ROYAL COLLEGE OF PHYSICIANS, LONDON

Charles Bland Radcliffe
1860 The Lancet  
of this remedy ought to be suspended, for a few days, whenever it produces spasms. Besides strychnine, there is another remedy which has often proved useful in cases of reflex paraplegia : it is sulphur. Graves employed it internally; we prefer, with several French physicians, to employ it in a bath, so that, on the one hand, we avoid its influence upon the functions of the digestive canal, and, on the other hand, we have the benefit of its stimulative action on the skin. It is the sulphuret of
more » ... is the sulphuret of potash which is made use of in that way; four or five ounces for the ordinary amount of water for a general bath. A wooden or zinc bath ought to be employed, instead of the common tin bath. The other means to be employed with the view of improving nutrition in the spinal cord, are the following :-1st. Po3ition of the patient in bed. -I have seen benefit result, in three cases of reflex paraplegia, and in two cases of hysterical paraplegia, from having directed the patients to lie flat on the back in a soft and warm bed, while the head and upper limbs and the bend of the knees were placed on high and hard pillows. In these cases there was a marked diminution of the paralysis every morning, and also, though in a less degree, in the course of the day, after the patients had assumed that position for one or two hours. This result, which I expected from the theory of these affections, may be readily explained if we admit that theory. We suppose there is a contraction of the bloodvessels of the spinal cord, and it is therefore easy to understand that, by diminishing the amount of blood in the head and limbs, we force, as it were, through the agency of gravitation, a larger quantity of this fluid through the bloodvessels of the spinal cord, and consequently increase the nutrition of this organ. 2nd. Application of cold and heat to the 8p,;ne.-To those patients who can bear the application of very cold water to the spine, I prescribe the use of a douche thrown with great force all along the dorsal and lumbar regions of the spine. The douche should be applied for one minute or a minute and a half; it ought to be supplied with a small jet, and the temperature of the water should be between 40° and 50° Fahr. I need hardly say that the spine must be rubbed hard with a warm flannel immediately after the application of the douche. In patients who cannot bear the cold douche, a very warm douche should be made use of. & p o u n d ; I sometimes make use of alternate applications of cold and heat, either with sponges-one soaked with ice-water and another with water at 100° Fahr.-or a towel folded somewhat like a cravat, the two ends of which are wet, one with ice-water, the other with warm water; the spine being struck with either end of this towel alternately. 3rd. Application of 2-evulsives. -Graves, Leroy d'Etiolles, jun., and all the writers on the reflex paraplegia, agree in stating that revulsives, issues, &c., applied on or near the spine, are utterly useless. I would not go so far; but I can state that they are hardly worth the trouble they may give. Graves insists upon the importance of the application of revulsives to the skin of the lower limbs. There is no doubt that applications of croton oil, of mustard poultices, of blisters, &c., to the skin of the thigh or of the calf of the leg, have often been employed with apparent benefit in the reflex paraplegia. 4th. Application of galvanis7n to tlae sine.-If we could pass a powerful current through the spinal cord, this mode of treatment would certainly prove very useful in the reflex paraplegia ; but, as shown by the experiments of Dr. F. Bonnefin,* we can hardly succeed in really passing a weak current through the cord; it is almost entirely through the excitation of sensitive nerves and a reflex action that we act upon the nutrition of the cord by galvanism. In those patients who can bear pain, a very powerful excitation of the skin along the spine, by interrupted currents, may be of service. III. The means of preventing the ill-effects of rest in nerves and muscles, which would naturally take place in proportion to the degree of the paralysis, consist essentially in the application of galvanism and of shampooing to the lower limbs in cases of reflex paraplegia. To avoid muscular atrophy, and the consequent diminution of irritability, in that kind of paralysis as well as in almost any other kind, it is of the greatest importance to apply galvanism to the paralysed muscles. Two or three applications, of ten minutes each, in a week, may be sufficient, especially if shampooing be employed. Besides the above means, it is of the utmost importance that the rest of the voluntary power over the paralyzed parts be exercised frequently, and also that the heat of the lower limbs be maintained or increased by artificial means. As regards hygienic rules, they will be mentioned in the next Lecture, when I treat of various kinds of paraplegia which require nearly the same treatment as the reflex paraplegia. * _Tnnrnal dn Phv;oJo<7ÎP Nn. TIL 1858n. 545. PHYSICIAN TO THE WESTMINSTER HOSPITAL, ETC. LECTURE III. -(Concluded.) I II. The Theory of Spaf3m. 1. IN catalepsy, the state is closely akin to that of a corpse. The blood, indeed, is well-nigh stagnant in the vessels; and it may be necessary to apply the ear to the chest to know for a certainty that the heart continues to beat. In tetanus there is no fever. All observers are agreed upon this point. It is found also, that the spasms are apt to become more general and more violent as the pulse weakens and the animal heat departs. The bouts of spasm, moreover, are distinctly coincident with paroxysms of difficulty of breathing; and in this way the spasm would seem to be connected, not with excitement of the circulation, but with a state in which the aeration of the blood is considerably interfered with. And, in the tetanus caused by strychnia, there is certainly nothing like vascular excitement; indeed, as we have already seen (p. 239), the ey-periments of Dr. Harley afford conclusive proof that the addition of a very minute quantity of the poison to the blood might be considered as equivalent to a loss of two-thirds of the whole amount of blood, inasmuch as it diminished by two-thirds the power which the blood has of absorbing oxygen, and so becoming arterial. During the spasms of cholera, the skin is frigid, clammy, and blue, the breath cold, the pulse well-nigh imperceptible; and that the coincidence of this state of collapse with the spasm is more than aocidental would seem to be evident from the fact that the spasms relax pari passu with the reaction of recovery. In hydrophobia, the state of the circulation is the very opposite of fever, as is proved by the cold hands and feet, the perspiring skin, the quick and feeble pulse, the sobbing and sighing respiration, as well as by the fact that the agitation, spasm, and convulsion increase in violence as the circulation fails. It would seem also, that this very depression of circulation must be connected with the agitation, spasm, and convulsion; for, on looking over the histories of a large number of cases, I find that there was less agitation, less spasm, less convulsion where the circulation was less depressed than usual. In spasmodic ergotisrn, so far as we know, the pulse presents no sign of excitement throughout the whole course of the malady. In the early rigidity" of cerebral paralysis, there may be at first no very evident alteration in the circulation, and the heat may not fall below the normal standard; but, before long, both pulse and heat fail in the paralysed parts. In " late rigidity," the local circulation is always feeble, and the heat in the part is kept up with difficulty. In acute spinal meningitis there may be symptoms of active fever at the onset, but, if so, these symptoms very shortly lapse into those belonging to the typhoid condition. Usually, however, the symptoms have a typhoid aspect from the beginning, and the respiration is too laboured and imperfect to allow of a different state of things. In acute myelitis, the circulation
doi:10.1016/s0140-6736(02)33114-3 fatcat:2nvpftuklzg5tewrfc7r2nacem