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ON SOME SUPPOSED DISEASES OF THE SPINE.
It has happened to me in practice to see a great number of these singular affections; in which certain morbid states of the nervous system, or occasionally visceral disorders, assume every character of spinal complaints, and are medically treated as such. A large proportion of these cases occur among females; and though the complaint is now better understood than formerly, yet I doubt not the instances are more frequent than is imagined. The simulation of serious disease of this nature, independently altogether of the will, is often so remarkable, that we may fairly presume many such fictitious disorders to remain undiscovered to the last.
A common cause of deception in these instances is the existence of pain, sometimes fixed, sometimes fluctuating, along the course of the spine; and this pain, according to the assertions of the patient, very often relieved by local bleeding, blistering, moxa, and other similar applications. There is frequently, moreover, weakness or numbness of the lower extremities, sometimes such in amount as to be construed into paralytic affection; — pain from exertion, relief from recumbency;—tendency to muscular spasms;—and often difficulty in emptying the bladder. Yet all these, and other symptoms, may arise from nervous or hysterical state of the constitution without any local affection; and in many cases are best relieved by remedies which have no relation whatever to the spine.
It is, in truth, one of the ill effects of the misunderstanding of the complaint, that its symptoms are often greatly aggravated by the means designed for their relief; and spinal disorders even produced, when not existing before, by the muscular debility due to long confinement, recumbent posture, and local depletions. I have seen cases, well worthy of notice, where patients having no nervousness or infirmity of mind, but suffering from topical nervous pains in some part of the spine (the result often of sympathy with internal organs), have been reduced by various treatment to a state of almost total inability of the lower extremities. The proof of the real cause is that afforded by their recovery in very few weeks, from symptoms which have had duration for months or years;—and this recovery derived, not from remedies applied to the spine, but from steel, bark, ammonia, and valerian, cold salt-water bathing or washing, and exercise of the limbs sedulously persevered in and extended. In those instances, by no means infrequent, where some mental infirmity is added to the physical condition producing this state, the moral remedies which the judicious practitioner may employ will greatly aid the success of the treatment.
I allude to these cases, not from any novelty they have to men of professional experience, but because it is important to press that due notice of them, which may exempt the young physician from the chance of error; and equally protect the patient from the mistakes of mere ignorance, and from the maltreatment of quackery and fraud. It well merits attention, in relation to the history of such disorders, how very large a proportion of those affected by them are females. As there are no causes which can adequately explain this degree of disparity between the two sexes as to actual spinal complaints; and as there are many peculiarities in the female constitution tending to produce the deceptive appearances of these, we have here a practical proof of the frequency of the latter, and of the importance of being well prepared for their recognition.
Both firmness and experience, indeed, are greatly required in treating these anomalous disorders. Our first steps are often embarrassed, not only by the fluctuating nature of the symptoms, but by the condition of the patient's mind and nervous temperament; a state of constitution generally concerned in some degree in producing the malady, and almost always aggravated in its progress. These are cases in which, if the foundation of our practice be well laid, we need in nowise be disconcerted by seeming failure in the outset. Some of the most remarkable instances I have seen of complete eventual success, have been those in which the contrarieties in the early part of treatment were most numerous and discouraging.
Ambiguous cases there no doubt are, where the topical symptoms of pain, fulness, or irritation upon some part of the spine, are sufficiently distinct to call for local remedies, on trial at least of their effects. In such instances, and equally so where cause is found for the continuance of these means, I think leeches are generally to be preferred to blisters, caustic, or other irritating applications. The symptoms, as already noticed, are most frequent in habits where there is a morbid sensibility of the whole system; and any active irritation, or even one so slight as hardly to affect other persons, will frequently be found to excite disordered actions, and disturb the whole progress of cure. I have often seen the most obvious and immediate good from removing an issue or open blister; which had effect only in aggravating the symptoms they were intended to relieve.
In cases of this nature, opium might be used much more extensively as an external application than is usual in practice; and, according to my experience, with great benefit. That very condition of the nervous system, which renders a slight local irritation of the cutaneous nerves a source of disturbance to the whole body, gives power and value to this means as an antidote. Where true inflammation has not existed, or has been removed; and where irritation and nervous sympathies are the source of the distress thus attached to the spine and limbs, it is singular what good this application will produce:—not used, however, in the careless and inefficient way which is common with external remedies; but sedulously, and with sufficient proportion of opium in the forms employed.
These cases of supposed spinal disease are further interesting, as they belong to and illustrate an important class of diseases, which, though much more closely examined than heretofore, have scarcely yet been defined in their whole extent. I allude to the various forms of hystefta; and especially to that frequent and curious variety of the complaint, where there is disorder of the sensations, or perhaps it may better be said, of the sensorial functions involving the former. The pains upon or along the spine, in the cases already referred to, often belong to this condition; as does also the inability to give proper action to the limbs, which is so marked a symptom in these disorders. Sir B. Brodie (with whom I have seen many examples of them) has made the observation, that in hysterical paralysis the muscles are not incapable of obeying the acts of volition, but the function of volition is not exercised. In the truth of this observation, all that I have seen leads me fully to concur. In fact, the whole series of symptoms in these cases, whatever the remote causes, is dependent directly upon sensorial derangement, affecting irregularly certain classes of sensations, and impairing the state and action of the voluntary powers.
Many of the anomalies just noticed are expressly due to a depraved state of the sense of touch; testified not solely by the increased irritability already noticed, but in other instances by the sensibility being unnaturally blunted. And these singularities are increased by what is often observed of their partial occurrence and frequent change of place;—phenomena which belong to the general theory of sensation, as well in healthy as in morbid states of the body.
In some of these cases the patient may be said to live in a sort of cycle of disordered sensations, displacing and replacing each other in the most singular way; but all removed for the most part when a real pain supervenes, the result of inflammation or other true diseased action. I have known a toothache, or a slight catarrh, or the irritation of a sprain, completely to banish, for a time, morbid impressions of the most distressing kind and long duration in the habit; all recurring when this cause of interference had subsided. The intellectual and moral faculties frequently partake, in greater or less degree, of the same infirmity; producing some of the most singular perversions of feeling and action which it falls to the lot of the medical man to encounter; and these sustained occasionally during a long period of time.* But, as I have remarked, there are many instances where the bodily symptoms alone exist, without any such conjunction; and it is to these chiefly that I seek to direct attention in the present chapter.f
* Such cases, of which I have seen examples quite as remarkable as any I find recorded, give aid in explaining some of those anomalous phenomena which have perplexed even thinking men, and furnished in all ages large material for wonder to the credulous or uninstructed.
f In the latter cases we may perhaps best seek for a cause in the reflex actions of the nervous system of the spine, which have recently been the subject of so much able research by Dr. Marshall Hall in this country, and Professors Miiller and Stromcyerin Germany. To Dr. M. Hall we owe