Technology Adoption in the Caribbean

Tourism Industry: Analyzing Service

Delivery in the Digital Age 1st ed.
Edition Andrew Spencer
Visit to download the full and correct content document:
https://ebookmass.com/product/technology-adoption-in-the-caribbean-tourism-industr
y-analyzing-service-delivery-in-the-digital-age-1st-ed-edition-andrew-spencer/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Technology and Creativity: Production, Mediation and

Evaluation in the Digital Age 1st ed. Edition Jesper
Strandgaard Pedersen

https://ebookmass.com/product/technology-and-creativity-
production-mediation-and-evaluation-in-the-digital-age-1st-ed-
edition-jesper-strandgaard-pedersen/

Digital Entertainment: The Next Evolution In Service

Sector 1st Edition Edition Subhankar Das

https://ebookmass.com/product/digital-entertainment-the-next-
evolution-in-service-sector-1st-edition-edition-subhankar-das/

Bodies of Work: The Labour of Sex in the Digital Age

1st ed. Edition Rebecca Saunders

https://ebookmass.com/product/bodies-of-work-the-labour-of-sex-
in-the-digital-age-1st-ed-edition-rebecca-saunders/

Technology, Activism, and Social Justice in a Digital

Age John G. Mcnutt

https://ebookmass.com/product/technology-activism-and-social-
justice-in-a-digital-age-john-g-mcnutt/
ERP Adoption in Organizations: The Factors in
Technology Acceptance Among Employees Hamidur Rahaman
Shibly

https://ebookmass.com/product/erp-adoption-in-organizations-the-
factors-in-technology-acceptance-among-employees-hamidur-rahaman-
shibly/

Dark Tourism in the American West 1st ed. 2020 Edition

Jennifer Dawes

https://ebookmass.com/product/dark-tourism-in-the-american-
west-1st-ed-2020-edition-jennifer-dawes/

Fintech, Digital Currency and the Future of Islamic

Finance: Strategic, Regulatory and Adoption Issues in
the Gulf Cooperation Council 1st ed. Edition Nafis Alam

https://ebookmass.com/product/fintech-digital-currency-and-the-
future-of-islamic-finance-strategic-regulatory-and-adoption-
issues-in-the-gulf-cooperation-council-1st-ed-edition-nafis-alam/

Brand Storytelling in the Digital Age: Theories,

Practice and Application 1st ed. Edition S M A Moin

https://ebookmass.com/product/brand-storytelling-in-the-digital-
age-theories-practice-and-application-1st-ed-edition-s-m-a-moin/

Mental Health in the Digital Age 2nd Edition Sheri

Bauman

https://ebookmass.com/product/mental-health-in-the-digital-
age-2nd-edition-sheri-bauman/
Andrew Spencer

Technology Adoption
in the Caribbean
Tourism Industry
Analyzing Service
Delivery in the
Digital Age
Technology Adoption in the Caribbean Tourism
Industry
 Andrew Spencer

Technology Adoption
in the Caribbean
Tourism Industry
Analyzing Service Delivery in the Digital Age
Andrew Spencer
Tourism Product Development Company
Kingston, Jamaica

ISBN 978-3-030-61583-3 ISBN 978-3-030-61584-0 (eBook)

https://doi.org/10.1007/978-3-030-61584-0

© The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer
Nature Switzerland AG 2021
This work is subject to copyright. All rights are solely and exclusively licensed by the
Publisher, whether the whole or part of the material is concerned, specifically the rights
of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on
microfilms or in any other physical way, and transmission or information storage and
retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc.
in this publication does not imply, even in the absence of a specific statement, that such
names are exempt from the relevant protective laws and regulations and therefore free for
general use.
The publisher, the authors and the editors are safe to assume that the advice and informa-
tion in this book are believed to be true and accurate at the date of publication. Neither
the publisher nor the authors or the editors give a warranty, expressed or implied, with
respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published maps
and institutional affiliations.

This Palgrave Macmillan imprint is published by the registered company Springer Nature
Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
 Contents

1 Introduction 1
Challenges in the Industry 5
The Research Context 8
Methodology 12
The Research Process 15
Limitations and Impediments 22
The Structure of the Book 22
References 23

2 Leadership and Technology: Understanding Adoption

Practices 27
Diffusion and Adoption 38
The Digital Divide 52
Ownership and Leadership 59
The Resource-Based View 67
Emergent Frameworks 70
References 73

3 Internal Firm Factors: An Examination of Travel

Companies Resource Base 87
Case Examples 92
Firm Strategy 95
Leadership and Strategy Formulation 98
References 108
v
vi CONTENTS

4 External Factors: The Digital Divide, Closing the Gap 111

Culture and Leadership 116
The Digital Divide 118
References 124

5 Transactional and Transformational Leaders: Their

Influence on Technology 127
Intellectual Stimulation 134
Leadership and Strategy 137
Transactional vs. Transformational: Leadership
Characteristics for Technology Adoption 139
Leadership Background 140
Risk Taking and the Owner-Manager 145
Leadership Characteristics for Technology Adoption
(Owner-Managed, Small Firms) 148
Education 149
Previous Work Experience 150
Technology Experience 151
Risk Aversion 151
Family Composition 152
Intellectually Stimulating Traits 153
References 155

6 The Applicability of an Innovative Theoretical Model

and Its Implications 157
Theory and Concepts 157
Adoption Stages 160
The Adopters 161
Contribution to Theories of Staged Technology Adoption 163
Resistors 164
Caretakers 165
Stabilizers 166
Reactors 168
Transformers 169
Strengths of the Model 171
Limitations of the Model 174
References 174
 CONTENTS vii

7 Conclusion 177
References 188

Appendix 191

References 195

Index 233
 List of Figures

Fig. 1.1 Full stack of steps in the innovation interdependence

perspective (Source Author’s Creation) 16
Fig. 2.1 Firm technology adoption framework: first-order iteration
(Source Author’s creation) 72
Fig. 2.2 Technology decision-making input framework (Source
Author’s creation) 73
Fig. 5.1 Formal education level (Source Author’s creation) 141
Fig. 5.2 Highest qualification and perceptions of internet
importance in sales and marketing (Source Author’s
creation) 142
Fig. 5.3 Cross-tabulation: highest qualification and perceptions
of online market importance (Source Author’s creation) 142
Fig. 5.4 Frequency of internet users (leaders) (Source Author’s
creation) 144
Fig. 5.5 Owner-manager’s risk taking (Source Author’s creation) 146
Fig. 6.1 Revised technology decision-making input framework
(Source Author’s creation) 158
Fig. 6.2 Resistors (Source Author’s creation) 165
Fig. 6.3 Caretakers (Source Author’s creation) 166
Fig. 6.4 Stabilizers (Source Author’s creation) 167
Fig. 6.5 Reactors 168
Fig. 6.6 Transformers (Source Author’s creation) 169
Fig. 6.7 Leadership typologies for staged technology adoption
(owner-managed small firms) (Source Author’s creation) 170

ix
 List of Tables

Table 5.1 Cross-tabulation: personal technology use

and owner-manager’s risk taking 147
Table 5.2 Cross-tabulation: highest qualification and internet sales
investment risk 147

xi
 CHAPTER 1

Introduction

According to the World Travel and Tourism Council (WTTC), the

tourism industry in the Caribbean contributes to 13.9% of the region’s
gross domestic product (GDP).1 Consequently, the state of the tourism
industry is exceptionally important to the Caribbean. However, the sector
is remarkably vulnerable to both internal and external shocks; including
natural disasters, global pandemics, economic crisis among other factors.
In light of the sector vulnerability there is a need to mitigate the impact
of these vulnerabilities, especially in light of the most recent global
pandemic—Covid-19. Which has significantly, reduced the movement of
people across the world, which has tremendous economic impact on the
Caribbean key foreign exchange sources. The use and widespread inte-
gration of Information communication Technologies has the ability to
mitigate the challenges experienced by the industry and improve the
provision of service.
As technology develops and firms increase their adoption of Infor-
mation and Communication Technologies (ICT), there comes a shift
in focus from what one may call “the Big Picture” to more bespoke
solutions that are appropriate for diverse, individualized scenarios. This
is not to say that more orthodox or mainstream management practices

1 The World Tourism and Travel Council. (2019). Economic Impact Reports. Retrieved
from https://wttc.org/Research/Economic-Impact.

