Electrocatalysis for Membrane Fuel

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Electrocatalysis for Membrane Fuel Cells
Electrocatalysis for Membrane Fuel Cells

Methods, Modeling, and Applications

Edited by Nicolas Alonso-Vante and Vito Di Noto

Editors All books published by WILEY-VCH are carefully
produced. Nevertheless, authors, editors, and
Prof. Nicolas Alonso-Vante publisher do not warrant the information
University of Poitiers contained in these books, including this book,
IC2MP-UMR-CNRS 7285 to be free of errors. Readers are advised to keep
4 rue Michel Brunet in mind that statements, data, illustrations,
F-86073 Poitiers Cedex 9 procedural details or other items may
France inadvertently be inaccurate.

Prof. Vito Di Noto Library of Congress Card No.: applied for

University of Padova
Department of Industrial Engineering British Library Cataloguing-in-Publication Data
Via Marzolo 9 A catalogue record for this book is available
I-35131 Padova from the British Library.
Italy
Bibliographic information published by
Cover Image: Courtesy of Vito Di Noto, the Deutsche Nationalbibliothek
Nicolas Alonso Vante and Keti Vezzù The Deutsche Nationalbibliothek lists
this publication in the Deutsche
Nationalbibliografie; detailed bibliographic
data are available on the Internet at
<http://dnb.d-nb.de>.

© 2024 WILEY-VCH GmbH, Boschstraße 12,

69469 Weinheim, Germany

All rights reserved (including those of

translation into other languages). No part of
this book may be reproduced in any form – by
photoprinting, microfilm, or any other means –
nor transmitted or translated into a machine
language without written permission from the
publishers. Registered names, trademarks, etc.
used in this book, even when not specifically
marked as such, are not to be considered
unprotected by law.

Print ISBN: 978-3-527-34837-4

ePDF ISBN: 978-3-527-83055-8
ePub ISBN: 978-3-527-83056-5
oBook ISBN: 978-3-527-83057-2

Typesetting: Straive, Chennai, India

 v

Contents

Preface xv

Part I Overview of Systems 1

1 System-level Constraints on Fuel Cell Materials and

Electrocatalysts 3
Elliot Padgett and Dimitrios Papageorgopoulos
1.1 Overview of Fuel Cell Applications and System Designs 3
1.1.1 System-level Fuel Cell Metrics 3
1.1.2 Fuel Cell Subsystems and Balance of Plant (BOP) Components 5
1.1.3 Comparison of Fuel Cell Systems for Different Applications 9
1.2 Application-derived Requirements and Constraints 10
1.2.1 Fuel Cell Performance and the Heat Rejection Constraint 10
1.2.2 Startup, Flexibility, and Robustness 13
1.2.3 Fuel Cell Durability 14
1.2.4 Cost 16
1.3 Material Pathways to Improved Fuel Cells 18
1.4 Note 19
Acronyms 20
Symbols 20
References 20

2 PEM Fuel Cell Design from the Atom to the Automobile 23

Andrew Haug and Michael Yandrasits
2.1 Introduction 23
2.2 The PEMFC Catalyst 27
2.3 The Electrode 32
2.4 Membrane 38
2.5 The GDL 42
2.6 CCM and MEA 46
vi Contents

2.7 Flowfield and Single Fuel Cell 50

2.8 Stack and System 55
Acronyms 57
References 58

Part II Basics – Fundamentals 69

3 Electrochemical Fundamentals 71
Vito Di Noto, Gioele Pagot, Keti Vezzù, Enrico Negro, and Paolo Sgarbossa
3.1 Principles of Electrochemistry 71
3.2 The Role of the First Faraday Law 71
3.3 Electric Double Layer and the Formation of a Potential Difference at the
Interface 73
3.4 The Cell 74
3.5 The Spontaneous Processes and the Nernst Equation 75
3.6 Representation of an Electrochemical Cell and the Nernst
Equation 77
3.7 The Electrochemical Series 79
3.8 Dependence of the Ecell on Temperature and Pressure 82
3.9 Thermodynamic Efficiencies 83
3.10 Case Study – The Impact of Thermodynamics on the Corrosion of Low-T
FC Electrodes 85
3.11 Reaction Kinetics and Fuel Cells 88
3.11.1 Correlation Between Current and Reaction Kinetics 88
3.11.2 The Concept of Exchange Current 89
3.12 Charge Transfer Theory Based on Distribution of Energy States 89
3.12.1 The Butler–Volmer Equation 96
3.12.2 The Tafel Equation 100
3.12.3 Interplay Between Exchange Current and Electrocatalyst Activity 101
3.13 Conclusions 103
Acronyms 104
Symbols 104
References 107

