ANTERO-LATERAL SCLEROSIS; POSTERIOR 
SCLEROSIS; PATHOLOGY AND TREATMENT 
OE LOCOMOTOR ATAXIA BY SUSPEN- 
SION AND BY APPARATUS. 
BY 
DE FOREST WILLARD, M.D., 
SURGEON TO THE PRESBYTERIAN HOSPITAL, PHILADELPHIA', CLINICAL PROFESSOR 
OF ORTHOPEDIC SURGERY IN THE UNIVERSITY OF PENNSYLVANIA ; 
GUY HINSDALE, M.D., 
AND 
ASSISTANT PHYSICIAN TO THE ORTHOPEDIC HOSPITAL AND INFIRMARY FOR NER- 
VOUS DISEASES AND OUT-PATIENT PHYSICIAN TO THE 
PRESBYTERIAN HOSPITAL. 
THE MEDICAL NEWS, 
FROM 
November 24, 1894. [Reprinted from The MEDICAL News, November 24, 1894 ] 
ANTEROLATERAL SCLEROSIS; POSTERIOR 
SCLEROSIS; PATHOLOGY AND TREATMENT 
OF LOCOMOTOR ATAXIA BY SUSPEN- 
SION AND BY APPARATUS.1 
SURGEON TO THE PRESBYTERIAN HOSPITAL, PHILADELPHIA J CLINICAL 
PROFESSOR OF ORTHOPEDIC SURGERY IN THE UNIVERSITY OF 
PENNSYLVANIA J 
DE FOREST WILLARD, M.D., 
GUY HINSDALE, M.D., 
AND 
ASSISTANT PHYSICIAN TO THE ORTHOPEDIC HOSPITAL AND INFIRMARY 
FOR NERVOUS DISEASES AND OUT-PATIENT PHYSICIAN TO 
THE PRESBYTERIAN HOSPITAL. 
The degenerations of the spinal cord, or the system- 
diseases of the cord, constitute the most hopeless class 
of affections in spinal pathology. Insidious ofttimes in 
their onset, relentless in their advance, cutting off one by 
one the means of progress, the exercise of the senses, and 
the control of the mind, these diseases have long been 
treated in vain. Why should we be content to calmly 
listen to the funeral march as these patients are borne, 
one by one, to their final resting place? In the lan- 
guage of a distinguished teacher, we are saying to them 
as they enter our consulting-rooms : " My dear sir, you 
have a strip of fibrous tissue in the back part of your 
spinal cord; it is very small, but it will get bigger, and 
you will grow worse. Why it comes there I do not know, 
1 One of the Mutter Course of Lectures delivered before the 
College of Physicians of Philadelphia. 2 
and why I cannot stop it I cannot understand; but I have 
triangulated your nervous centers, located the lesion, and 
if I ever get your cord I can dye the affected part a 
beautiful orange-yellow or a bright carmin-red." 
The whole range of the scleroses and palsies of 
various types has waited patiently, despairingly, at the 
fountain of science. We can pity the patients, but our 
outstretched arms seem powerless to save. We are en- 
couraged, nevertheless, to find some faint streaks of 
light in the East that are beginning to dispel the gloom 
that has overshadowed us and that are ushering in a 
day of new things, 
Although, as a rule, the scleroses of the cord are 
gradual in their onset, and although it is customary to 
ascribe to slowly-operating causes their production, yet 
cases of acute locomotor ataxia are not infrequently ob- 
served. It is quite likely., also, that traumatism is the 
initial cause oftener than is generally supposed. Care- 
ful inquiry will sometimes elicit the fact that the disease 
dates from an injury to the back, or that a slight acci- 
dent has hastened or developed an attack. It has hap- 
pened that a man has received a blow upon the back 
producing myelitis with paraplegia and sensory disturb- 
ances of the lower extremities; the disturbances, let us 
say, were chiefly on the left side; a second injury was 
sustained, and ataxia and loss of knee-jerks supervened. 