© The Author(s) 2021 1

A. Spencer, Technology Adoption in the Caribbean Tourism Industry,
https://doi.org/10.1007/978-3-030-61584-0_1
2 A. SPENCER

have been discarded. While these still prove effective, especially in smaller
owner-managed travel firms, it does illustrate an expansion of perspectives.
The use of computers and other technologies in the travel industry is
not a new idea. Computers have been in use by travel agencies since the
1950s with the creation of the first reservation systems—TIS and Gulliver
during the 1980s,2 and major global distribution systems (GDSs) like
SABRE and Amadeus in the 1990s. Over the years these systems have
evolved into more advanced tourist information systems.
We see this trend continuing today, resulting in a myriad of travel reser-
vation and monitoring systems across the internet; each of them able to
access, and benefit from, the others’ information databases and architec-
tures. This has resulted in the most leveled playing field the industry
has witnessed to date, with numerous options in products and services
available to both producers and consumers.3
Emerging characteristics of this trend include the development of new
value chains and systems. This new infrastructure allows industry players
to take increased advantage of the opportunities presented by applying
the latest technologies.4 However, in order for a travel agency to take
advantage of these benefits, certain preconditions must be met.
Moital et al. (2009) make it clear that the adoption of this new
paradigm requires familiarity with, or at least a basic understanding of,
the tools inherent in this new paradigm. Specifically, computers and the
internet.
A travel firm’s staff requires a certain minimal level of fluency in
computer literacy. They may not need to be able to code programs, but
they do need to understand how to interact with computer hardware and
software. This is a fundamental prerequisite to being able to access and
navigate the internet.
The staff also require, at the very least, a basic level of understanding
of the internet itself. This is necessary for them to be able to effectively
engage in activities such as internet sales, also referred to as e-commerce,
and internet marketing. These may also be referred to as SEM (Search
Engine Marketing) and SEO (Search Engine Optimization). Internet

2 Werthner (1995, 1996), Werthner and Klein (1999).

3 Poon (2001).
4 Buhalis (2002).
 1 INTRODUCTION 3

Marketing is a wider term, encompassing both SEM and SEO, but in

common parlance, they tend to be used interchangeably.
This stepwise progression allows us to appreciate the dependencies
between each step. This also establishes the notion that engagement at
each step assumes previous engagement (and experience) in preceding
steps. We may refer to this as the “innovation interdependence perspec-
tive.” From this perspective, we can project a full stack of progressive steps
as follows:
Since 2000 it’s been argued that different regions in the world are
at different levels when it comes to being able to integrate and utilize
the internet; this is referred to as “internet readiness.” While America
and Canada were strong early adopters, Europe, in the nineties and early
2000s, had been a year and a half behind North America when it came to
levels of internet adoption.5 However, while Europe has essentially caught
up to North America, countries in the developing world, including the
Caribbean, are lagging behind, and there are unfortunate consequences
for countries and businesses that are slow to integrate ICTs.
Most travel agencies in the Caribbean are focused on the outbound
traveler. As such, they may not experience issues like disintermediation—
the consolidation and reduction of intermediaries—at the same pace as
more developed countries. This has resulted in a lack of strategic planning
and proactive measures on the part of local travel agencies.
The reason for this was partially the perception that most Caribbean
people did not place much trust in the concept of making purchases on
the internet, reflected in a study by Lin.6 This led to certain consid-
erations. Firstly, most travel firms in the Caribbean are focused on the
outward-bound market. Secondly, there is a gap with regard to access to
technology (what may be termed as the “digital divide”) between tourists
and Caribbean travel destinations. These considerations raise the question
of whether the inbound travel market is a gap that the local travel firms
can fill if they can bridge the digital divide.
There is, however, another disincentive for local firms in catering to the
inbound market. Inbound travel does not provide a commission compa-
rable to what they may make in outbound travel. This is, unfortunately,
a shortsighted view as it fails to take into consideration opportunities

5 Law and Leung (2000).

6 Lin et al. (2009).
4 A. SPENCER

presented through value-adding and dynamic packaging, i.e., creating

travel solutions on a more individualized basis.
More recently, the digital divide has been shrinking, but according to
Minghetti and Buhalis,7 there are still significant gaps between Caribbean
destinations, developed nations and the tourists thereof. This will lead
to varying levels of “digital exclusion,” where certain companies lose
business opportunities because of some technological inadequacy.
Minghetti and Buhalis have conducted research on the digital divide
in the context of the tourism industry. Their work highlights chal-
lenges in areas such as marketing and communications between tourism-
generating countries and tourist destinations. Tourists and enterprises
from these developed, tourism-generating regions interact on electronic
platforms. These platforms reduce the need for brick-and-mortar loca-
tions where enterprises and clients have to interact face-to-face. According
to Minghetti and Buhalis,

The study of the digital divide is critical for less technologically devel-
oped regions that need to expand their ICT usage to be able to promote
their offerings, interact with consumers, and reduce their dependence on
intermediaries.8

One important consideration from the study is the fact that tourists who
are not tech-savvy, and destinations that are behind current trends in ICT,
still rely on the older way of doing things and, naturally, utilize travel
agencies with physical locations. This scenario applies to the Caribbean.
There appears to still be a fairly high dependence on physical interme-
diaries, i.e., travel agencies with physical locations that clients can visit for
face-to-face engagement. Specifically, The Jamaica Tourist Board, along
with other enterprises in the tourism and hospitality industry, ensure that
relationships are maintained with intermediaries such as The American
Society of Travel Agents and The Association of British Travel Agents.
Due to this state of affairs, three issues become clear.
Tech-savvy tourists from developed countries who prefer to conduct
their travel arrangements online may not be captured by more traditional
marketing efforts in the Caribbean.

7 Minghetti and Buhalis (2010).

8 Minghetti and Buhalis (2010, p. 278).
 1 INTRODUCTION 5

The Caribbean’s image as a tourist destination may be negatively

affected if they are unable to interact with the islands’ tourism and travel
options via the internet. According to Govers, “covertly induced and
autonomous agents, in particular, have a dramatic influence” over the
image of a travel destination in the minds of consumers.9 These agents
include television, magazines, and the internet itself. And in the case of
Jamaica, where the Jamaica Tourist Board is focusing most of its efforts on
television advertisements,10 online promotion and engagement are paid
little attention; this is the reality for many other Caribbean islands as well.
As a result, the television advert may intrigue potential tourists, but be
disappointed when attempting to gain more information or seek booking
options online. Such circumstances wear away at a destination’s image.
Travel agencies within the Caribbean have significantly lessened over
the past decade. Regardless, they do play an active role in driving inbound
travel and tourism to the islands. They are typically focused on the
outbound market due to the fact that they do not receive commission
on inbound travel sales. The key to the issues previously highlighted the
online presence of Caribbean islands and their travel firms. Currently,
travel agencies receive little attention from local statutory bodies. The
potential opportunities provide an excellent argument for greater govern-
mental collaboration and support. The challenge is to motivate existing
travel firms to adopt ICT beyond simply an exchange of emails, and to
establish a stronger and more vibrant online presence. Right now, only
about 5% of local travel companies have active websites. So, the question
is, how do we motivate these companies to more readily adopt ICT and
make it a pivotal component of their company strategy?