4 Quantifying the Kinetic Parameters of Fuel Cell

Reactions 111
Viktoriia A. Saveleva, Juan Herranz, and Thomas J. Schmidt
4.1 Introduction 111
4.2 Electrochemical Active Surface Area (ECSA) Determination 114
4.2.1 ECSA Determination Using Underpotential Deposition 115
4.2.1.1 Hydrogen Underpotential Deposition (HUPD ) 116
4.2.1.2 Copper Underpotential Deposition (CuUPD ) 117
4.2.2 ECSA Quantification Based on the Adsorption of Probe Molecules 118
 Contents vii

4.2.2.1 CO Stripping 118

4.2.2.2 NO−2 ∕NO Sorption 119
4.2.3 Double-layer Capacitance Measurements and Other Methods 120
4.2.4 ECSA Measurements in a PEFC: Which Method to Choose? 120
4.3 H2 -Oxidation and Electrochemical Setups for the Quantification of
Kinetic Parameters 121
4.3.1 Rotating Disc Electrodes (RDEs) 122
4.3.2 Hydrogen Pump (PEFC) Approach 124
4.3.3 Ultramicroelectrode Approach 125
4.3.4 Scanning Electrochemical Microscopy (SECM) Approach 125
4.3.5 Floating Electrode Method 127
4.3.6 Methods Summary 128
4.4 ORR Kinetics 129
4.4.1 ORR Mechanism Studies with RRDE Setups 129
4.4.2 ORR Pathway on Me/N/C ORR Catalysts 130
4.4.3 ORR Kinetics: Methods 132
4.4.3.1 Pt-based Electrodes 132
4.4.3.2 Pt-free Catalysts: RDE vs. PEFC Kinetic Studies 133
4.5 Concluding Remarks 133
Acronyms 134
Symbols 134
References 135

5 Adverse and Beneficial Functions of Surface Layers Formed

on Fuel Cell Electrocatalysts 149
Shimshon Gottesfeld
5.1 Introduction 149
5.2 Catalyst Capping in Heterogeneous Catalysis and in
Electrocatalysis 151
5.3 Passivation of PGM/TM and Non-PGM HOR Catalysts and Its Possible
Prevention 156
5.4 Literature Reports on Fuel Cell Catalyst Protection by Capping 161
5.4.1 Protection of ORR Pt catalysts Against Agglomeration by an Ultrathin
Overlayer of Mesoporous SiO2 or Me–SiO2 161
5.4.2 Protection by Carbon Caps Against Catalyst Detachment and Catalyst
Passivation Under Ambient Conditions 162
5.5 Other Means for Improving the Performance Stability of Supported
Electrocatalysts 166
5.5.1 Replacement of Carbon Supports by Ceramic Supports 166
5.5.2 Protection of Pt Catalysts by Enclosure in Mesopores 167
5.6 Conclusions 170
Abbreviations 171
References 171
viii Contents

Part III State of the Art 175

6 Design of PGM-free ORR Catalysts: From Molecular to the

State of the Art 177
Naomi Levy and Lior Elbaz
6.1 Introduction 177
6.2 The Influence of Molecular Changes Within the Complex 179
6.2.1 The Role of the Metal Center 179
6.2.2 Addition of Substituents to MCs 183
6.2.2.1 Beta-substituents 184
6.2.3 Meso-substituents 186
6.2.4 Axial Ligands 187
6.3 Cooperative Effects Between Neighboring MCs 190
6.3.1 Bimetallic Cofacial Complexes – “Packman” Complexes 191
6.3.2 MC Polymers 191
6.4 The Physical and/or Chemical Interactions Between the Catalyst and Its
Support Material 193
6.5 Effect of Pyrolysis 194
Acronyms 196
References 196

