CASES OF PARAPLEGIA ASSOCIATED WITH GONORRHEA AND STRICTURE OF THE URETHRA.' In the year 1833 Mr. Stanley read before the Society some cases of paraplegia arising from primary disease of the urinary organs. According to the views expressed by him, disease of the kidneys may produce a morbid impression upon the cord through sentient nerves, which, being reflected outwards to the extremities, may occasion an impairment of both motion and sensation, and paraplegia result without organic lesion of the cord itself. It would require a more minute examination of the cord than was made in the cases given in the paper referred to before the important negative assumed in their explanation could be regarded as established, since it is known that the structure of the cord may be extensively disorganised where an experienced observer, without the aid of the microscope, may fail to discover the traces of disease. In proof of this I may quote the following case, which was under the care of my friend and colleague, Mr. Hilton, who has kindly placed it at my disposal. Paraplegia following gonorrhoea and syphilis; inflammation of the substance of the cord; no traces of lesion discoverable without the microscope. James L, æt. 20, admitted into Guy's Hospital March 14th, 1855; a gentleman's servant, unmarried. Always had good health until he contracted gonorrhoea and had a chancre eight months ago. He was under 1 1 Reprinted from the 'Medico-Chirurgical Transactions,' 1856, p. 195. LANE MEDICAL LIBRARY treatment for three months. After the chancre had healed he again became infected, and ulceration followed at the seat of the old cicatrix. For this he was again under treatment until the beginning of the year 1855. At that time (January 18th), having occasion to go from home, he slept, as he thinks, in a damp bed, and three days afterwards began to have pains and weakness in the legs and about the neck and occiput. On the 26th he had a rigor, and the weakness of the legs was rather suddenly increased, with loss of sensation above the ankles and formication in the feet. Incontinence of urine came on at the same time. On the 28th he managed to get downstairs with the help of his mother and the use of a crutch, but at night he had lost all power in the legs, and was carried to bed. During the next fortnight the loss of sensation gradually extended upwards to a line corresponding to the distribution of the ninth dorsal nerve. The sphincters were paralysed. The susceptibility to the excito-motor movements continued to increase, and the cord at length became so irritable as to occasion the patient great distress; the least agitation or the slightest touch bringing on violent spasmodic contractions of the legs, though the irritation was quite unfelt. There was a painful sense of constriction across the chest. Bedsores formed and rapidly extended. There was no important change in his symptoms until April 18th. The urine was ammoniacal and continually dribbled from him, excoriating the scrotum and inner parts of the thighs. The bedsores sloughed. There were frequent involuntary spasms of both legs, but especially of the left. At this date he began to have cough, headache, and more frequent rigors. Tongue became furred. Pulse accelerated. He died rather suddenly, May 16th (four months from the beginning of his symptoms), having during the last month become much exhausted from frequent rigors and hectic. On a sectio cadaveris the vertebral canal was healthy. On opening the dura mater the two layers of arachnoid were found united, as usual, on the posterior surface of the cord by delicate adhesion. There were some osseous plates on the visceral layer of the membrane. No traces of vascular injection or of inflammatory exudation. The cord had the normal size and appearance, and neither to the touch nor on section presented any obvious softening. With a lens of an inch focus the surface of the columns at and below the origin of the sixth nerve had a mottled appearance, some portions being opaque and yellowish; and a more minute microscopical examination discovered extensive disorganisation of the nervous structure, the focus of the morbid change being at the middle of the dorsal region and principally in the anterior columns. The fibrous structure was loose, and amongst it, and apparently resulting from its disorganisation, were numerous oily granules, together with a great number of the characteristic mulberry masses (granule-cells). Sections of the cord at the lower part of the dorsal and in the cervical region gave the same results, but in a less degree. This proves that we ought to look with great mistrust upon the evidence which the unassisted eye supplies in the examination of nervous structures, where but slight lesions produce such decided and striking symptoms. The following cases seem to show that, instead of regarding the nerves as the channels through which the cord is secondarily affected in disease of the urinary organs, we ought rather to look to the veins or the blood itself as the means by which the lesion is propagated, and, instead of attributing the paraplegia to functional depression of the nervous energies, to refer it to inflammatory changes. In the following case this pathological relation certainly existed. For the particulars of it I am indebted to my friend Dr. Habershon. Paraplegia; acute spinal arachnitis and softening of the cord following retention of urine from stricture. William W—, æt. 29, a cabman, admitted into Guy's Hospital on Sunday morning, September 19th, 1847, for retention of urine and stricture, to which he had been subject for several years. After a warm bath, and with some difficulty, the smallest catheter was passed and the urine drawn off. On the following day he had again difficulty in emptying the bladder, and twenty leeches were applied to the perinæum. From this date until the 28th the stricture was dilated daily, and he was going on favorably, being a considerable part of the day up and about the ward, apparently in his usual health. On the 28th he complained of a fixed and constant pain near the angle of the tenth rib on the right side, for which a blister was applied, with relief. Three days after (October 1st) he was free from pain, but feverish. He dressed himself as usual and sat by the fire; but, on attempting to return to his bed in the afternoon, he suddenly found his legs weak and numb. Pulse 120. Tongue thickly furred. He was freely purged without benefit. On the 3rd the loss of sensation and motion was complete in both legs, and sensation was imperfect on the surface of the abdomen as high as the umbilicus. He had no pain in the spine, nor any convulsive movements of the legs. The bladder was emptied morning and evening by the catheter. In the intervals it dribbled away, highly ammoniacal and purulent. Mr. Key, under whose care the patient had been admitted, saw him on the 5th, and considered the paralysis to depend upon thickening of the posterior common ligament. sacrum. He gradually became more prostrate. A large slough formed over the The evacuations passed involuntarily. He expired on the 27th, one month from the commencement of the spinal symptoms. There was no affection of the brain throughout. Sectio cadaveris.-Head not examined. On removing the cord with its membranes from the canal a small quantity of pus was found lying on the outside of the sheath, opposite the bodies of the sixth, seventh, eighth, and ninth dorsal vertebræ, and one of the vertebral veins in the lumbar region |