A CASE OF 
ANTERIOR SPINAL PARALYSIS 
WITH FORMATION OF VACUOLES IN THE GANGLION 
CELLS OF THE SPINAL CORD. 
READ BEFORE THE AMERICAN NEUROLOGICAL ASSOCIATION, NEW YORK, 
JUNE 19, 1879. 
BY 
ROBERT T. EDES, M. D. 
[Reprinted from The Boston Medical and Surgical Journal, July 24, 1879.] 
CAMBRIDGE: 
fPrintct) at tfjc ftitocrsiitic 3pte&& 
1879.  cells 
. ,. Co^eL. X '«■ 300 
l~"7* £Wvm.oItu5W u-ac-u-fr^t^ 
l~ H. by cjl </?- c<syoL becitcA 6vd t'u alUitiruM. 
$~- 7 Ana Sce+xctL#. II 
vJeA (u5Vvurtj<A\icu{S ijJU. . 
The HructwePwktmoCo. II0 Dsyqmskibh St Boston A CASE OF ANTERIOR SPINAL PARALYSIS 
WITH FORMATION OF VACUOLES IN THE GANGLION 
CELLS OF THE SPINAL CORD.1 
BY ROBERT T. EDES, M. D. 
Mary M., aged twenty-six, born in Ireland, living in Boston, house- 
wife, entered the Boston City Hospital March 13, 1879. 
March 13th. Perfectly well until four weeks ago, when she vomited 
steadily for four days. Was costive for two weeks. One week from 
beginning of illness began to suffer from pain on inner aspect of both 
legs, appearing first in the feet, shooting as far as ankles, then to the 
knees, and finally up the thighs. A few days later she began to lose 
power in both legs, and sensation below the knee became impaired. 
After the loss of power was noticeable, numbness and prickling feelings 
were felt in legs. Two or three days ago hand began to feel numb, 
and its strength impaired. Has vomited occasionally during last three 
weeks. Cannot now stand, and suffers greatly from pain. No vesical 
trouble. Bowels constipated. No sensation of constricting band above 
umbilicus. Vomiting came on about twelve, and she complained of 
pain, which was relieved by morphia. 
March 14th to 19th. There is but little power of voluntary motion in 
legs. Can move her fingers, but cannot grasp a pen well enough to 
write. The muscles of the calf are much wasted. Muscles above knee 
react to faradic current, but much less than normally. Hardly any 
reaction below knee. The strongest current of Fleming and Talbot’s 
battery hardly produced contraction of muscles. Tendon reflex absent. 
Ordinary sensibility somewhat diminished, but no complete anaesthesia 
of legs. Numbness in hands, but not in arms. Complains of pain at 
lower part of thorax, from line of nipple on right to somewhat behind 
the corresponding point on the other side. Pulse rapid aud feeble; 
temperature a little raised, only once or twice above 100° F., and much 
of the time below 99° F. Cups to the back, and morphia pro re nata. 
Urine dark, 1035, acid; sugar and albumen absent; sediment, blood, 
pus, bladder epithelium, fusiform cells, one or two granular casts(?), uric 
acid. March 21st. Did not sleep, delirious all night, some delirium 
1 Read before the American Neurological Association, New York, June 19, 1879. 2 
A Case of Anterior Spinal Paralysis. 
tliis morning, r. m. Was very noisy. Hallucinations during early part 
of night were marked. Marcli 24th. For two days there have been 
involuntary and unconscious discharges from bowels and bladder. 
April 1st. Mouth drawn a little to left, and a slight twitching of a 
little muscular slip below septum narium. April 5th. Delirious. Com- 
plains of pain in her chest, which she attributes to being run over by 
the cars. 
From this time her condition remained nearly the same. She lay 
partly conscious and stupid, with occasional screaming or crying. She 
could move her feet, but only by swinging them from the thigh and by 
the thigh muscles. She could move her hands somewhat in the same 
way, constantly drawing them up, as if to pull the bed-clothes, which, 
however, she was entirely unable to grasp. The symmetrical atrophy 
of both legs below the knees and of both arms below the elbows was very 
striking. The treatment consisted of chloral or bromide, with as much 
food as she could be got to take. Refuses food. Involuntary dejections. 