It is probable that in persons of a neurotic predisposi- 
tion, locomotor ataxia is precipitated by traumatisms of 
even a slight degree. Spillman and Parisot have an- 
alyzed fourteen cases of tabes associated with peripheral 
injuries of various kinds, and they cite fractures, contu- 
sions, and wounds of the extremities, the extraction of 
teeth, or even the operation for cataract, as precipitating 
the disease. But here, as elsewhere, the danger is that 
post hoc is not always propter hoc. 
Acute locomotor ataxia, according to Leyden, may 
follow acute diseases; it may succeed to diffused neuritis. 3 
It may begin as traumatic myelitis or as meningo- 
myelitis. We are not without evidence that there is a 
tendency toward secondary degeneration of a particular 
set of fibers after a local accident to the cord, such, for 
example, as compression-myelitis. In a recent case of 
Preston's, of Baltimore (Medical News, March 18, 
1893), this was well shown. In this instance a man, 
aged twenty-three, was crushed by a bank of earth. 
There was no external injury of note. There was entire 
loss of sensation and of motion below the level of con- 
trol over the bladder and rectum. The superficial and 
deep reflexes were abolished. Bedsores of a trophic 
nature formed. Death occurred on the fiftieth day, and 
examination showed a fracture of the last dorsal and 
first lumbar vertebrae, with compression of the cord. A 
microscopic examination showed degeneration of the 
posterior columns reaching into the cervical region. On 
the other hand, there may occur a degeneration also of 
the lateral and direct cerebellar tracts. 
Following an accident an ascending degeneration ot 
the posterior columns and direct cerebellar tracts may 
ensue, and at the same time a descending degeneration 
of the crossed pyramidal tracts of the lateral column. 
Such a case was reported to the College of Physicians 
of Philadelphia, four years ago by Meigs (Trans. Col- 
lege of Physicians, 1890). In this instance a sailor was 
struck by a wave and dashed against the bulwarks of 
a vessel, causing him to strike the back of his head and 
neck against the rail. He at once lost all sensation and 
power of motion from the clavicle downward, and from 
the time of the accident he had retention of urine 
and incontinence of feces. Post-mortem examination 
thirty-six days after the accident showed that there was 
neither luxation nor fracture of the spine, but there was 
a small extra-dural hemorrhage into the spinal canal at 
the level of the seventh cervical vertebra. Microscopic 
sections of the cord above the seat of injury showed de- 4 
generation of the posterior columns (columns of Burdach 
and Goll), of the whole of the direct cerebellar tract, 
and of a portion of the antero-lateral ascending tract, 
while below the seventh cervical vertebra the crossed 
pyramidal tracts of the lateral column were degenerated. 
(See illustrations in article alluded to.) In the lumbar 
region the lateral limiting layer and the direct cere- 
bellar tracts, together with the enclosed crossed pyra- 
midal tract, were degenerated, though in less degree 
than the latter. Cases of this kind and other cases in 
which the traumatism is not so severe show that after 
the primary lesion has cleared up a system-lesion may 
be left as a residuum in the cord. 
The relation of the different forms of myelitis to the 
various scleroses has not yet been investigated as it 
should be, and it offers an excellent subject for special 
study. How far these affections are a part of the pro- 
cess of inflammation is a matter of dispute. The term 
is broad enough to embrace the most flagrant febrile 
process as well as the chronic succession of changes 
pervading an organ or certain tracts of tissue, and dis- 
closing, after years of existence, simply a hyperplasia 
of fibrous tissue without any febrile symptoms having 
been observed. 
At the foundation of all inflammatory processes lies 
the principle of infection, and it is not altogether un- 
likely that all cases of myelitis and all the scleroses, 
whether primary or secondary, may in the future be 
harmoniously related to their respective infections. 
How far we may be carried by the present all-pervad- 
ing belief in the microbic origin of these diseases we 
cannot now say, but I note that no less an authority 
than Dana has recently published a paper entitled "The 
Microbic Origin of Chorea, with a Case,'' {Trans. Amer. 