Challenges in the Industry

This work was motivated by the fact that the Caribbean travel industry is
facing significant challenges. While the disintermediation that advanced
economies already experienced is only recently taking place in the
Caribbean travel industry, we have already seen a significant reduction
in the number of firms. For instance, according to the Jamaican Associ-
ation of Travel Agents (JATA), between 1999 and 2009 the number of

9 Govers et al. (2007, p. 19).

10 Williams and Spencer (2010).
6 A. SPENCER

travel agencies declined from 105 to 43; while in Trinidad and Tobago
the number of agencies moved from 11 to 5.
Upon further assessment, many firms in Jamaica, The Bahamas, and
Trinidad and Tobago were not implementing changes to similar opera-
tional procedures as those that were taking place in the global market-
place. The operational component that saw the least change was the use
of technology.
After the adoption of Global Distribution Systems (primarily Sabre and
Amadeus) in the 1990s, adoption of new technologies stalled. This was
considerably more the case with technologies that directly impacted sales
and marketing, despite the growing popularity of the internet. This obser-
vation leads one to wonder why domestic travel agencies were so slow to
adapt despite the obvious need for evolution in their business models.
It would be beneficial to understand why firms with similar character-
istics, and in similar contexts, have varying levels of ICT adoption. This
research will look at a number of possible factors, with the aim of deter-
mining the prime factor(s), as well as investigating pertinent issues and
challenges in the global environment.
Studies that focus on technology adoption are usually placed in one
of two phases, pre-internet or post-internet. The most renowned pre-
internet phase studies are based on earlier works by Rogers (1962) and
Davis (1989). These two schools of thought have fundamental differences
in understanding what drives the adoption of technology.
Roger’s perspective, termed the “diffusion of innovations,” focuses on
innovation, communication, and the role of society. Davis, on the other
hand, sees adoption from the perspective of the user and their assessment
of this new technology. Is it easy to use? Does it do what I need it to? This
school of thought is referred to as the “technology acceptance model.”
When it comes to post-internet phase studies, the general consensus is
that the internet is the most widespread, most pervasive technology ever
devised. Even more so than those technological developments that led
to improvements in farming production, such as those studied by Rogers
(1962).
It has been observed over the last 30 years that industrial economies
have evolved into information economies. According to Parker (1988), it
is information, not land nor capital, that will drive the creation of wealth
and prosperity for the foreseeable future. Technology has permanently
changed the way that the world does business. Drucker (1990) takes it
 1 INTRODUCTION 7

a step further by arguing that, due to this shift, knowledge now has the
greatest impact as a means of production.
Naturally, those businesses that are quick to adopt technologies that
facilitate the transfer of knowledge (ICTs) gain a competitive advantage.11
Unfortunately, providing a simple definition of ICT is not an easy thing
to do.
Buhalis (2002) shows that ICTs include hardware, software, group-
ware (software that allows multiple remote individuals to collaborate on
a common project simultaneously), and NetWare (hardware and soft-
ware that facilitates communication between computers, including other
devices, on a digital network). But other major components of ICT are
the capacities and capabilities of the users of ICTs to develop, program,
and maintain these technologies. The best technologies in the world are
only as powerful as the capabilities of those who are using them. Given
how broad the topic of ICT is, it’s important to point out that the main
focus of this book is the single most pervasive technology of them all, the
Internet.
While the internet was originally conceived and had its tentative start in
1969, it was not until 1991, more than twenty years later, that it became
publicly accessible and grew into the internet we know today.
The internet became one of the most ubiquitous technologies ever,
spreading across regions faster than any technology before it. Its impact
and potential are so profound that organizations and businesses world-
wide had to reassess their policies, procedures, and general ways of doing
things.12
Other post-internet phase theorists argue that, apart from affecting
various aspects of business, the internet has led to the modification and
restructuring of entire economic sectors.13 The internet demonstrated
this amazing ability to penetrate and transform these multiple economic
sectors and industries, both as an external force and as an internal driver.

11 Porter (2001).
12 Klein (1996), Grieger (2003), Amit and Zott (2001).
13 Kalakoa and Whinston (1996), Gatty (1998), Ghosh (1998), Timmers (1998), Wirtz
(2001).
8 A. SPENCER

The Research Context

In the Caribbean, travel and tourism is one of the leading sources of
economic activity, as such the industry is one of the leading industry
providers of jobs in Jamaica, and the Bahamas whether directly or
indirectly. While in Trinidad it contributes significantly in regards to
employment, with room for tremendous improvement. That being the
case, it is vital that we gain an understanding of the local economic
environment in which travel and tourism firms operate.
The Bahamas and Trinidad and Tobago can be classified as high-
income countries while Jamaica is a middle-income country. Both Jamaica
and The Bahamas are oil-importing countries. The typology of these
Caribbean countries under examination is slightly nuanced with The
Bahamas being a predominantly customer service export or tourism
industry; Jamaica on the other hand can be classified as a mixed
goods export/customer service (or tourism) industry while Trinidad and
Tobago mainly exports Goods particularly, oil but the tourism industry is
one that thrives in the country.14 The Caribbean has made tremendous
progress in the post-independence period, with numerous countries like
the aforementioned earning middle income and high-income status based
on growth per capita income. Nonetheless, the region is riddled with
several developmental challenges which negatively impact growth and
productivity. In light of these challenges, the region has been tasked to
rethink and restructure their approach to development. Therefore, struc-
tural changes in terms of identifying and investing in priority economic
industries especially when faced with crisis have been the balancing act
carried out by Caribbean states. For instance, Jamaica’s focus on the
tourism industry occurred due to the downturn of the bauxite and
aluminum industry in the 1970s despite it being the heart of the Jamaican
economy decades prior.
The social context of the Caribbean influences the perception of new
technologies. A major vehicle for this influence is the formal education
system. Before independence, most schooling was provided by churches;
today, the majority of schools are provided by the government.15

14 Economic Commission for Latin America and the Caribbean (ECLAC). 2012. Devel-
opment paths in the Caribbean. Retrieved from https://www.cepal.org/en/publications/
38253-development-paths-caribbean.
15 Whyte (1983).
 1 INTRODUCTION 9

Driven by a mandate of universal literacy, tuition became free and school

attendance in the Bahamas, Jamaica and Trinidad and Tobago was made
compulsory for all children at various educational levels.
As for higher education, courses are offered by numerous tertiary insti-
tutions, namely The University of the West Indies which has campuses
located in The Bahamas, Jamaica, and Trinidad and Tobago.
Interestingly, even some American universities have recently begun
offering courses locally in Jamaica.
Courses on tourism have been available at the University of the West
Indies since the 1970s. Initially, students would enter their first year at
one of UWI’s three campuses (Mona, St. Augustine and Cave Hill) and
complete their final two years of study in The Bahamas. Since 2006,
however, the Mona campus initiated a full three-year course, allowing
Jamaican students who wish to study tourism to do so in their own
country.
Each of the aforementioned tertiary institutions has contributed, to
some degree, to tourism and hospitality training of the country’s work-
force. In Jamaica, this effort saw significant growth when the College
of Arts, Science and Technology became the University of Technology
(UT). Unlike the courses offered on other campuses, those offered by UT
have a more scientific focus, with the additional aim of imparting tech-
nical skills to its students. It appears, however, that the “trickle-down” of
these skills to the rest of Jamaican society has been slow, and this is having
a direct negative impact on business in the island; the same can be said
for other Caribbean states.
Travel agencies tend to use technology that has been adopted by the
public at large. This makes the technological context of the country
important when it comes to understanding why travel agencies operate
the way they do. Internet penetration within The Bahamas, Jamaica, and
Trinidad and Tobago are 89,16 95, and 160%17 respectively.18
As mobile and cell phones increased in popularity, the demand for land-
lines dropped precipitously. The number of landlines supplied dropped

