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Clinical Lecture ON ERB'S SPASTIC PARALYSIS

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828 fifteen or twenty minutes before it is eaten. Certain dishes commonly uRed hy invalids—faridaceous gruels, milk, bread and milk, milk flavoured with tea or cotfee or cocoa, and soups strengthened with farinaceous matters, or with milk- are suitable for this mode of treatment. A teaspoonful or two of the liquor punf-reaticus should be stirred up with the warm food as soon as it comes to table. And such is the activity of the preparation that even as the invalid is engaged in eating—if he eat leisurely as an invalid should do-a change comes over the contents of the cup or basin-the gruel becomes thinner, the milk alters a shade in colour, or perhaps curdles 8ottly, and the pieces of bread soften. The transformation thus begun goes on for a time in the stomach, and one may believe that before the gastric acid puts a stop to the process the work of digestion is already far advanced. This mode of administering pancreatic preparations is simple and convenient. No addition of alkali is required, and of course no final boiling. The only precaution to be observed is that the temperature of the food, when the extract is added, shall not exceed 150° F. (65° C.) This point is very easily ascertained, for no liquid can be tolerated in the mouth, evrn when taken in sips, which has a tempera- ture above 140° F. (60° C.) If, therefore, the food is suffi- ciently cool to he borne in the mouth, the extract may be added to it without any risk of injuring the activity of the ferments. Pancreatic Extract as ati Addition to Nutritive Enemata. - Pancreatic extract is peculiarly adapted for administration with nutritive edemista,. The enema may be prepared in the usual way with milk-gruel and beef-tea, and a dessert- spoonful of liquor pancreaticus should be added to it just before admini,tration. In the warm temperature of the bowel the ferments find a favourable medium for their action on the nutritive materials with which they are mixed, and there is no acid secretion to interfere with the completion of the digestive process. I have now had some experience in this method of alimen- tation, and have been satisfied with its success. In one case a patient suffering from post-pharyngeal abscess, which entirely occluded the oesophagus, was nourished exclusively for a period of three weeks (until the abscess broke) on enemata of milk-gruel mixed with pancreatic extract. Clinical Lecture ON ERB’S SPASTIC PARALYSIS. Delivered at Glasgow Royal Infirmary, Dec. 8th, 1879, BY M. CHARTERIS, M.D., PROFESSOR OF MEDICINE, ANDERSON’S COLLEGE. GENTLEMEN,-I desire to draw your attention to-day to a rare form of spinal disease, which, from the accurate de- scription given of it hy Erb, Professor of Electro-Therapy at the University of Heidelberg, is now named after its author. An analogous affection is, by Charcot, designated "amyotrophic lateral sclerosis," and "spasmodic dorsal tabes." These terms seem too vague, and Erb’s nomen- clature, conveying a certain clinical picture, appears to be the justest and the most likely to be lasting. You all know in a general way what is meant by the word "paralysis." It conveys the idea to a greater or less extent of loss of motion, inability to perform actions which in health are easy and natural. Clinicists have, in regard to spinal diseases, described certain peculiar gaits. Thus when there is more or less extensive paralysis of the lower extre- mities before complete loss of motion has been established, it is noted that the patient walks with a shuffling gait, dragging his feet after him, with the tips of the toes pointed to the gronnd, and the heel raised high. This is called "the paralytic gait." Again, if there is disturbed conduction of muscular move- ments in walkillg; if the patient throws his foot forward and outward with force, and brings it to the ground heel first with a decided stamp; if, further, his eyes are stantly on the ground, aud he reels and staggers whec tii.- is not the case,—the gait is termed "ataxic." A further gait is described as the "spastic gait." Herthe patient has also a peculiar characteristic walk or riiii. all may be termed. For the feet seem to clear the ground and the tips appear to feel obstacles in every inpqnaltty of the surface, so much so as to give rise to a hopping elevation of the whole body, which is slightly bent forward, the leg-. meanwhile keeping close together, especially at the kne This gait depends on muscular tension, and reflex co;. tractions in the various groups of muscles, which are set in activity during the process of walking. In " spastic paralysis " the earlier symptoms in movemeo, are as I have mentioned, and hence the disease I speak about to-day is termed " spastic paralysis. " Before giving the history of the patient before you let me attempt to explain the pathology of the disease. I knov that the " ataxic gait " is associated with disease of the posterior columns of the spinal cord. I know that with thi, "ataxic gait" there is disturbed sensibility; that, to take one prominent feature of the disease, there is an absence-of th, tendon-reflex ; that when I strike the patella smartly there is no response, no reflex contraction takes place, the leore. mains as it were dead and lifeless. But in this other form of paralysis, "spastic paralysis," there is great increase in the reflex action of the tendons, not merely the tendon of the patella, but also of the tendo Achillis and of the addnctors. If, therefore, as post-mortem evidences show, the ataxic gait means disease of the posterior columns, posterior gray horns, the central gray substance, and probably also a great part of the anterior gray horns, we exclude these divisions of the spinal cord from participating in the disease in question. Of course, also, we must exclude the brain. Where, then, can we localise this disease ? We have only got for this purpose the so-called motor portions of the spinal cord—i.e., the antero-lateral columns, and perhaps also a portion of the gray substance. Still further gene- ralising, and consequently dogmatising from our present physiological knowledge, we exclude the anterior columns proper as being implicated in a disease which, as you will afterwards observe, has paralysis without atrophy of the affected muscles. We reduce our field of observation to the lateral columns of the spinal cord. Here, accordingly, is the seat of the disease. Here, says Charcot, and with him Erb, we have a chronic inflammatory process going on; here, in the posterior divisions of the lateral columns, we have the highly probable anatomical basis of "spasmodic spinal paralysis." So much having been said for the pathological explanation of this disease-an explanation which in theory seems ex cellent, but which from the limited number of cases as yet recorded has not been verified by post-mortem examina- tions-let me now direct your attention to the leading features of the history and present condition of our patient. You observe as she lies in bed, with her body covered, that her face is full and well-nourished ; that her eye is not wanting in intelligence, and that her general expression is, so far as you can see, that of a healthy, contented woman. If you ask her questions, she will give rational and satis- factory replies. She notes everything that is going on. takes a lively interest in other patients in the ward, and reads newspapers and other periodicals with avidity. Take away the bedclothes, and you will see that her legs are drawn up, that they are bent at the knee to such an extent that one of them actually touches with the heel the corre sponding hip. You will note further that at the knee thev meet, and require force to separate them. Try to extend either leg and you will find you cannot do so beyond a certain point, for the hamstring muscles with their tendons will not allow them to proceed further, and on desisting from your efforts they slowly return to their original position. Test the sensibility and you will readily perceive it is not affected. Tap the patellar tendon, and you will see a quivering movement of the foot in response. Similarly tap the tendr Achillis, and there is passive dorsal flexion of the foot. Ttp over the region of the lumbar vertebrae, and you excite the activit,y of the tendons of the adductors. Note also that the muscles of the leg and thigh, though flabby, are in no way atrophied. Such is the patient’s present condition-a condition which very fully and faithfully illustrates Erb’s clinical picture N the disease. What, it may be asked now, was her pass history - what her condition when admitted six monew
Transcript