Neurolog. Assoc., 1893). Dana found diplococci in the 
superficial layer of the cortex and in the deep layer of 
the pia, in which situation there were cellular infiltra- 5 
tion and degenerative changes, and in the medullary 
and upper part of the cord there were evidences of men- 
ingeal irritation, vascular disease (arteritis) and nerve- 
root irritation. At the Congress of American Physicians 
and Surgeons, in 1891, Dana discussed the nature and 
causes of the scleroses of the spinal cord, and announced 
his faith in the newer pathology. The old belief that 
sclerosis of the cord is a parenchymatous inflammation 
with secondary growth of connective tissue is giving 
way. It is a degenerative process, showing under the 
microscope a gradual decay and death of the nerve-fiber 
and cell. In some sclerotic processes, like locomotor 
ataxia, this decay is accompanied by the development 
of irritating products, leukomains or tox-albumins, which 
may produce so active a change in the connective tissue 
as to lead to something resembling a secondary or reac- 
tive inflammation. Just what is the ultimate cause of 
these degenerative processes is not known. As yet no 
microbe has been discovered. We have simply the 
toxin theory-a working hypothesis-a disturbance that 
may be likened to that which has been observed upon 
the solar system, and which the French astronomer 
knew was due to an undiscovered planet. 
Some believe that this is a steadily secreted poison in the 
human body, and that it is constantly acting on diseased 
tissue; they bring in evidence the fact that many degen- 
erative processes follow syphilis and the infectious fevers 
and they account for it in the suggestion " that patho- 
genic germs have poured into the system a poison or 
have so modified the cellular nutrition that there is a 
poison constantly thrown out which irritates and de- 
stroys certain areas of nerve-tissue." 
Then, again, in Friedreich's ataxia, the hereditary form 
of sclerosis, it has been shown that certain strands of 
the spinal cord were never endowed with vitality enough 
to carry on their functions for more than a decade or 
two. With this premise some have enunciated the view 6 
that by the presence of the poisons of certain infectious 
organisms the nerve-cell is stunned and its growth 
stunted; it follows that nutritional equilibrum is destroyed 
and premature senility and death are brought about. 
Sanderson in his Croonian Lectures on the " Progress 
of Discoveries in Relation to Infectious Diseases " 
{Brit. Med. Journ., 1891) states, that whereas degenera- 
tive diseases do not follow those infections which do not 
confer long immunity, such as diphtheria, sepsis, ery- 
sipelas, tuberculosis; and whereas on the other hand, 
diseases that do confer long immunity, like typhoid 
fever, measles, scarlet fever, smallpox, syphilis, etc., are 
most likely to set up degenerative changes, it would, 
therefore, not seem unlikely that the very thing which 
protects against recurrence of infection may be the cause 
of some internal degenerative change ? It is probable 
that immunity is secured through the modification of 
cell-nutrition and through the continued presence of 
some antitoxin in the liquor sanguinis. 
It is important to bear in mind in connection with 
researches in the pathologic anatomy of the nervous 
system that there are important and often misleading 
changes, both gross and minute, produced in the spinal 
cord by injury during its removal from the body and its 
preparation for microscopic study. Attention has been 
called to this subject by Van Gieson (TV. Y. Med. Journ., 
1892), who has compared the lesions produced by 
bruises with the conditions found in a number of reported 
cases of malformation of the cord. The lesions artifi- 
cially produced are reduplications of the gray matter, 
irregularly shaped horns, canals, cyst-like spaces, and 
misplaced gray matter, and they may be produced any 
time at an autopsy by careless technique or bruising. It 
has been shown that just such artefacts have been 
erroneously described as congenital malformations or as 
the result of pathologic processes, and have given occa- 
sion for extensive and interesting speculations as to 7 
their supposed relations to the production of disease- 
processes. 