Some drawing of face to left. Left pupil larger than right, but both 
react to light. April 23d. Died. 
At the autopsy, made by Dr. Cutler, beyond some not remarkable 
staining and congestion, nothing special was found in the thorax and 
abdomen. The uterus bore the marks of a former pregnancy. In the 
brain the puncta vasculosa were normally distinct; vessels not abnor- 
mal. Nothing remarkable found in the cortex or great ganglia. The 
spinal cord was perhaps a little less injected proportionally than the 
brain and the rest of the body. The distinction between the gray and 
white matter at the cervical enlargement was thought to be a little less 
marked than elsewhere. 
After the cord had been placed in alcohol with iodine for a few days, 
then in chromic-acid solution, and again in alcohol, sections were pre- 
pared in the usual manner. Portions of the anterior horns were also 
picked out in glycerine. 
The white substance of the cord appears normal in every respect, 
there being no increase of neuroglia,1 and no atrophy or swelling of the 
nerve fibres. 
The gray substance retains its normal conformation and symmetry. 
Its connective tissue, so far as can be seen in sections, and upon careful 
examination of portions picked out in glycerine, is unchanged. 
The vessels in most of the sections presented no alteration, but here 
and there one could be found which appeared to have an unusual num- 
ber of nuclei in its sheath. In one section, from the cervical region, 
where a piece of artery of this kind was seen in the anterior horn, an 
1 My friend, Dr. J. C- Shaw, of Brooklyn, thought that he detected the presence of sclero- 
sis in the lateral columns. A careful examination of a new set of sections has failed to con- 
vince me of its existence. A Case of Anterior Spinal Paralysis. 
3 
oval clump of small cells, highly colored by carmine, was present in the 
“ neck ” of the posterior cornu. These were the only appearances 
which pointed toward any proliferative process. 
The principal alteration to be found was in the large cells of the an- 
terior cornua, which presented a very striking and obvious lesion to an 
examination even with low powers. 
Large numbers of these cells were marked by the formation of vac- 
uoles, round, oval, or, in case of pressure, somewhat polygonal spaces, 
appearing transparent, clear, and uncolored. These cavities were pres- 
ent in varying numbers, from one or two small ones, situated near the 
periphery of the cell, up to a dozen or more, transforming the cell into a 
swollen, honey-combed structure, in which the protoplasm formed but a 
scanty frame-work supporting the vacuoles. The nucleus was some- 
times present and normal in appearance, even when a large part of the 
cell was transformed into the vacuoles; but in other cases seemed to be 
pushed to one side and compressed, or altogether wanting. The proc- 
esses were comparatively little changed, but a careful examination 
showed that especially in those cells where the alteration was most ad- 
vanced they were smaller, and could not be traced so far into the sur- 
rounding structure. The pigment was but little altered, and the gen- 
eral appearance of the protoplasm, where it remained, was not mark- 
edly different from the normal. 
Beside these “ dropsy-cells ” (I use the word merely for the sake of 
brevity, and not as having any pathological significance), there were to 
be found a few which were altered in another way, being rounded, the 
processes shrunken or indistinguishable, the nucleus invisible, and con- 
tents pale and homogeneous. These were much less numerous than the 
others, and not to be found in all sections. None of the shrunken and 
atrophied cells often found in cases of various forms of myelitis were to 
be found, and if any had undergone the “ vitreous ” change often ob- 
served I was unable to recognize it. I saw no vacuoles in any nu- 
cleus, nor any other change than the compression already described. 
The distribution of these “ dropsy-cells ” forms an interesting and 
suggestive study. It can be easily seen in the accompanying sketches, 
the outline of the gray substance and the position of the degenerated 
cells being determined by the camera lucida.1 The abundance of the 
“ dropsy-cells ” is, if at all erroneous, rather understated. The lesion, 
so far as could be seen, was confined to the cervical enlargement, with 
some traces in the upper dorsal region, and to the lumbar enlargement. 