16 https://www.helgilibrary.com/indicators/mobile-phone-penetration-as-of-popula
tion/bahamas/#:~:text=Mobile%20phone%20penetration%20as%20a,than%20in%20the%
20previous%20year.
17 https://oxfordbusinessgroup.com/overview/three-company-liberalisation-has-bro
ught-host-benefits-consumers-along-stronger-0.
18 https://www.internetworldstats.com/carib.htm.
10 A. SPENCER

from over half a million to approximately three hundred thousand as

of 2006 in Jamaica. The introduction of internet connectivity to the
Caribbean, connecting States like the Bahamas, Jamaica, and Trinidad and
Tobago to the rest of the world opened up a whole new set of possibilities:
e-commerce.
As developing nations, the Bahamas, Jamaica, and Trinidad and
Tobago has a lot to gain by participating in the global economy. America
is our largest trading partner, and we are competing with the world. It is
vital that we implement the infrastructure that will allow us to engage with
those consumers on the same level as other nations around the world.
Given the limited size and scope of these States, including its human
capital, we have to develop quickly. Otherwise, we risk eventually facing
record deficits. While tourism, agriculture, mining or energy currently
provide a substantial portion of the revenue for these States, all of those
local industries, by US standards, suffer from deficient technology.
The Bahamas, Jamaica, and Trinidad and Tobago have never been a
major tourist-generating country, and most of the travel associated with
the islands is inbound. Specifically, tourism began in Jamaica in the 1890s
when the United Fruit Company had been experiencing a spate of excess
capacity in their ships. Seeing an opportunity, they began offering cruises
to Jamaica. Tourist hotels on the island soon followed, but it was not until
after the Second World War that tourism in Jamaica began to flourish. The
number of hotels tripled between 1945 and 1970, as investments at that
time were benefiting from accelerated depreciation allowances.
Being geographical neighbors, most of the Bahamas, Jamaica, and
Trinidad and Tobago’s inbound travelers are from the United States.
Likewise, most of their outbound travel is to the United States. This is
reflected in the sizable diaspora in that country. As a tourist destination,
though, these States receive far more tourists than it generates.
While it is commonly understood that Bahamians, Jamaicans, Trinida-
dians and Tobagonians travel to visit friends and family overseas, data on
them traveling to other countries for vacation is practically nonexistent.
This is probably due to the limited economic means of the average house-
hold. Despite the lack of data for outbound vacationers, the number of
Caribbean citizens living in other countries would indicate that there is a
demand for outbound travel for those who wish to visit family and friends
overseas.
For instance, the Jamaica diaspora is huge! According to some esti-
mates, there are as many people of Jamaican descent living outside of the
 1 INTRODUCTION 11

island as within it. The largest concentrations of the diaspora are located
in three countries:

• The United States

• Canada
• The United Kingdom.

As of 2008, there are roughly 637,000 second-generation Jamaican immi-

grants (those born in foreign countries) in the United States; 123,500
in Canada; and 150,000 in the United Kingdom, according to each
country’s statistical bureau.
Outbound travel in Jamaica and other Caribbean States is usually
handled by travel agencies with physical locations; agencies that have been
facing significant challenges over the past two decades. In 2000, American
Airlines, British Airways, and the regional-carrier Air Jamaica cut commis-
sions for regional travel agencies from 9 to 6%. According to the Jamaica
Gleaner, American Airlines implemented the cuts first, then travel agencies
responded by boycotting the sale of American Airlines tickets.
This action proved futile, however, as American Airlines (which
accounted for 70% of the air traffic to the region) opted to offer
direct bookings. The agencies’ position was further weakened when, two
months later, British Airways and Air Jamaica followed suit. In 2009,
further cuts followed, taking commissions from 6 to 3%. This, and other
changes in airline reservation practices, has led to the closure of numerous
travel agencies and a proliferation in unregistered agencies. In Jamaica the
Minister of Tourism stated, local unregistered agencies have no insurance
nor protection for their clients. Some have even faced the consequences
for selling travel packages that did not materialize.19
To provide a deterrent against the practice, the government passed
legislation to increase the fine for operating an unregistered travel agency
to a maximum of JMD$1,000,000.
The strategy being used up to this point, offering a limited set of
services to outbound travelers, is failing. This research posits that, in
addition to a reexamination of the market, current business practices and
processes must also be reexamined in order to generate a more adaptable
business model, especially with regard to technology.

19 Jamaica Gleaner (2011).

Another random document with
no related content on Scribd:
columns of Burdach and Goll. The leading symptom manifested by
the patient was a hemiplegia of the muscular sense.156
156 Besides my case, others have been recorded by Homén, Meyer (Strassburg), and
Schrader, which are impure. In the former and latter degeneration of the pyramid
tract, in the second degeneration of the olivary fasciculus, coexisted. It is not
generally known that Westphal, in one of the first volumes of the Archives now edited
by him, found an ascending degeneration of the same tract for a short distance.

FIG. 35.

Secondary Degeneration of Interolivary Layer, Caudal or Descending

Portion: A, in caudal half of pons; B, cephalic end of oblongata; C, middle
of oblongata; D, at level of so-called upper pyramidal or interolivary
decussation; E, at level of true pyramidal decussation. The atrophy in this
level has entirely crossed the middle line; in D it is seen in the act of
crossing.

Ascending degeneration is found in a very distinct form after

compression of the cauda equina. It is limited to the posterior
columns, occupying nearly the entire area of the latter in the lumbar
cord, particularly the triangular field of Burdach's column mentioned
in the article on Tabes. In the dorsal and cervical cord it is limited to
the columns of Goll, and terminates in the clava of the oblongata at
the nuclei of those columns.
Higher lesions produce the same ascending degeneration of the
column of Goll, and in addition involve other, probably centripetal,
tracts which happen to be injured at their origin or in their course. For
example, a transverse lesion of the dorsal cord would produce
ascending degeneration for its whole length of the column of Goll
and of the direct cerebellar tract. In addition, it would, in obedience to
the law previously stated, produce descending degeneration of the
pyramid tract. This combination is almost a typical sequence of
compression myelitis of the cord, as well as of ordinary transverse
sclerosis. Recently, Gowers157 has described a secondary
degeneration in such a case of transverse lesion not previously
noticed. It is found in cases showing gross disturbance of cutaneous
sensibility, and occupies a narrow belt encircling the anterior quarter
of the circumference of the crossed-pyramid tract. It is continuous, in
my opinion, with a tract which in the upper cervical cord is situated in
a corresponding situation, and which degenerated a short distance
caudad in a case of secondary degeneration of the olivary fasciculus
described by Meyer, and in which similar sensory symptoms were
noted.
157 Diseases of the Spinal Cord, and Neurologisches Centralblatt, 1886.

FIG. 36.
 Decussating Degeneration of Interolivary Layer: Dr, Darc, the crossing
degenerated fasciculi; Arc, the undegenerated fasciculi, after emerging
from the partly sclerosed raphé.