Among the surgical measures that have been adopted 
in the treatment of lateral and posterior spinal sclerosis, 
suspension has been the most widely employed. The 
apparatus used was brought to the notice of the pro- 
fession by Motschutkowski, of Odessa, Russia, and about 
the same time Charcot reported encouraging results 
from its use in France. Three or four years previously 
Dr. Weir Mitchell liad adopted the same measures in 
two cases of sclerosis, but failure to obtain good results 
prevented further trial at that time. The measure in 
itself is not by any means a new one, having been used as 
long ago as 1826 by Prof. J. K. Mitchell in cases of Pott's 
paralysis; in fact, it has been in use for centuries for 
various conditions of the spinal column. Motschutkowski 
made his observations first on a tabetic patient to whom 
he was applying Sayre's plaster jacket for the treatment 
of spinal curvature. He noticed a remarkable improve- 
ment in certain symptoms. Raymond, of Paris, who 
was in Russia on a scientific mission called Charcot's 
attention to the Russian publication. 
Without going into the history of this procedure it 
will be enough to say that an enormous amount of litera- 
ture appeared upon this subject in 1889. Five-hundred- 
and-sixty cases are reported in which suspension was 
adopted, and several valuable papers on this subject 
were published in the Transactions of this College in 
that year. The treatment has been extensively adopted 
in Philadelphia since that date, but with varying success. 
For a time almost every large hospital in this and in 
other cities gave the plan a fair trial. The various re- 
ports claimed improvement in a proportion varying from 
30 to 87 per cent., the highest being Motschutkowski's 
original record, but no cures were noted. 
In 1890 Dr. Guy Hinsdale, of Philadelphia, reported 
twenty-three cases treated at Dr. Weir Mitchell's clinic 8 
at the Orthopedic Hospital and Infirmary for Nervous 
Diseases. Of the twelve cases which had fifty or more 
suspensions, in seven there was reported a lessening of 
pain ; in two there was no change ; one had no pain to 
start with and none at the end of treatment; while in 
two the pains were worse. As to sexual power five re- 
ported increase; one, lessening; one had always been 
good ; and one not stated. In no case was there such a 
gain in sexual power as to make a man competent who 
had been incompetent before the commencement of the 
treatment. The gait was improved in four cases ; in 
seven it was unchanged. Station improved in six ; was 
unimproved in four, and was good to start with in two. 
Knee-jerk was unchanged in all the cases. Bladder- 
control was impaired in four; rectal control was unaf- 
fected. In general it was found that many cases feel an 
indescribable sense of gain from suspension. They feel 
better, eat better, sleep better, and wish to continue the 
treatment. Now that the novelty of the treatment has 
worn ofif, it is natural to find fewer cases at present 
being treated by this method. 
At the University Hospital suspension has yielded 
fair results, and by the kindness of Dr. C. S. Potts 
I am enabled to give the results in the following cases 
hitherto unpublished. In a total of eleven cases four 
were very much improved, and the remaining seven, 
while not sustaining any marked improvement, invari- 
ably felt better for some time; and several of them 
after the treatment had been stopped returned request- 
ing to have it continued. The special symptoms 
relieved were the pain, incontinence of urine, sexual 
weakness to some extent, and several in whom muscular 
weakness of the legs was present felt much stronger after 
the suspension. 
The apparatus used was that of Charcot, as modified 
by Mitchell, in which the elbows are displaced in slings, 
a band around the waist preventing the arms from get- 9 
ting away from the chest. In this way the force applied 
to the head may be easily regulated. The duration of 
suspension was one-and-a-half minutes at first, gradu- 
ally increasing to four minutes. The only bad symptoms 
reported were subsequent attacks of vertigo ; one fainted 
the first time, but bore it well afterward; the patient, 
however, was in an enfeebled condition. It is proper to 
state that all but three of these patients took, in addition, 
internal remedies, potassium iodid, mercury, etc. The 
treatment was certainly palliative if not curative. 
The following are synopses of three cases in which 
improvement was observed. 
Case I.-Mrs. S. was in the first stage of locomotor 
ataxia, probably of specific origin. She had been treated 
with anti-syphilitic remedies for some time with benefit, 
except that severe burning pains in the feet were not re- 
lieved. She was then suspended every day for six weeks, 
and the pains almost entirely disappeared in that time. 