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fifteen or twenty minutes before it is eaten. Certain dishescommonly uRed hy invalids—faridaceous gruels, milk, breadand milk, milk flavoured with tea or cotfee or cocoa, andsoups strengthened with farinaceous matters, or with milk-are suitable for this mode of treatment. A teaspoonful ortwo of the liquor punf-reaticus should be stirred up with thewarm food as soon as it comes to table. And such is theactivity of the preparation that even as the invalid is engagedin eating—if he eat leisurely as an invalid should do-achange comes over the contents of the cup or basin-thegruel becomes thinner, the milk alters a shade in colour, orperhaps curdles 8ottly, and the pieces of bread soften. Thetransformation thus begun goes on for a time in the stomach,and one may believe that before the gastric acid puts astop to the process the work of digestion is already faradvanced.

This mode of administering pancreatic preparations issimple and convenient. No addition of alkali is required,and of course no final boiling. The only precaution to beobserved is that the temperature of the food, when theextract is added, shall not exceed 150° F. (65° C.) This pointis very easily ascertained, for no liquid can be tolerated inthe mouth, evrn when taken in sips, which has a tempera-ture above 140° F. (60° C.) If, therefore, the food is suffi-ciently cool to he borne in the mouth, the extract may beadded to it without any risk of injuring the activity of theferments.

Pancreatic Extract as ati Addition to Nutritive Enemata.- Pancreatic extract is peculiarly adapted for administrationwith nutritive edemista,. The enema may be prepared in theusual way with milk-gruel and beef-tea, and a dessert-spoonful of liquor pancreaticus should be added to it justbefore admini,tration. In the warm temperature of thebowel the ferments find a favourable medium for their actionon the nutritive materials with which they are mixed, andthere is no acid secretion to interfere with the completion ofthe digestive process.