CLINICAL HISTORY.—Secondary degenerations are passive results of

other more active processes, and few clinical signs are attributable
to them. The most important of these is the contracture which is
found in old hemiplegias, and attributed, like the secondary
exaggeration of deep reflexes in such, to the descending
degeneration of the pyramid tract. Bouchard believed that it was the
retraction of the sclerotic strand which acted as an irritant on the
neighboring fibres. The development of spastic symptoms in
amyotrophic lateral sclerosis and in focal lesions of the crossed-
pyramid tract is in favor of this view. On the other hand, the
occurrence of flaccid hemiplegia, and its conservation for years after
the most extensive lesions, is against it, as it is in these very cases
that the secondary degeneration is most intense. That the retraction
of a longitudinal strand exercises any serious effect on neighboring
and parallel fasciculi is questionable, as the process is slow. There
is, however, one situation where such influence is very likely to occur
—the decussations of the oblongata. In the case already referred to,
the retracting sclerosing bundles undoubtedly must have exercised a
damaging effect on their fellows of the opposite side, which,
interdigitating with them, were compelled to pass through the
sclerosing tissue. It has occurred to me that the slight sclerosis
which is sometimes observed in the crossed-pyramid tract of the
same side of a cerebral lesion, even where that lesion is strictly
unilateral, is due to a similar influence. I think it can be shown that
such sclerosis cannot be traced to the primary lesion; it begins at the
decussation, and it is more than probable that the firm constriction to
which the healthy fibres are subjected in crossing through their
shrinking fellows of the opposite side is not alone the cause of the
symmetrical yet slighter lesion, but also accounts for the observation
by Pitrés and Charcot of a slight motor weakness observed on the
same side as the hemiplegia, producing lesion in ordinary cases of
capsular hemorrhage.158
158 Some of the French observers claim that this occurs only in the early period, but a
careful study of the matter by R. Friedländer shows that the weakness of the side not
usually regarded as involved is found in the later periods, and well marked then
(Neurologisches Centralblatt, June 1, 1886).

The PROGNOSIS and TREATMENT of secondary degenerations are

practically involved in the primary lesion which gave rise to them.
The contractures attributed to secondary sclerosis of the motor tracts
is to be treated on the principles mentioned in the following section.

The Treatment of Spinal Sclerosis.

As the histological character of the different forms of sclerosis is

similar—at least in the terminal period—the causes producing them
identical even in name, and the indications furnished by leading
symptoms analogous if not identical, the treatment of these various
disorders is naturally based on the same leading principles. There
are two objects to be aimed at in dealing with these chronic
disorders: The first is the cure or arrest of the morbid process itself;
the second is the amelioration of distressing and disabling
symptoms.

It is generally recognized that a perfect cure of a sclerosis is a

consummation never to be realized by any plan of treatment now at
our disposal. The experiments of Kahler and others have shown that
spinal tissue, once destroyed, is not regenerated. The post-mortem
examination of cases of tabes which were considered as cured
during life (Schultze) has shown that the sclerosis had not been
removed; the process had merely become quiescent, and the
apparent recovery had been due to the vicarization of other nerve-
elements than those destroyed for the latter.

But if attempts at the regeneration of destroyed fibres and cells are

to be regarded as futile, the arrest of the destructive process is to be
considered as an object which offers better chances of realization,
and which is worth attempting for other than merely conservative
reasons. In a number of the forms of sclerosis described, notably in
tabes and the disseminated form, it is remarked that the axis-
cylinders lying within the morbid district are in part intact and in part
but slightly affected. Here and there groups of nerve-tubes may be
found which retain even their myelin. While subject to the
vicissitudes inseparable from their position in the midst of active
pathological changes, these channels of nerve-force, though
anatomically patent, may have their function perverted or destroyed,
just as a nerve outside of the cord may be paralyzed by pressure or
anæmia though its structure be intact. Should the active phase of the
sclerotic process be arrested, these intact or nearly intact fibres will
resume their function, and thus an apparent improvement will be
effected. The spontaneous ameliorations in the course of tabes
dorsalis and the less marked ones of diffuse sclerosis, coupled with
temporarily improved sensation in the former and improved motion in
the latter disease, show that retrogressions of this character are
possible and do occur. How is the physician to imitate the action of
nature? how to intensify it so as to secure the permanent
improvement which nature unaided does not grant? The first factor
to be considered is the removal of the cause of the disease. A
number of cases are due to exposure to wet and cold and to over-
exertion. Such exposure and over-exertion, if not already rendered
impossible by the disease, is to be discontinued. A large number of
cases of tabes—according to many authors, a majority—a
considerable number of cases of diffuse sclerosis, and not a few of
other forms, are connected with the syphilitic dyscrasia. Here, at the
very outset, we have a definite indication for treatment, and while we
may be disappointed in the results of such treatment in a large
proportion of cases, yet enough of well-assured and substantial
success has been and is obtained to render it almost a matter of
duty for the physician to try antisyphilitic measures in every such
instance.

The mixed treatment in chronic spinal disorders should be followed

out for long periods and faithfully. Most tabic and other sclerotic
subjects affected with constitutional syphilis are in what is called the
tertiary period of that disease, when iodide of potassium is less
useful than mercury. I have never gained anything by pushing either
drug to the extreme point in advanced cases, and it should be borne
in mind that mercurialization carried too far may itself prove directly
injurious to the nerve-centres.159 In cases where gastric crises, gross
ataxia, muscular atrophy, and bladder disturbance have been of long
duration this treatment is rarely successful.160 But in the initial and
early periods of tabes and in diffuse sclerosis of slight intensity the
effect is sometimes gratifying, and of such a nature that it cannot be
attributed to a coincidence with spontaneous remissions of the
disease. In one case both knee-jerks and the pupillary reflexes
returned, to disappear on premature discontinuance of the treatment;
and on resumption one knee-jerk again returned, and has remained
demonstrable now over half a year. In a second case the fulminating
pains and the bladder disturbance disappeared, a slight indication of
the pupillary reflex developed, and the patient has remained
stationary with this gain for a period of three years.161 In a third case,
one of established ataxia, with which luetic osseous lesions
occurred, the pupillary reflex has returned twice, disappearing after
the first reappearance. In one case of combined sclerosis in which
no syphilitic antecedents could be found the paresis of the arms has
disappeared, and the ataxic paresis of the lower extremities has
improved to such an extent that the patient can stand with his eyes
closed and his feet together, and on one leg with the eyes open—
feats which a year ago he was unable to perform. None of the
changes in symptoms taking place in these cases occur
spontaneously in sclerotic spinal disorders, and they must be
attributed to the treatment. Such treatment is best carried out in
conjunction with warm bathing. The Hot Springs of Arkansas, those
at Las Vegas, New Mexico, and the baths of Aix-la-Chapelle in
Europe enjoy a special reputation in this field. The springs of
Arkansas, as regards the intrinsic character of the water, possess
advantages which are probably not excelled by any European baths,
but the therapeutical management162 is far from that ideal point of
development attained, for example, at Aix-la-Chapelle.
159 Mendel thus found in his experiments made on dogs, developing cerebral disease
from rotation with the head directed toward the axis of rotation, that dogs who had
previously received subcutaneous injections of corrosive sublimate showed an
increased vulnerability to the action of the rotary apparatus.

160 A remarkable exception is related in the section on Chronic Myelitis.

161 There was concentric limitation of all color-fields, and only central perception of
green; to-day, if anything, the color-fields of this patient are a little greater than in the
physiological average. The case was undoubtedly one of initial tabes.

162 Mercurial ointment is used by the hundredweight, to quote the expression of a

patient, and in certain establishments the sufferers from the common taint plaster
each other from head to foot, as with mud, with this panacea for most of those ills
which flock to the springs. Still, there seems to be no doubt that enormous quantities
of mercury are borne well by those who use the baths, and who under other
circumstances are susceptible to its most undesirable effects.