Case II.-T. P. had been ataxic three years, and un- 
able to walk without a person supporting him. He suf- 
fered from incontinence of urine and gastric crises. 
After the third suspension he felt better; after the fifth 
he could walk without assistance, and the bladder-symp- 
toms were much improved. After two weeks' treatment 
he had an erection of the penis, the first for over a year. 
This recurred every morning throughout the remainder 
of his treatment. At the end of a month of suspension 
he returned to his home, able to control his urine and to 
walk much better; and his attacks of vomiting and pain 
were much less frequent. In addition to the treatment 
by suspension he took silver nitrate for two weeks. 
Case III.-The disease was of specific origin. The 
man had had internal treatment for seven months with- 
out much improvement. He suffered pain in the legs, 
sexual weakness, and was unable to walk a block with- 
out sitting down. After suspension his pains ceased, his 
legs grew stronger, and after treatment on alternate days 10 
for four months he returned to his work as a shoemaker. 
One year later he was married, and since that time a 
child has been born. 
Stewart has reported (The Medical News, Sept. 12, 
1891), from the Jefferson Medical College, a case of 
postero-lateral sclerosis which showed remarkable im- 
provement as to gait, station, and tactile sensation. The 
patient was suspended three times a week for five months, 
suspension being made as frequently by the head alone 
as with the arm and head supports. The duration of 
each treatment was about five minutes. 
That suspension produces a change for the better in 
many of these refractory cases has been definitely proved, 
but just how it acts upon the living spinal cordis still a 
matter of conjecture. Measurements show an elongation 
of the spinal column amounting in some instances to one- 
and a-half inches. This stretching involves in its ten- 
sion the surrounding structures, the muscles and tendons, 
and also the spinal cord and dura mater, and spinal 
nerve-roots. Adhesions from chronic meningitis are 
broken down, and it is possible, but not proved, that 
this allows a freer transmission of nervous influence 
along the nerve-tubes, more especially those which run 
on the surface of the posterior columns. Hegar's post- 
mortem studies show that in the dorsal region the dura 
of the cord is lengthened 5 mm. by moderate flexion of 
the spinal column. He produced this by placing blocks 
under the chest and abdomen, and bending the neck, 
the legs being free. Strong flexion was found to increase 
this length to 7 mm. The dura returned to its normal 
length on placing the cadaver in a straight position. 
Hegar laid bare both sciatic nerves, inserted threads at 
different levels and made a strong pull. The distance 
increased one millimeter; the spinal column was again 
flexed and the distance increased six millimeters, and in 
this position the sciatic nerves were strongly pulled and 
the distance increased eight millimeters. The spinal 11 
column was next exposed, and the two threads were 
stitched into the substance of the cord at a distance of 
15.35 c. m. from each other. Moderate flexion length- 
ened the cord 0.75 c.m., and strong flexion over 1.05 c. m. 
Thus it was shown that the cord itself allows greater ex- 
tension than does the dura.-(Douglass Graham, Hegar, 
Wiener med. Blatter, 1884, No. 3.) 
Cattani has shown that stretching of nerve-trunks is 
accompanied by tearing of the axis cylinder, stretching 
of the medullary sheaths, with subsequent degeneration 
and regeneration. Such manipulation of the nerve tissues 
doubtless makes a great change in their vascularity. Just 
as Swedish movements and massage renovate the mus- 
cular system, so it is highly probable that flexion and 
extension of the cord and the accompanying stretching 
that occurs combine to alter and improve the nutrition 
of the tissues affected. 
The first surgeon to apply stretching of peripheral 
nerves in a case of ataxia was Langenbeck. This oper- 
ator stretched the sciatic, and improvement at once 
followed; the pains were diminished in a remarkable 
degree, and the incoordination became less. The expe- 
rience of other operators has not been satisfactory, how- 
ever, and it is only in cases in which the pain is intense 
and referable especially to the sciatic nerve that nerve- 
stretching should be considered. All theories proposed 
to explain the action of this procedure have failed to 
satisfy the profession, and " it would seem now to be 
passing into merited disuse " (Gowers). 