7 Recent Advances in Electrocatalysts for Hydrogen Oxidation

Reaction in Alkaline Electrolytes 205
Indra N. Pulidindi and Meital Shviro
7.1 Introduction 205
7.2 Mechanism of the HOR in Alkaline Media 206
7.3 Electrocatalysts for Alkaline HOR 212
7.3.1 Platinum Group Metal HOR Electrocatalysts 212
7.3.2 Non-platinum Group Metal-based HOR Electrocatalysts 214
7.4 Conclusions 220
Acronyms 221
References 221

8 Membranes for Fuel Cells 227

Paolo Sgarbossa, Giovanni Crivellaro, Francesco Lanero, Gioele Pagot,
Afaaf R. Alvi, Enrico Negro, Keti Vezzù, and Vito Di Noto
8.1 Introduction 227
8.2 Properties of the PE separators 228
8.2.1 Benchmarking of IEMs 229
8.2.2 Ion-exchange Capacity (IEC) 229
8.2.3 Water Uptake (WU), Swelling Ratio (SR), and Water Transport 231
8.2.4 Ionic Conductivity (𝜎) 233
8.2.5 Gas Permeability 234
8.2.6 Chemical Stability 235
8.2.7 Thermal and Mechanical Stability 237
 Contents ix

8.2.8 Cost of the IEMs 239

8.3 Classification of Ion-exchange Membranes 240
8.3.1 Cation-exchange Membranes (CEMs) 240
8.3.1.1 Perfluorinated Membranes 240
8.3.1.2 Nonperfluorinated Membranes 245
8.3.2 Anion-exchange Membranes (AEMs) 246
8.3.2.1 Functionalized Polyketones 247
8.3.2.2 Poly(Vinyl Benzyl Trimethyl Ammonium) (PVBTMA) Polymers 248
8.3.2.3 Poly(sulfones) (PS) 249
8.3.3 Hybrid Ion-exchange Membranes 249
8.3.3.1 Hybrid Membranes with Single Ceramic Oxoclusters [P/(Mx Oy )n ] 250
8.3.3.2 Hybrid Membranes Comprising Surface-functionalized Nanofillers 254
8.3.3.3 Hybrid Membranes Doped with hierarchical “Core–Shell”
Nanofillers 254
8.3.4 Porous Membranes 257
8.3.4.1 Porous Membranes as Host Material 257
8.3.4.2 Porous Membranes as Support Layer 258
8.3.4.3 Porous Membranes as Unconventional Separators 259
8.4 Mechanism of Ion Conduction 259
8.5 Summary and Perspectives 268
Acronyms 271
Symbols 272
References 272

9 Supports for Oxygen Reduction Catalysts: Understanding and

Improving Structure, Stability, and Activity 287
Iwona A. Rutkowska, Sylwia Zoladek, and Pawel J. Kulesza
9.1 Introduction 287
9.2 Carbon Black Supports 288
9.3 Decoration and Modification with Metal Oxide Nanostructures 289
9.4 Carbon Nanotube as Carriers 291
9.5 Doping, Modification, and Other Carbon Supports 293
9.6 Graphene as Catalytic Component 293
9.7 Metal Oxide-containing ORR Catalysts 296
9.8 Photodeposition of Pt on Various Oxide–Carbon Composites 299
9.9 Other Supports 301
9.10 Alkaline Medium 302
9.11 Toward More Complex Hybrid Systems 303
9.12 Stabilization Approaches 306
9.13 Conclusions and Perspectives 307
Acknowledgment 308
Acronyms 308
References 308
x Contents