Optic-nerve atrophy, according to the best authorities, constitutes a

contraindication to the use of mercury in any form. It may be laid
down as a general rule that the more rapidly the symptoms indicating
a sclerotic process are developed, and the more recent its advent,
the more energetically should the treatment be pushed. Mercurial
inunctions and the so-called heroic doses of iodide are to be
employed. But in cases progressing slowly and of long antecedent
history what may be called a dilute plan is more apt to yield good
results. Small doses of mercury,163 given steadily for years, and
iodide of potassium, administered in well-tolerated doses for periods
of ten days, alternating with corresponding periods of intermission,
have, in my opinion, delayed or arrested the progress of tabes and
other forms of sclerosis for the long periods referred to in the
preceding sections.164 Although the antisyphilitic measures adopted
in sclerosis of syphilitic origin are the most important, and the
prognosis of no such case can be regarded as hopeless as to
recovery or duration until they have been tried, other procedures,
detailed under the head of Peripheral Treatment, should not be
neglected. While some very severe cases improve rapidly on
antisyphilitic treatment, other much less severe and more recent
cases, in which the same cause is assigned with equal reason, are
not affected by it in the slightest visible degree. The reason for this
difference is unknown, but it necessitates the bearing in mind that by
limiting the treatment to the etiological indication valuable time may
be wasted in which the symptomatic indications could be profitably
followed.
163 The tablet triturates of biniodide of mercury or corrosive sublimate furnished by
Fraser & Co. of New York I have found peculiarly useful; one one-hundredth or more
of a grain may be thus administered every two to four hours.

164 I am now employing the same treatment in some cases showing no syphilitic
history. If any medicinal measures can act upon connective-tissue proliferation, it is
these very ones.

In cases of sclerosis due to other causes than syphilis a number of

medicinal agents have been recommended as calculated to affect
the central disease directly. Ergot is recommended in sclerotic
troubles, particularly tabes, by a large number of writers. It is
admitted that this substance can produce tabes itself, so that its
administration in the large doses recommended by some is not
without its possible dangers. I have seen a patient well advanced in
the disease who had received the drug for three weeks
consecutively in such quantities165 that on estimates made I came to
the conclusion that he had received more than some of the persons
in whom Tuczek discovered the development of ergotin tabes.
Favorable results are reported ensuing after its use in the early
stages, particularly where signs of irritation preponderated, such as
lightning-like pains, hyperæsthesia, and frequent erections; and it
has been suggested that the beneficial action is due to an effect on
the blood-vessels, which are supposed to be congested in the
beginning of the disease. Proof of such congestion has not been
furnished: the vessels are usually sclerosed and their lumen
narrowed. In view of the undeniable danger which attends the
administration of ergot in tabes, it may be properly insisted that its
indications be more precisely formulated than has yet been done. It
is commonly noticed in the natural progress of tabes that the
lightning-like pains disappear, usually about the time the anæsthesia
becomes greater. The anatomical parallel is supposed to be the
destruction of the nerve-tubes whose previous irritation caused these
pains. If, as is claimed—and it seems to be substantiated—ergotin
does produce amelioration of the lightning-like pains, it would prove
a damaging revelation which showed that it did so in imitation of the
natural process; that is, by increasing the sclerosis.
165 An expert ophthalmoscopist found that the retinal vessels, which were somewhat
dilated in this patient, were not influenced by the treatment.

The first drug to which an influence was assigned upon the sclerotic
processes, and which has maintained its reputation longest, is nitrate
of silver.166 Its claim to being regarded as a remedy may be best
characterized by the fact that an author who is far from being
prejudiced against it, and who recognizes the claims of Wunderlich,
its advocate, speaks of it as a valuable placebo.167 I have never
obtained any effects from this drug in the scleroses, or from the
chloride of gold, which has been also recommended for these
affections, nor have I seen any in cases where either or both had
been faithfully tried by others for years. The same is to be said of the
chloride of barium, which has been warmly extolled on the basis of a
very limited trial in disseminated and diffuse sclerosis.
166 One of the first patients on whom Wunderlich tried this drug died while I studied at
Leipzig. He had extensive argyria and sclerosis of the posterior columns.

167 Leyden, op. cit., vol. ii. p. 359.

The direct application of the galvanic current to the spine is

recommended, more particularly by Erb and Neftel.168 I am unable to
state anything regarding currents derived from as many as twenty of
Siemens cells and applied in the ascending direction, as the latter
recommends beyond an experience which occurred in the practice of
a colleague, who, alarmed by the event to be related, referred the
patient subjected to this treatment to me. The patient suffered from
tabes dorsalis, the symptoms being limited to the lower extremities,
the ulnar distribution, and the pupils. The belt was in the lower
thoracic region; the ataxia and lightning-like pains were not great.
After a single application of an ascending current from twenty-two
cells, continued for ten minutes, the patient suddenly felt a severe
dull pain in the occiput and terrible lancinating pains in the
distribution of the occipital nerves. With this there occurred
scintillation before the eyes, and at the subsequent examination I
found that the belt sensation had moved into the neck. The
coincidence was so close, and sudden changes in the distributional
area of tabic symptoms are otherwise so uncommon, that I attributed
the observed change to the treatment.
168 In describing a case in which this measure not only ameliorated lancinating pains
and vesical symptoms, but also, applied to the head, relieved the diplopia—usually a
spontaneous occurrence, according to both American and European writers—this
writer takes occasion to state that in the year 1869 tabes dorsalis was practically
unknown to American physicians (Archiv für Psychiatrie, xii. p. 619). Duchenne
described progressive locomotor ataxia in that and the preceding year; the necessity
of referring to the unfamiliarity of American physicians with a disease not at the time
recognized on either side of the Atlantic is hence not apparent. Leyden (op. cit., vol. ii.
p. 325) candidly admits that the German medical profession was at first averse to
recognizing Duchenne's limitation: this reproach cannot be laid at the door of
 American physicians, as I can distinctly recollect the demonstration of several well-
marked cases exhibiting the characteristic symptoms then known, in the year 1870.
The disease obtained recognition in American textbooks and journals as early as in
those of any other land.

Erb does not recommend such powerful applications. But the most
sanguine electro-therapeutist must admit that the action of galvanic
currents on the spinal cord is an exceedingly uncertain one. It is
questionable whether weak ones deflect sufficient current-loops to
reach the cord and to exert any material effect. As to currents
powerful enough to produce an effect, it is not known, except in the
loosest and most empirical way, what that effect is. The procedure
followed by Erb is to use large electrodes, the cathodal one being a
little smaller than the anodal, the former being placed stabile, over
the upper cervical sympathetic ganglion of one side, the latter labile,
on the opposite side of the vertebral spines, moving gradually
downward, the session not exceeding three minutes. This is
repeated daily or every alternate day.169 It would prove a strong proof
that this treatment really affected the morbid process in a remedial
direction if any of the exact signs of the disease were to be modified
by it, be it ever so slightly. If, after galvanization of the cervical cord
and the sympathetic nerve, the initial myosis of tabes were
temporarily lessened or the reflex contraction to light restored for
ever so short a time, a brighter future would dawn for electro-
therapeutics than seems now to be in store for it.170
169 Why, if the procedure be really remedial or efficiently palliative and devoid of evil
consequences, it is not recommended to be repeated oftener I am at a loss to explain
or understand. There are some factors involved in practical electro-therapeutic which
it is scarcely possible to discuss without encroaching on delicate ground.

170 In healthy persons the extent of the knee-jerk is increased by the spinal ascending
galvanic current, and possibly this observation may lead to the establishment of a
rational basis for its use in cases where the reflex is abolished or diminished.