One of the remarkable features of the surgical pathol- 
ogy of spinal scleroses, particularly of locomotor ataxia, 
is an occasional trophic alteration of skin, teeth, bones, 
and joints. Prof. Charcot's name is identified with the 
knowledge of these spinal atrophies, while other French 
writers, notably Ball, Oulmont, Bouchard, and Dejerine, 
and in this country Dr. H. C. Wood and J. C. Shaw 
have rendered important contributions to the subject. 12 
Charcot depicts on the one hand cases of extraordinary 
wasting of the articular ends of the bones. In a femur 
it was found that the head and most of the great tro- 
chanter had disappeared; the edge of the acetabulum 
had atrophied to a corresponding degree. On the other 
Fig. i. 
Fig. 2. 
hand, the changes to which attention was first attracted 
are those of swelling of the joints and thickening of the 
bones. (Fig. I.) While it is possible for any of the 
joints to become affected, the arthropathy is more com- 
mon in the knees, the ankles, and the small bones of the 
foot. (Fig. 2.) This typical swollen foot has been charac- 13 
terized by Charcot as "la pied tabetique." The tabetic 
hand (Figs. 3 and 4), as well as the tabetic foot, may 
occur, and the example which is shown in the drawing 
from the publication of M. Ball is characteristic; it is 
extremely rare, and Dr. Wood, who has portrayed it in 
his work, says that he has never seen an example. 
Fig. 3. 
Fig. 4. 
Tabetic bones in the stage of hypertrophy have been 
carefully analyzed in France; the phosphates were found 
to be greatly diminished, but the fatty matter in the 
dilated Haversian canals was enormously increased. 
"The histologic and chemic results show a strongly 
marked resemblance between the bones of locomotor 
ataxia, of osteomalacia, and of general paralysis" 
(Wood). An atrophy secondary to hypertrophy suc- 
ceeds in advanced cases of tabes, and in such cases 
fractures of the long bones are liable to occur. When 14 
this happens there is apt to be rapid and excessive 
formation of callus; or again, it is possible to have 
atrophy in one limb and enlargement in the other. 
Thus, in locomotor ataxia, as in general paralysis and 
allied diseases of the nervous system, the changes in 
the bones are of a trophic character, tending to atrophy 
and hardness; or, on the other hand, there may be 
permanent alterations related to those found in osteo- 
malacia. 
Much light has been thrown on the occurrence of 
atrophy in tabes by the discovery that in some cases of 
locomotor ataxia the nerves themselves are the seat of 
the disease. Investigations of the peripheral nerves in 
tabes by Dejerine, Goldscheider, Shaw, and others show 
that the ganglion-cells of the anterior horns of the 
spinal cord are not always accountable for the atrophy, 
but that the peripheral nerves as far as the atrophied mus- 
cles have undergone disease, in cases in which atrophy 
is the marked symptom.1 Atrophy in tabes usually affects 
the lower extremities, and as it progresses the muscles 
and tendons undergo shortening, giving rise to con- 
tractures and fixation of the neighboring joints. Much 
of this contracture and fixation is due to want of use, as 
well as to spinal arthropathy. Attempts have been 
made to produce these bone-changes artificially in ani- 
mals by operations upon the nerve-centers, so that, if 
possible, degeneration might occur in the spinal cord 
with a resultant lesion of the joints. Giacomo (Soc. de 
Biologie, March, 1885, p 156, quoted by Wood), in a 
very large dog cut the posterior roots of three lumbar 
nerves between the ganglia and the cord. After some 
months the joints of the left foot became enormously 
swollen and edematous, without increase of sensibility 
or temperature. At the autopsy it was found that sec- 
ondary degeneration had occurred in the spinal cord at 
a level corresponding with the joint-changes. 
