VOL. II.

ORIGINAL ARTICLES.

CONCUSSION OF THE SPINAL
CORD.

BY C. H. PRESTON, M. D., DAVENPORT.

No. 1.

in dress parade. His back got very weak,
but not painful, and he again slept well
at night. On Friday, the 17th, the weather
being quite hot, he joined in a grand pa-
rade through the principal streets of the
town, during which he felt some pain in
the back but did not suffer from heat.
After stacking arms in the park, and
while strolling about with some of his
companions, he suddenly sank to the
ground with a feeling as if his back were
broken, and became unconscious for a
short time. On coming to he seemed to
have no power to so much as move a fin-
ger or open his eyes, though perfectly
aware of all that was said and done
about him. He was soon revived, how-
ever, by stimulants, and conveyed to the
train to return with his company. The
treatment prescribed was absolute quiet
with rest in bed, a mild initial cathartic
-the bowels being confined—potassium
bromide as required for sleep and coun-
ter-irritation to the spine. In a fortnight
he had so far improved as to be up and
about, although instructions as to rest,
etc. had been only partially observed.
On returning from a walk about this
time, he was taken with a sudden, sharp
pain in the back of the head, and fell vi-
olently to the floor, where he lay uncon-
scious and as if dead for some five min-
utes. This attack was repeated four or
five days later, and soon seldom a day
passed without one or two tumbles. Any
extra excitement or exertion sufficed to
induce them, but often when talking,
reading, or walking, and not in the least
excited, the sharp occipital pain would
take him without warning and he would
fall unconscious to the ground.

Case-J. W. L., aged 19, single, member
of Co. B., 2d regiment, I. N. G., was in-
jured August 15, 1883, at Fairfield, Iowa,
by a blanket-tossing at the hands of com.
rades of Co. A, on the occasion of the an-
nual encampment of the Guards. On
August 18, I saw him at his boarding
place in this city, whither he had been
carried from the train the evening be-
fore. He complained of a constant, quite
severe pain in the lower dorsal region,
with a feeling of great weakness. There
was no paralysis present, no marked lo-
cal tenderness nor altered surface sensi-
bility, and the mind seemed in no wise
affected. The patient was a slight built,
light-complected youth, of a rather excit-
able, nervous temperament, but previous
to this injury had never suffered from
any nervous affection. He was cheerful
and bright, and gave the following his-
tory of his mishap. Being seized from
behind by his facetious friends, he was
thrown into the blanket and tossed twice
into the air, the second time coming flat
to the ground on his back from a height
of some six or eight feet. He felt a ting-
ling sensation, succeeded by numbness,
but soon arose to his feet, thinking he
was not hurt. Three or four hours later,
however, he noticed a dull pain across
the lower part of the back. Returning
to his tent he slept pretty well that night
but felt lame the next day, and kept quiet
till evening, when he joined his regiment

On September 22, Dr. W. W. Grant

was called in consultation, and reasoning that these semi-spasmodic unconscious spells, were probably due to vaso-motor disturbance-inhibition, dilatation, and consequent medullary congestion - we decided to continue a sedative course combined with alteratives and counterirritation. A mixture containing na. br., 20 grs., and ka. io., 5 grs., per dose, was prescribed to be taken after meals with an ergotine pill, 3 grs. t. i. d. This medication was continued until some time in December, save that after a time the dose of the mixture was doubled, and the ergot reduced to one pill on retiring. The patient could not be induced to submit to renewed vesication, and, although better for a few weeks, the improvement soon ceased. He grew nervous and irritable; everything and everyone about him annoyed him; the weakness in his back incleased; his appetite failed; and he became petulant, despondent and miserable. The "misty, cloudy" feeling seemed to deepen, and his falling spells-averaging about one every second day-from which at first, he could get right up and go about as usual, now left him in a depressed, hysterical state, lasting often for half a day. Marked photophobia developed, requiring the use of smoked glasses while in the sunshine, and he was unable to read for any length of time, or to distinguish an acquaintance across the street. Following the stage of total unconsciousness in his attacks, there now developed an intermediate state of horrible sensations and imaginings, as, for instance, that melted lead was being poured into his brain, or that he was to be consigned to an insane asylum. Under the influence of these ideas he would struggle and bite, tear his hair, and seek to dash his head against the ground. He was much troubled with insomnia, and would wander restlessly about with a peculiar stiff, erect bearing, supporting himself with a cane. From a very courteous and pleasant youth he became irritable, passionate, and almost unmanageable, his persistent mental unrest putting physical quietude out of the question. In the latter part of November he was taken to the home of his sister in Raton City, New Mexico, but did not improve. He grew even

more irritable than before, and a continuous dull occipital was added to the persistent lumbar pain. The severer hystero-epileptoid (?) attacks, however, would now sometimes alternate with milder ones-fits of weakness only-without loss of consciousness. In December I decided, with Dr. Grant's concurrence, to adopt a purely tonic course, feeling convinced that spinal anæmia was perpetuating the trouble. The patient was placed on a combination of iron, quinia, and strychnia aud soon began to improve. He now consented to a series of fly blisters in the cervical and lumbar regions at the hands of his local physician, Dr. Shuler, who kept them discharging for about a month.