Peripheral Treatment.—A number of therapeutical applications are

made to the periphery where the symptoms of the sclerotic process
are localized. The rationale of such applications is based on the
assumption that peripheral conditions are capable of modifying the
nutrition and functions of the cord. This is proven not alone by a host
of observations made on the normal cord, but is also disastrously
illustrated in the part played by surface chilling in the etiology of
many acute and chronic diseases of the cord. Notwithstanding this
latter, a large and influential body of German neurologists
recommend cold baths and cold spinal douches in these affections. I
have seen such excellent results from the use of warm baths that I
am compelled to plead, in defence of my ignorance of the effect of
cold ones, that I have never dared to use them. In numerous cases
the beneficial effect of a warm bath is almost instantaneous. Warmth
in any shape, whether atmospheric or in the shape of baths, is
usually agreeable to patients suffering from the various forms of
sclerosis. Cold, on the other hand, is disagreeable, aggravates the
symptoms, and in many cases at least hastens the progress of the
disease. A winter spent in the latitude of New York or Boston means
so much ground lost by the patient, and a sojourn during the colder
months in Southern California, New Mexico, Florida, or the West
Indies enables the patient to avoid this loss. As regards the choice of
climate and baths for sclerotic patients, I should be inclined to
roughly formulate the indications as being identical with those of
chronic rheumatism. The reaction against the use of warm baths in
Germany, where they once were popular,171 is due to the
employment of too high temperatures. Hot baths, in the strict sense
of the term, including the various forms of vapor-bath, act badly.
They increase instead of calming the irritative symptoms, as
moderately warm baths do, and they entail too sudden a change in
the bodily state. That, for the present, it is advisable not to adopt
unreservedly either the extreme plan once in vogue or the equally
extreme one which constitutes the reaction against it, is shown by
the observations of Richter of Dalldorf, who records some
discouraging results obtained by the use of cold baths in cases of
tabes dorsalis. It is but necessary to refer to the fact that the
lancinating pains of the latter disease, the rigidity of diffuse myelitis,
and the spasms of lateral sclerosis are usually most severe in cold
weather, and that the diseases mentioned appear to be rare in warm
countries, to show the need of caution in using a therapeutical
measure so similar in its action, even if it be but momentary and
followed by a reaction, to those which provoke or aggravate the
original disease. Eulenburg has seen five recoveries in tabes, and
under such different plans of treatment that the latter is not credited
by him with the good result. Three were treated with warm baths,
one with cold baths, and one with nitrate of silver. It is seen here that
the warm baths were used with good results more frequently than
the cold.
171 The mud-baths of Cudowa in Gallicia had a very high reputation.

One of the most singular delusions of modern therapeusis—nerve-

stretching—has, following the prediction made by several on both
sides of the Atlantic, become obsolete. Introduced by Langenbuch, a
surgeon, and attacking the disease at the sciatic nerve—a point
where, as well-versed students knew, it was not located—the
operation was looked upon with distrust from the beginning. The
enthusiasm with which it was taken up by surgeons and by the
interested portion of the laity—ever hopeful as tabic patients are of
new drugs and methods of treatment—has led to a large number of
trials, now numbering several hundred, and from which the useful
lesson can be gathered that the good ripens slowly. Nerve-stretching
in an organic disease of the spinal cord may take its place among
the needless vivisections; it has not influenced the progress of a
single case in any essential feature. On the contrary, it has more
than once been directly responsible for acute myelitis, spinal
hemorrhage,172 and pyæmia. In a number of cases reported by
Langenbuch,173 Benedict, Erlenmeyer, Schweminger, Debove, and
W. J. Morton, the ataxia of the patient has been reported as relieved;
in one case, exhibited by the latter operator before the American
Neurological Association, this appeared quite evident, but not
because the disease proper had been influenced, but for the same
reason that prevents the development of marked ataxia in combined
sclerosis. Just as the lateral-column lesion inhibits the ataxia which
is due to the posterior-column lesion, so the motor paresis produced
by stretching the sciatic nerves neutralizes the manifest features of
the ataxic gait. As soon as the paresis is recovered from, the ataxia
returns in its original form, unless, happily, one of the common
spontaneous changes for the better occur. As a therapeutic
procedure nerve-stretching is to-day properly limited to affections of
the peripheral nerves.
172 Zacher, Archiv für Psychiatrie, xv. p. 430.

173 Westphal showed after the autopsy of Langenbuch's first successful case that
there had been no spinal lesion whatever.

One of the most useful peripheral remedies in the sclerotic

processes is the faradic wire brush. It is both an anodyne and
remedial for anæsthesia. A number of the tabic patients to whom I
referred as not having deteriorated within long periods are provided
with a portable faradic battery, and apply the brush to the spots
affected by terebrating pains the moment these commence,
obtaining instantaneous relief. As has been shown by Rumpf,174 the
cutaneous space-sense becomes more delicate in healthy and
improved in tabic patients under its continued use. And while the
inco-ordination of tabes is in part independent of the disturbance of
cutaneous sensibility, yet if the latter can be refined the ataxic
disturbance may be mitigated—a result occasionally obtained
through the methodical use of the wire brush.
174 Report of a discussion, Neurologisches Centralblatt, 1885, p. 526.

It is frequently found that sufferers from tabes dorsalis and other

forms of sclerosis accompanied by ataxia walk much better in their
stocking feet and in slippers than they do in the conventional street
shoe or boot. The reason for this is obvious. The patient's gait is
impaired by the disease, and, whether the ataxia be a pure co-
ordinatory trouble or no, subjective uncertainty regarding contact
with the ground which is experienced by most ataxic patients is an
aggravating factor. Our modern foot-clothing, with its inflexible soles
and raised heels, handicaps the patient as it were, depriving him of
the use of what little tactile sensibility may be left him.175 The use of
low-heeled shoes with thin and flexible soles is therefore
advantageous.
 175 The question whether tabes dorsalis is a disease of civilization has not been
raised in any treatise I am acquainted with. Myelitis, both acute and chronic, occurs,
however, rarely in the lower animals, as do also central dilatation of the cord and
congenital defects of the latter. Posterior sclerosis I can find no record of in veterinary
pathology. The influence of the repression of normal aids to locomotion by the foot-
gear of civilized life as a possible predisposing factor in the etiology of ataxic troubles
is a legitimate subject of inquiry. The lateness of the infant of civilized parents in
acquiring the art of skilled locomotion may be in part, as philosophers claim, a penalty
of exuberant development of the higher and inhibitive centres. But what part has the
artificial obliteration of solar sensibility and pedal flexibility played in this inherited
feature? What is its influence in establishing a pathological vulnerability?

The tremors of sclerotic affections, particularly those accompanying

the disseminated forms, are from their distressing character
prominent objects of special treatment. The bromides have been
given with alleged good effect which I am unable to confirm. Curare
has caused the tremor to disappear for two days in one of
Erlenmeyer's patients. I have seen good results from the descending
galvanic current applied in long sittings to the head and neck, sliding
in to the point of tolerance, and sliding out before discontinuing. The
mydriatics, atropine, and particularly hyoscyamin, often remove
tremor radically for the time being; unfortunately, it is necessary to
give them in almost toxic doses to obtain this effect. Recently, Feris
recommended veratrum in doses of half a milligram repeated every
four to five hours. It acted very well in every case in which I tried it,
but, as it became necessary to increase the dose, the same
objection was encountered as in the case of hyoscyamin. All these
measures should be used as emergency remedies only; they cannot,
in the nature of the case, prove curative, while their continued use
produces a physiological indifference to their effect, and to that
extent decreases their value as the case progresses.