1 J. C. Shaw, International Clinics, 1892, vol. iii, p. 176 15 
In cases of tabes which extend through a compara- 
tively long period of time, degeneration of the peripheral 
nerves may involve the patient in another very serious 
change, to wit: symmetrical gangrene of the toes. I am 
not aware that such cases have been reported in Phila- 
delphia, but a recent case of Pitres, of Bordeaux, pre- 
sented this condition in the following history : 
The first symptoms of tabes were observed in 1875; 
five years later lancinating pains in the legs began, and 
the chief clinical features of the case were well estab- 
lished ; ten years later the patient felt as though his toes 
were dead during cold weather, while in hot weather 
they became blue and swollen and pained greatly. 
In the sixteenth year from the onset of this train of 
symptoms gangrene became fully developed in all 
the toes of the right foot and in the great toe 
of the left foot. The patient dying by accident 
shortly afterward, the usual condition of the spinal 
cord was found, together with a very marked de- 
generation of the corresponding peripheral nerves. 
Nevertheless, numerous apparently normal nerve- 
fibers existed. (Revue Neurologique, May 15, 1893.) 
Another case of symmetrical gangrene of the toes 
occurring in a tabetic patient has recently been re- 
corded by Kornfield (Wiener med. Wochenschr., No- 
vember 5, 1892.) An interesting feature of the case 
was a certain resemblance to cases of syringomyelia, 
viz.: in the characteristic dissociation of sensibility; or, in 
other words, symptoms of posterior poliomyelitis, anes- 
thesia to pain, to heat, and to cold, with preservation of 
tactile sensibility and of the muscular sense. But, on the 
other hand, there was no characteristic muscular atrophy. 
Post-mortem examination showed, besides the sclerosis 
of the posterior columns, an acute inflammation of both 
peroneal nerves, fully explaining the occurrence of 
gangrene. (Fig. 5.) 
Those who have investigated the peripheral nerves in 16 
tabes concur in finding the most decided changes 
in the peripheral ends. The microscope shows the 
myelin broken up into irregular masses of various 
sizes ; later on absorption of this granular-looking mate- 
rial occurs, and the sheath of Schwann is found empty 
and shrivelled. The axis-cylinder frequently remains 
Fig. 5. 
for a long time unaffected, and in some specimens it can 
be seen very sharply stained by carmin in the sheath 
with very little myelin around it. (Shaw, International 
Clinics, vol. iii, 1892.) 
The view is gaining ground that tabes is a more dif- 
fused lesion of the cerebro-spinal axis and of its branches 17 
than has hitherto been realized. It would be much better 
in post-mortem studies of locomotor ataxia if attention 
were not riveted too closely to the spinal cord, but 
that more attention be given to the peripheral nerves 
and to the arterial blood-supply of these and of the spinal 
cord. Gowers has called attention to this, and lately 
Preston (Medical News, July 8, 1893), attributes to 
arterio-sclerosis of the intercostal vessels a diminished 
amount of blood in the spinal cord, and in consequence of 
this imperfect supply of nutriment an atrophy and degene- 
ration of the nerve-elements. As a consequence of this 
degeneration of nerve-matter there starts partly from 
the sheath of the nerve, partly from the bloodvessel, 
an outgrowth of connective tissue, which in its turn 
encroaches upon this often less resistant nervous matter, 
giving the characteristic picture of sclerosis. Preston 
shows that the etiologic factors, by common consent 
conceded to be the most important in the causation of 
tabes, viz : syphilis, exposure to cold and wet, or rheu- 
matism, and alcoholism, are the exact conditions most 
favorable to the development of arterio-sclerosis. Acting 
on this supposition, he has suggested the use of nitro- 
glycerin in order that the small branches of the spinal 
arteries may be dilated and a larger supply of blood be 
afforded the cord. 
In the surgical treatment of these pathologic condi- 
tions it is obvious that but little can be done. Contrac- 
tures occur so late, marking the hopeless progress of the 
affection, that interference by the surgeon can only avail 
little. The condition of the limbs can, however, some- 
times be benefited by tenotomy when the existing de- 
gree of incoordination does not present an insuperable 
obstacle to locomotion. The Medical News. 
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