration, the reverse will be found to obtain; as the former would be favored by the presence of a large number of blood vessels, the latter would spread more in a part not copiously supplied with them. The tint of the gray matter is deepened, and a rose-blush pervades the white matter in the red form, while this hue is replaced by a more or less yellow tinge when the suppurative stage has set in. A form of white softening occurs in the spinal cord which is analogous to the white softening met with in the brain, as a result of the effusion of serum or oedema, which is in no way connected. with inflammation. Another product of myelitis is induration of the cord; this is found coexistent with ramollissement, or by itself. It is more frequently 1 Diseases of the Brain, &c., 1845, p. 355. brought on by chronic or cachectic inflammation than softening, and it is not unfrequently complicated with hypertrophy of the affected part. When the induration is very considerable, the nerve-tissue resembles, as Ollivier observes, in consistency, density, and appearance, boiled white of egg; it is a condition that Esquirol has repeatedly met with in epileptic subjects. Gluge,' in adverting to the extreme difficulty of a minute analysis of all the elements of disease occurring in nerve-matter, alludes to the coagulability of the contents of the tubules as a point of great importance, though he admits the obstacles that oppose themselves to a determination of such relations in disease. He is inclined to think that the coagulation takes place in certain diseases, such as tetanus, during life. That a change in the contents of the nerve-tubules must materially affect their conducting power, is too manifest to require enlarging upon theoretically; still, the proof has, as yet, evaded our means of demonstration. Softening of the spinal cord occurs, as in the brain, as a sequel of morbid growths, such as carcinoma, or tubercle. Neither of them is, however, frequently met with, though they are oftener seen in the cord itself than its membranes. Ollivier, whose work contains the largest collection of cases of this kind on record, denies the occurrence of melanosis affecting the cord, nor have we been able to discover any other instance but the one already alluded to, in which the melanotic tumor was attached to the dura mater. Acephalocysts are also met with in the spinal cord. Rokitansky states that he has repeatedly met with the cysticercus in the cervical portion of the spinal marrow; but his experience agrees with that of Ollivier, that they do not occur in the substance of the medulla. They in most instances are situated externally to the dura mater. In this case, it is manifest that they had been first developed outside the column, and had forced their way in through the intervertebral foramina; they have, however, also been found within and underneath the arachnoid. It is a curious fact, for which we can offer no explanation, that the cases of acephalocyst occurring in the spinal column, have all been females. In concluding the subject of the pathological anatomy of the spinal cord and its membranes, we must again express our regret that our knowledge of the morbid changes occurring in it are in no way commensurate with the importance and dignity of the organ. With reference to no other part of the body are we so often at a loss to explain the connection which exists between the symptoms of disease, and the actual pathological condition of the organ. The hyperesthesia of the spinal cord (which is manifested in so marked a manner in tetanus, hydrophobia, hysteria, and poisoning by strychnine) is a palpable derangement of its functions; and yet the anatomist can discover no satisfactory reason to satisfy his desire for establishing the etiological relation. A comparison suggests itself between these cases of diseased action which appear as yet to be out of the reach of science, and those calamitous accidents on our railways which generally seem to be due rather to some 1 Atlas der Pathologischen Anatomie, Lief. xx. p. 12. Deus ex machina, than to those physical laws which are generally supposed to rule mechanical appliances. Had we desired to enter into theoretical discussion, either regarding the brain or the spinal cord, much more might have been said on the subject; and we have carefully abstained entering into the debated ground of hypothesis, as, for instance, with regard to the participation of these organs in fever, as we should thus have outstepped the limits which the practical character of this work seems to impose upon us. CHAPTER XIV. THE NERVES. Ir very rarely happens that individuals die of an affection residing solely in the nerves; consequently, we are left to surmise their morbid appearances in those diseases in which they are manifestly affected, from analogy. At the same time, we must never forget that the nerves are not central organs, but that they are the telegraphic wires destined to convey intelligence to and from the central organs. When, therefore, we have to deal with a nervous symptom, we must first inquire whether it be due to a centric or to a peripheral cause; or, in other