MANAGEMENT OF SPECIAL SYMPTOMS AND COMPLICATIONS.—Among the

most distressing features of many sclerotic affections is pain, which
is usually associated with sleeplessness. The fulminating variety
may be often relieved by the use of the actual cautery applied over
the affected level of the cord and along the course of the nerve
involved. But in the majority of cases morphine will have to be
resorted to. Erb cautions against the use of this anodyne in cases
where there is much reflex irritability of the cord, as morphine is said
to increase this irritability when administered in small doses, and to
reduce it again only when larger ones are administered. It is the
latter alone which are serviceable with pain, and I have not yet seen
any bad effects in the direction apprehended by Erb from such doses
as it is necessary to give. That the physician administering it should
be always on guard against the possible formation of a drug habit it
is unnecessary to add. But it is also unnecessary to add what
alternative he shall adopt when his choice lies between the lesser
evil of the opium or morphine habit and the terrible martyrdom which
some patients would be compelled to submit to if not allowed to
indulge in it.176 The evil effect of opium and its preparations on the
visceral functions is to be neutralized, as far as possible, by the
administration of laxatives and bitter tonics.
176 Few sufferers from spinal disease use anodynes habitually; opium and its
preparations are not fascinating to the majority of persons. On the other hand, there
are two cases of tabes dorsalis now under my observation in which the patients have
been compelled to use hypodermic injections of Magendie's solution for two and three
years without any materially bad effect.

The deep-seated diffuse pains, such as are found in disseminated

and diffuse sclerosis, are not as markedly relieved by opium as the
terebrating and lightning-like variety. Frequently spastic or other
signs of increased reflex excitability are associated with them; and
as both are favorably influenced by the bromides, the latter are
doubly indicated in such conditions.

With pains of a rheumatic character static electricity has been

recommended. It undoubtedly relieves such pains, as skilfully-
applied galvanism would. Its chief effects, it seemed to me from a six
months' trial with it, are on the imagination and hopes of the
patient.177
177 A large apparatus of the new and improved make was at my disposal at the
nervous department of the Metropolitan Throat Hospital. It was very popular with
 sufferers from rheumatism, who had been allowed to accumulate in the class before I
took charge, and with a paretic dement who suffered with the rheumatoid pains often
found with diseases such as his.

The bromides and camphor178 are recommended for the obstinate

priapism found in some cases of early tabes and transverse myelitis.
I have seen better results from warm hip-baths and general baths in
this condition than from any drug. As a general rule, the exercise of
the sexual function, where not already forbidden by the results of the
disease, should be limited as much as possible. The frequency of
normal seminal emissions in a given case is a guide to the amount of
indulgence in this direction which may be permitted. Where there is
the slightest indication of irritative or destructive lesions in the upper
lumbar cord sexual acts should be entirely prohibited, for under
these circumstances no greater injury could be done the weakened
centres than to permit them. This is particularly noticed in those
cases of tabes dorsalis which are marked by satyriasis in the early
period.
178 Particularly the monobromate of camphor.

The treatment of the bladder trouble and of bed-sores is carried out

in the manner described in the section on Acute Myelitis. For bed-
sores Hammond recommends the application of a stabile galvanic
element consisting of a plate of silver and one of zinc, the two being
united by a wire isolated in the usual way. The silver plate is laid on
the bed-sore; the zinc plate, covered by a piece of moistened cloth,
is laid on the unbroken skin somewhere in the neighborhood. The
result is a weak current under whose stimulant effect the healing
process takes place very rapidly. I have seen excellent results that
had been obtained by this means in indolent ulcers of the leg. It does
not, however, seem to have been tested with the malignant variety of
bed-sore.

With regard to the management of muscular atrophies by electricity,

massage, and strychnia, the same rules are to be followed which are
laid down in the section on the Myopathic Atrophies. It is only to be
specially remarked that few authorities encourage the administration
of strychnia in sclerotic affections, and fewer still in such large doses
as could be of any benefit in a wasting process.

Faradization of the affected eye-muscles is often useful in diplopia.

The current may be applied by means of a cup-shaped eye-
electrode, or, better, by using a finger as an electrode.

The moral management of sufferers from sclerotic spinal affections is

very important. The popular notion about spinal disease generally is
such that the announcement made to a patient that he is suffering
from any form of it is as alarming as would be the discovery of a
tumor in his brain or a cancer in his stomach, and exerts a
depressing effect. This it should be sought to avoid. A large number
of sufferers from sclerosis live longer and suffer less than a portion of
those afflicted with rheumatic and gouty affections; and the physician
is justified in obtaining the desirable effect which a hopeful or
resigned state of the mind undoubtedly has on the body, by laying
great stress on this undeniable fact.

CONCUSSION OF THE BRAIN AND SPINAL

CORD.

BY WILLIAM HUNT, M.D.

The writer was asked to contribute a short article upon Concussion
of the Brain and Spinal Cord for this work, as these injuries are apt at
first to come under the notice, if not charge, of the general
practitioner. The article will therefore not be an exhaustive one, and
there will be little but the details of personal experience and less
quoting of authorities. Much has been written recently upon the
subject both in volume and in pamphlet.

Diverse views of equally competent judges of the matter have been

put forth, and the brains and spinal cords of the partisans appear to
have received as severe a shaking up as the real recipients of the
lesions, if absolute lesions there be.

This, in fact, is the point of controversy, for there are those who
seem to deny that there can be a jarring or shaking of the cerebro-
spinal mass sufficient to cause positive symptoms without producing
positive lesions, whilst others are as firm in their convictions that
pronounced symptoms may follow a mere disturbing ripple of the
nervous elements. How is the question to be settled? The slightly
shocked or injured recover rapidly, whilst some who only appear to
be as slightly injured or shocked at first, go on to death, during the
progress to which event there is no doubt as to the existence of
lesion and no difficulty in finding it at the autopsy. Hence, say the
lesionists, the first ones had it, but got well, whilst the non-lesionists
affirm that it never existed in them.

The logician would think that these differences in opinion were only
differences in degree about the same thing, but, nevertheless, the
question is one for serious discussion, and is of much greater
importance than would appear to be the case to the average layman.

This importance lies in the medico-legal aspects of the suits arising

out of the alleged injuries and their consequences. Judges, lawyers,
and doctors know them well. In doubtful cases authorities of equal
eminence are quoted, and the results of trials are equally as doubtful
as to whether justice or injustice has been done. These remarks, as
will be seen, are especially applicable to injuries of the spine, but
they also may have place in the consideration of consequences
arising from concussion of the brain.

Concussion of the Brain.

Whatever doubts there may be as to concussion of the spine, there

are none, I believe, who deny the appropriateness of the expression
as to the brain, it being, by its anatomical relations, so much more
exposed to shock than the spine.

We understand that pure concussion, uncomplicated with fracture,

refers to a condition caused by external violence, direct or indirect,
which communicates a jar or shock to the cerebral mass, and which
expresses itself by certain well-defined symptoms. The nervous
system and the circulation are most manifestly involved, but in a
pure case it may be said that all of the symptoms arise from central
nervous disturbance. Even could it be shown that they were
dependent on temporary congestions, these congestions, I think it
will be admitted, would be due to vaso-motor derangements.

The anatomical appearances after early death from concussion of

the brain are often insufficient for us to comprehend the fatal result,
for we know that the organ will bear, both from disease and other
kinds of injury, vastly greater inroads upon its structure and
surroundings without causing death. Often there is mere localized
cerebral congestion, with no ruptures of vessels; then there are slight
extravasations shown as points or dots of blood in the nerve-matter;
and, again, there is what is called the bruised brain. Sometimes
there is nothing abnormal whatever to be found. Most of these
cases, under modern criticism, have been justly shut out from the
record as having no value; for it has been shown that the post-
mortem examinations of them have been very imperfect, the brain
only having been inspected, whereas the chest, the abdomen, or the
spine might readily have revealed the cause of death.