Since the middle of March his condition has been markedly better, although he has never quite regained the health enjoyed preceding his injury. The falling spells since then have been wholly replaced by occasional attacks of sudden weakness without loss of consciousness, or with, at most, a simple faint. His sleep, appetite, and digestion are good; he is cheerful, ambitious, and hopeful, but he still lacks strength, and the pain in his back has not wholly disappeared. There is a tender spot over the last lumbar spine, with considerable hyperæsthesia throughout the whole dorsal region, most marked in the near vicinity of the seat of pain. There can be little question, I think, that the depressed, irritable, semi-hysterical condition of the patient has been caused by anæmia of the cord, while the unconscious falling spells were due to relaxation of the habitual vasomotor spasm, permitting sudden medullary congestion.

Concussion of the cord without gross lesion requires great care in diagnosis. The "railroad spine" and "litigation symptoms" have justly come to be viewed with distrust. And not only malingering but neuromimesis must be carefully guarded against in these cases. Sprains, bruises, or ruptures of ligament or muscle may give rise to pain in the back and other symptoms often ascribed to concussion; or some form of gross lesion such as fracture, dislocation, hemorrhage, or tearing of nerve trunk or cord may exist undetected. In each case a care

ful and methodical examination should be made, a close study of sensibility, motility, reflex, vaso-motor, trophic and functional disturbances before diagnosing organic disease. Page of London, in his recent work on "Injuries of the Spine and Spinal Cord without Apparent Mechanical Lesion," holds that cases of serious, uncomplicated concussion are very rare, and calls attention to the great tendency to unconscious or conscious exaggeration of symptoms. Erichsen, whose interesting work on this subject takes rank as a classic, gives a vivid clinical description which I may be pardoned for presenting, much condensed, in connection with the case above detailed.

In simple concussion, he says, we have a history of some violent jar or jolt, which, although productive of no appreciable lesion, doubtless alters the functional integrity of the cord much as a blow may affect a magnet. The initial giddiness and confusion are followed by a state of unusual calm and self-possession which, in its turn, when the sustaining excitement of the hour has passed, is followed by an emotional revulsion. The next day the patient feels stiff and bruised, and, in a few days or weeks, finding himself unequal to his accustomed tasks, he is forced to seek medical aid. Weeks, and even months, may lapse before the more positive and serious symptoms set in, but at no time-and this is a point to which especial attention is called-is there a return to the full normal standard of previous health either physical or mental. The patient looks ill and worn, and is very easily fatigued, while his symptoms grow more and more confirmed as time wears on. His countenance is usually pallid, his memory defective, thoughts confused, will enfeebled and vacillating, temper fretful, and sleep disturbed. His head is giddy, throbbing or heavy. There are often loud and incessant noises-roaring, rushing, singing, etc.-in his ears. Asthenoapia, photophobia, muscæ volitantes, and various subjective spectra, harass him. His sharpness of sight and hearing, one or both, may be affectedeither lessened or increased. Taste and and smell, too, may be perverted or lost, though they are not likely to be disturbed. There is rarely an impairment of speech,

but touch and the sense of weight may suffer. The bearing is usually stiff and erect, and motion constrained. There are usually one or more painful spots along the spine, in the lower cervical, middle dorsal, or lumbar regions. The gait is characteristic, resembling that of partial inebriation, the patient usually steadying himself with a stick and keeping his feet somewhat apart. One leg, usually the left, is often weaker than the other and is apt to give way if subjected to the entire weight of the body. The patient can walk for a short distance only, and loses both grip and balance if he attempts to ride a horse. He may suffer from diaphragmatic spasm, hiccough, and sense of constriction about the waist. There may be motor or sensory impairment, one or both, but especially the former, and especially in the extensors of the lower limbs; but there is seldom any complete paralysis, and the incipient paraplegia, when present, is much less apparent when the patient is lying down. Coldness of an extremity, either subjective or actual, due to defective nutrition, may be complained of. Sexual desire and power may be greatly impaired, but neither paralyzed sphincters, ammoniacal urine, nor priapism result from simple concussion. In the latter stages the skin is apt to be cold and clammy, and the pulse weak, irregular and rapid.

The development of symptoms, as a rule, is gradual and insidious, with many deceptive remissions and times of seeming improvement. There is first lassitude with inability to discharge accustomed tasks; then pains, tinglings, and numbness in the limbs; then rigidity of spine with fixed pain; then mental confusion with other cerebral symptoms; then impairment of the senses, and more or less loss of motor power.

Such is concussion resulting in inflammation—meningitis, myelitis, or more often both-the clinical features varying with the predominance of one or the other. More or less cerebral is generally associated with spinal meningitis, and a local softening of the whole or a part of the thickness of the cord, with consequent paralysis, etc., is apt to follow as the sequel to myelitis.

But a concussion whose effects stop