In these regions, again, it affected a special portion of the gray sub- 
stance, namely, the outer group of cells, and, in the cervical enlarge- 
ment, those lying externally and posteriorly. The little group occu- 
1 In most of the figures only one horn is represented, the distribution of the diseased cells 
being exceedingly symmetrical. 4 
A Case of Anterior Spinal Paralysis. 
pying tlie anterior inner angle of the anterior horn was in only one 
instance, and to the extent of two cells, affected, and in the cervical 
region the group next to it remained free. 
As the lesion begins to appear in descending the cord, we first find 
two cells in the little antero-internal group, which from this point down 
afterward remains entirely free. Then we find two or three cells in 
the outer angle ; then more of them along the middle and posterior por- 
tion of the anterior horn. In the upper dorsal region, in a tew sec- 
tions, a single degenerated cell may be found in the middle or external 
portion of the horn. In the lumbar region, so far as the more rounded 
form of the gray matter permits the distinction of the various groups, a 
similar distribution was observed. 
The posterior vesicular columns of Clarke were not affected. 
In the posterior horns I was unable to find any change of the few 
cells occupying that region. 
The muscles below the knee, which were the only ones examined, 
exhibited the usual granulo-fatty degeneration in various stages. 
I will not fatigue the association by referring to all or many of the 
cases in which a similar lesion has been observed. Suffice it to say that 
vacuoles have occasionally been seen by various observers in the gan- 
glion cells, both of the spinal cord and the cerebral cortex, and that 
they have been supposed to have some pathological significance. Thus 
Mierzejewski represents some small ones in the brain of a general para- 
lytic..1 Leyden figures and describes them in his work on spinal diseases, 
and Gower and Sankey 2 speak of vacuoles “ partly outside the cells ” as 
being found in the spinal cord in cases of “ canine chorea.” 3 A case, 
however, a report of which I saw for the first time after my own had 
been described and figured, has been recently published, in which, as 
in the present one, this seems to have been the most marked lesion of 
the spinal cord found; and the authors consider it worthy of a detailed 
description both clinically and pathologically. It is reported by Kalder 
and Pick.4 Clinically it belongs to the group of anterior spinal paralyses, 
and agrees closely with the “ subacute general anterior spinal paralysis ” 
of Duchenne, except in the supposed absence of the atrophy of certain 
muscular groups en masse, a feature the authors think may, after all, 
have been present, though masked by the development of fat. 
In the account of the examination of the spinal cord it appears that 
only the lower part of the cervical enlargement was examined, and the 
distribution of the altered cells, as regards the various groups, is not 
mentioned. They say expressly that the white matter was normal, and 
1 Arch, de Physiologie, Deuxi&me Serie, Tome ii., PI. vi. 
2 Med.-Chirurg. Trans., 1877, vol. lx. p. 234. 
8 At a subsequent session, Dr. Seguin exhibited sections from a case of ordinary trans- 
verse myelitis, in which some of the cells contained a few vacuoles. 
* Vierteljahrsschrift fur Praktische Heilkunde, Bd. cxlii. p. 5. A Case of Anterior Spinal Paralysis. 
5 
the connective tissue not increased. All the cells are said to have had 
a faded, dull outline, and many of them to have contained the vacuoles 
shown in their plate. 
This case, together with my own, would go far to show that a par- 
enchymatous change may take place independently of a lesion, or with 
a very slightly developed alteration of the connective tissue or blood- 
vessels. 
The case of Dr. Webber, published in the first volume of the trans- 
actions of this society, as well as that of Cornil and Lepine, shows 
clearly enough that changes of an inflammatory character are likely to 
be present, and may be one of the causes of degeneration; but it is 
also probable that they are not necessary to a complete development of 
symptoms of great or fatal severity, and that the parenchymatous lesion, 
whether we call it inflammatory or degenerative, is of primary impor- 
tance. It seems to me, therefore, that the name given by Duchenne, 
“ subacute general anterior spinal paralysis,” is really a more compre- 
hensive one than the more modern “ polio-myelitis, or “ tephro-myelitis,” 
since the question of inflammation, implied by this terminology, is pre- 
cisely that about which doubt still hangs.