I have now had some experience in this method of alimen-tation, and have been satisfied with its success. In one casea patient suffering from post-pharyngeal abscess, whichentirely occluded the oesophagus, was nourished exclusivelyfor a period of three weeks (until the abscess broke) onenemata of milk-gruel mixed with pancreatic extract.

Clinical LectureON

ERB’S SPASTIC PARALYSIS.Delivered at Glasgow Royal Infirmary, Dec. 8th, 1879,

BY M. CHARTERIS, M.D.,PROFESSOR OF MEDICINE, ANDERSON’S COLLEGE.

GENTLEMEN,-I desire to draw your attention to-day to arare form of spinal disease, which, from the accurate de-scription given of it hy Erb, Professor of Electro-Therapyat the University of Heidelberg, is now named after itsauthor. An analogous affection is, by Charcot, designated"amyotrophic lateral sclerosis," and "spasmodic dorsaltabes." These terms seem too vague, and Erb’s nomen-

clature, conveying a certain clinical picture, appears to bethe justest and the most likely to be lasting.You all know in a general way what is meant by the word

"paralysis." It conveys the idea to a greater or less extentof loss of motion, inability to perform actions which inhealth are easy and natural. Clinicists have, in regard tospinal diseases, described certain peculiar gaits. Thus whenthere is more or less extensive paralysis of the lower extre-mities before complete loss of motion has been established,it is noted that the patient walks with a shuffling gait,dragging his feet after him, with the tips of the toes pointedto the gronnd, and the heel raised high. This is called"the paralytic gait."Again, if there is disturbed conduction of muscular move-

ments in walkillg; if the patient throws his foot forwardand outward with force, and brings it to the ground heel

first with a decided stamp; if, further, his eyes are

stantly on the ground, aud he reels and staggers whec tii.-is not the case,—the gait is termed "ataxic."A further gait is described as the "spastic gait." Herthe

patient has also a peculiar characteristic walk or riiii. all

may be termed. For the feet seem to clear the ground andthe tips appear to feel obstacles in every inpqnaltty of thesurface, so much so as to give rise to a hopping elevationof the whole body, which is slightly bent forward, the leg-.meanwhile keeping close together, especially at the kneThis gait depends on muscular tension, and reflex co;.

tractions in the various groups of muscles, which are set inactivity during the process of walking.In " spastic paralysis " the earlier symptoms in movemeo,

are as I have mentioned, and hence the disease I speakabout to-day is termed " spastic paralysis.

"

Before giving the history of the patient before you let meattempt to explain the pathology of the disease. I knovthat the " ataxic gait " is associated with disease of theposterior columns of the spinal cord. I know that with thi,"ataxic gait" there is disturbed sensibility; that, to take oneprominent feature of the disease, there is an absence-of th,tendon-reflex ; that when I strike the patella smartly thereis no response, no reflex contraction takes place, the leore.mains as it were dead and lifeless. But in this other formof paralysis, "spastic paralysis," there is great increase inthe reflex action of the tendons, not merely the tendon of thepatella, but also of the tendo Achillis and of the addnctors.If, therefore, as post-mortem evidences show, the ataxicgait means disease of the posterior columns, posterior grayhorns, the central gray substance, and probably also agreat part of the anterior gray horns, we exclude thesedivisions of the spinal cord from participating in the diseasein question. Of course, also, we must exclude the brain.Where, then, can we localise this disease ? We have only

got for this purpose the so-called motor portions of thespinal cord—i.e., the antero-lateral columns, and perhapsalso a portion of the gray substance. Still further gene-ralising, and consequently dogmatising from our presentphysiological knowledge, we exclude the anterior columnsproper as being implicated in a disease which, as you willafterwards observe, has paralysis without atrophy of theaffected muscles. We reduce our field of observation to thelateral columns of the spinal cord. Here, accordingly, is theseat of the disease. Here, says Charcot, and with him Erb,we have a chronic inflammatory process going on; here, inthe posterior divisions of the lateral columns, we have thehighly probable anatomical basis of "spasmodic spinalparalysis."So much having been said for the pathological explanation

of this disease-an explanation which in theory seems excellent, but which from the limited number of cases as yetrecorded has not been verified by post-mortem examina-tions-let me now direct your attention to the leadingfeatures of the history and present condition of our patient.You observe as she lies in bed, with her body covered, that