words, whether the nerve is propagating a morbid impression from the brain, the spinal marrow, or the sympathetic ganglia which may simulate peripheral disease, or whether it is giving evidence of local disease by producing in the brain the consciousness of that affection. In the majority of instances of irregular or painful action of the nerve, we should be as much in error in seeking for the cause of the derangement in the nerve itself, as if, when our galvanic battery does not act, owing to the trough containing no acid, we sought to remedy the defect by changing the conducting wires. The nerves have repeatedly been made the subject of inquiry in diseases, in which either local symptoms predominate, or in which, from the known physiological action of the nerves, controlling the parts affected, the morbid phenomena could fairly be sought in an individual nerve; thus, the sciatic has been subjected to examination in individuals who had been affected with sciatica, and the vagi have been explored as the hypothetical excitants of hooping-cough. Pathologists have, in neither case, succeeded in demonstrating a relation between the malady and an uniform alteration in the respective nerves. A case has long been transcribed, and has thus acquired traditional importance, by which Cotugno, the first who wrote on sciatica, is made to affirm a lesion, oedema of the nerve, as the causa proxima of that malady; but although he records a case of the kind, he himself would certainly not have approved of the interpretation which has been given to it, since he distinctly states that he attributes no importance whatever to the circumstance. With regard to hooping-cough, we find instances recorded of the vagus having been reddened and swollen, indicating inflammatory action, but the large majority of cases in which the point has been attended to have presented no such change. Thus, Dr. Albers examined the vagi, in forty-seven children who had died of hooping-cough, and found them perfectly normal in forty-three; Dr. West, who has also paid especial attention to the subject, has, only in one case out of eighteen, met with any change in the nerves; in this case they were decidedly redder than usual. We are inclined to conclude, with the latter Fig. 130. author, that an appearance so frequently absent cannot be one of much moment, and that, like Cotugno's famous case, to which we have just referred, it may be set down to a cadaveric change. In our examinations of nerves, supposed to be diseased, we must be careful to distinguish between the neurilemma and its alteration, and the nerve-tubes; thus, in the stump of an amputated limb, we commonly find the nerve terminating in a button; this is owing to the effusion of plastic matter, which serves as a protection to the divided nerve, and not to an hypertrophy of its tubules. The morbid condition most commonly seen in the nerves throughout the body is atrophy; this, however, can rarely be said to be a primary Portion of a cerebrum with the affection; it is brought on by the influence of optic nerves and remains of the left eye. The cornea is opaque, and the coats of the eye are collapsed. The left optic nerve is considerably diminished in size between the diseased eye and the optic commissure. Behind the com side is rather smaller than that on the left, but the thalami appear to be of equal size. From St. Bar No. 5. pressure, acting immediately upon the nerve, and causing gradual, and even entire absorption at the point upon which the pressure acts; this we find occurring in the case of aneurism, or enlarged glands, lying in the vicinity of nerves. missure, the nerve on the right Atrophy of the nerve results from the part to which it is supplied ceasing to perform the functions for which it receives the nerve; thus, tholomew's Museum, Series viii. atrophy of the optic nerve may follow destruction of the eye, by mechanical injury; or the nerve of an extremity wastes, when the muscles of the part are condemned to inactivity. A case is related by Swan,1 in which, however, other nerves, the vagi, appear to have been idiopathically affected with atrophy. An individual had, for eighteen months, been unable to satisfy his appetite; the food was vomited four hours after being taken, without showing any signs of digestion; respiration became laborious and sibilant; emaciation and death ensued. At the section, the lungs were found normal, but the vagi, from the middle of the neck, were atrophied, and their terminations in the oesophagus red and thickened. The left was found smaller than the right. Mr. Swan adds that, in two consumptive patients, he found the vagi smaller than usual. In cases of atrophy and degeneration of the spinal cord, the nerves passing from the diseased portion are, necessarily, in an atrophic condition thus, in an instance given by Cruveilhier, in which the disorganization of the cord was limited to the posterior strands, extending from the lower end to the cerebellum, the posterior nerves were entirely atrophied and converted into transparent threads, which contrasted 2 1 Treatise on Injuries and Diseases of the Nerves. London, 1884, p. 174. |