her face is full and well-nourished ; that her eye is not

wanting in intelligence, and that her general expression is,so far as you can see, that of a healthy, contented woman.If you ask her questions, she will give rational and satis-factory replies. She notes everything that is going on.takes a lively interest in other patients in the ward, andreads newspapers and other periodicals with avidity. Takeaway the bedclothes, and you will see that her legs aredrawn up, that they are bent at the knee to such an extentthat one of them actually touches with the heel the corresponding hip. You will note further that at the knee thevmeet, and require force to separate them. Try to extendeither leg and you will find you cannot do so beyond a certainpoint, for the hamstring muscles with their tendons will notallow them to proceed further, and on desisting from yourefforts they slowly return to their original position. Test thesensibility and you will readily perceive it is not affected.Tap the patellar tendon, and you will see a quiveringmovement of the foot in response. Similarly tap the tendrAchillis, and there is passive dorsal flexion of the foot. Ttpover the region of the lumbar vertebrae, and you excite theactivit,y of the tendons of the adductors. Note also that themuscles of the leg and thigh, though flabby, are in no wayatrophied.Such is the patient’s present condition-a condition which

very fully and faithfully illustrates Erb’s clinical picture Nthe disease. What, it may be asked now, was her passhistory - what her condition when admitted six monew

829

ago into the wards. Well, the report of her case states thatshe is thirty-six years of age, that for twenty of these yearsshe has been married, and that she is the mother of tenchildren. Her confinements were easy, and her health gooduntil she became pregnant with the tenth child, when sheexperienced an uneasy feeling, but not actual pain, in herback. This uneasy feeling—weakness she terms it-con-tinued daring the whole of her pregnancy. When she cameto the full term, twelve months ago now, she was deliveredof a healthy child after a somewhat lingering labour. The

placenta carne away naturally, hut after that she never"saw anything," not even the ordinary lochia. She kept toher bed for three weeks, the weakness in the back beingmore apparent. It was not, however, until the expiry ofthat time that, on attempting to get out of bed, she noticedthat, though able to put her feet to the ground, she was un-able to walk without her crutches. " I thought," she said,"this would pass away, hut it did not, and day by day tnoticed I could with greater difficulty put my heel to theground. I could only place my toes there. Then I becamealarmed, and applied for admission to the Infirmary." Shecontinued to suckle her child until the day of admission.The report goes on to state :-The patient is well nourished,

her countenance cheerful, her understanding clear, and speechunaffected. She lies in bed upon her back, with her thighsflexed slightly upon the pelvis and her legs forcibly upon thethighs. The adductor muscles of the thigh are powerfullyacting, so much so that the knees are locked forcibly togetherand cannot be separated, neither can the legs or thighs beextended to any great degree. She has no tenderness aboutthe spine, no giddiness in the head, no sense of constric-tion round the abdomen ; and she states that at the onset ofher disease she had no difficulty of walking with her eyesshut or in the dark. Sensation is complete in both her limb-!,but the motor power is lost. When the limbs are touched inany part, violent reflex actions are excited in the muscles ofthe thigh and calf. The cardiac and respiratory systems arenormal. With regard to the digestive system, it is notedthat the appetite is good, tongue clean, bowels somewhatconstipated. She has complete control over the rectum.Under the genito-urinary system it is observed that theurine contains no albumen or sugar, and is slightly acid inreaction. From the day of her admission until this date shehas menstruated regularly.You will observe that there has been little change in the

patient’s condition now from what it was six months ago.We have tried every remedy which might be considereduseful, but without effect. The 11 constant current" hasnever been omitted, but though some hope was entertainedof it at firt, this has had to be ahandoned. Under chloroform,it may be added, the limbs could not be extended any fur-ther than without it. She now desires to return home, audto this I can place no obstacle in her way, for unfortunatelyI know of nothing which will tend permanently to benefither interesting hut unfortunate state. This is the first truecase of the kind, so far as I am aware, which has beenreported from the west of Scotland.

THE DISEASES OF THE EYE OCCURRINGIN CONNEXION WITH PREGNANCY.

BY HENRY POWER, M.B. LOND., F.R.C.S. ENG.,SENIOR OPHTHALMIC SURGEON AND LECTURER ON OPHTHALMIC

SURGERY AT ST. BARTHOLOMEW’S HOSPITAL.

(Concluded from p. 759.)

THE formation of the white patches in albuminuric reti-nitis may take place with great rapidity. A case, thoughnot occurring in pregnancy, fell under my care, in whichvery large patches appeared in the course of three days, thefunctional activity of the retina being of course abolished inthose parts where they existed.As a matter of prognosis it may be said thathnemorrbages,

even of somewhat large extent, will be absorbed. Thewhite spots I am less certain about, but think they also dis-appear in time, though more slowly than the haemorrhages.

In regard to treatment I have nothing to say, since it isnecessarily the same as that applicable to the renal disease,and no special treatment is required for the eyes.

Mr. Macnamara has recommended the induction of pre-mature labour in these cases, and has (THE LANCET, vol. ii.,18i8, p. 842) recorded a perfectly successful case which wasunder his own and Dr. Potter’s care. On this point it wouldbe inreresting to obtain the opinions of those who arespecially engaged in the practice of midwifery, particularlyin regard to the period when premature labour would underthese circumstances best be induced.

Passing from these I may now briefly refer to intracranialdisease as occurring in pregnancy.The sudden loss of a large quantity of blood in delivery

has been known to produce partial or co nplete loss of vision.No instance of this kind has come under my own observa-tion, hut the following is a good example ot it, and I am in.debted for it to Dr. J. P. Atkinson of Bampton. " tn July,1874, I attended the wife of a clergyman in her eighth con-finement. All went well until the expulsion of the placenta,when frightful hæmorrhage took place, which, however,afrer some time I succeeded in arresting. I then found shehad lost the faculty of sight of her right eye. This, how-ever, returned in a few hours, and she made a good recovery.Last year, when visiting some friends in Norfolk, she had anattack of facial palsy of the right side. The palsy gotgradually better, but on her return home I saw her; she wasvery nervous, vision weak on right side. Upon ophthalmo-scopic examination I found the right retina decidedly anaemic,and she assured rne her sight on that side had never been sogood since her last confinement. She is now better, but stillcomptaining."

In such a case as this I presume the sudden withdrawalof blood from the system either leads the vessels of certainregions of the brain to contract so firmly that the circula-tion is never again restored through them, and the nutritionof the part falls from defective supply of pabulum, or thesudden diminution of pressure occasions some lesion of thedelicate tissue of the central nervous system.

In regard to the intracrauial diseases of the eye occurringin pregnancy, I fear they should almost he classed underthe head of "anomalous affections." They are cases ofmore or less complete loss of vision in which we are unableto localise the disease, and are obliged to launch out intothe airy regions of speculation to afford an explanation.The difficulty occurs in all those cases in which the patientcomplains of impaired vision, and in which no disease canbe recognised under ophthalmoscopic examination. Thepart affected being beyond our ken, we guess that somepart of the optic nervous apparatus is diseased, using theterm in its widest sense, and as including the optic nerve,chiasma and tract, the optic lobes or corpora quadrigemina,the posterior part of the optic thaiami, the cerebetlum, andlastly, if the localisation of the cerebral functions be a factand not a theory only, the cerebral centres of vision, whichare probably situated in the occipital lobes of the hemi-spheres.The discovery of the ophthalmoscope five-and-twenty yearsago has enabled us to materially reduce the number of casesthat were formerly included under this head, aud the in-ahility of the older writers to see beyond the lens renders itimpossible to arrive at an absolute conclusion in regard tomany of the cases they record.The following are one or two cases that have fallen under

rny care, and I think it may be said that, however slightmay be the visible change in the disc and retina of the eyeor eyes affected in the early period, they a!most always passif)to white atrophy. Nl"e may meet with a perft-ctly blindeye, or with an eye in which part of the field of vision is

perfectly hlind; but I believe it will be fuuud that we rarelyor never meet with an eye that has been comp!ete)y blindfor some time, say for a few months, without fiudipa atrophypresent, the disc being whiter than natural.Feb. 27th, 1880.-Fanny 0-, a delicate-looking woman,

aged forty, states that she could see pertectly weli wilh botheyes up to Sept. 1st, 1879, which date was twt-nty-’wo daysbefore her confinement. For several weeks previously shehad slept badly, and during the earlier months of her

pregnancy had experienced continuous pain for weekstogether, both night and day. The pain had, however,greatly diminished before Sept. 1st, the date of her attack.Un the night of that day, being much exhausted, she wentto bed early, and awoke about day break with curious sensa-tions in her left eye, wbi’h she described as a quiveringbefore her eye, a kind of bubbling bubbles of%atr, yellow and green, differeot colours,’’ A darknessthen came over the eye, which in the course of two or three


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