Part IV Physical–Chemical Characterization 319

10 Understanding the Electrocatalytic Reaction in the Fuel Cell

by Tracking the Dynamics of the Catalyst by X-ray Absorption
Spectroscopy 321
Ditty Dixon, Aiswarya Bhaskar, and Aswathi Thottungal
10.1 Introduction 321
10.2 A Short Introduction to XAS 323
10.3 Application of XAS in Electrocatalysis 325
10.3.1 Ex Situ Characterization of Electrocatalyst 325
10.3.2 Operando XAS Studies 330
10.4 Δ𝜇 XANES Analysis to Track Adsorbate 334
10.5 Time-resolved Operando XAS Measurements in Fuel Cells 338
10.6 Fourth-generation Synchrotron Facilities and Advanced
Characterization Techniques 340
10.6.1 Total-reflection Fluorescence X-ray Absorption Spectroscopy 341
10.6.2 Resonant X-ray Emission Spectroscopy (RXES) 341
10.6.3 Combined XRD and XAS 342
10.7 Conclusions 342
Acronyms 343
References 344

Part V Modeling 349

11 Unraveling Local Electrocatalytic Conditions with Theory and

Computation 351
Jun Huang, Mohammad J. Eslamibidgoli, and Michael H. Eikerling
11.1 Local Reaction Conditions: Why Bother? 351
11.2 From Electrochemical Cells to Interfaces: Basic Concepts 352
11.3 Characteristics of Electrocatalytic Interfaces 355
11.4 Multifaceted Effects of Surface Charging on the Local Reaction
Conditions 356
11.5 The Challenges in Modeling Electrified Interfaces using First-principles
Methods 358
11.5.1 Computational Hydrogen Electrode 359
11.5.2 Unit-cell Extrapolation, Explicit Solvated Protons, and Excess
Electrons 360
11.5.3 Counter Charge and Reference Electrode 361
11.5.4 Effective Screening Medium and mPB Theory 361
11.5.5 Grand-canonical DFT 362
11.6 A Concerted Theoretical–Computational Framework 362
11.7 Case Study: Oxygen Reduction at Pt(111) 364
 Contents xi

11.8 Outlook 367

Acronyms 367
Symbols 368
References 368

Part VI Protocols 375

12 Quantifying the Activity of Electrocatalysts 377

Karla Vega-Granados and Nicolas Alonso-Vante
12.1 Introduction: Toward a Systematic Protocol for Activity
Measurements 377
12.2 Materials Consideration 378
12.2.1 PGM Group 378
12.2.2 Low PGM and PGM-free Approaches 379
12.2.3 Impact of Support Effects on Catalytic Sites 381
12.3 Electrochemical Cell Considerations 382
12.3.1 Cell Configuration and Material 382
12.3.2 Electrolyte 385
12.3.2.1 Purity 385
12.3.2.2 Protons vs. Hydroxide Ions 386
12.3.2.3 Influence of Counterions 388
12.3.3 Electrode Potential Measurements 388
12.3.4 Preparation of Electrodes 391
12.3.5 Well-defined and Nanoparticulated Objects 395
12.4 Parameters Diagnostic of Electrochemical Performance 396
12.4.1 Surface Area 396
12.4.2 Hydrogen Underpotential Deposition Integration 397
12.4.2.1 Surface Oxide Reduction 398
12.4.2.2 CO Monolayer Oxidation (CO Stripping) 400
12.4.2.3 Underpotential Deposition of Metals 401
12.4.2.4 Double-layer Capacitance 402
12.4.3 Electrocatalysts Site Density 402
12.4.4 Data Evaluation (Half-Cell Reactions) 404
12.4.5 The E1/2 and E (jPt (5%)) Parameters 405
12.5 Stability Tests 407
12.6 Data Evaluation (Auxiliary Techniques) 409
12.6.1 Surface Atoms vs. Bulk 410
12.7 Conclusions 411
Acknowledgments 412
Acronyms 412
Symbols 413
References 414
xii Contents

13 Durability of Fuel Cell Electrocatalysts and Methods for

Performance Assessment 429
Bianca M. Ceballos and Piotr Zelenay
13.1 Introduction 429
13.2 Fuel Cell PGM-free Electrocatalysts for Low-temperature
Applications 431
13.3 PGM-free Electrocatalyst Degradation Pathways 432
13.3.1 Demetallation 432
13.3.2 Carbon Oxidation 436
13.3.3 Micropore Flooding 439
13.3.4 Nitrogen Protonation and Anionic Adsorption 439
13.4 PGM-free Electrocatalyst Durability and Metrics 440
13.4.1 Performance and Durability Evaluation in Air-supplied Fuel Cell
Cathode 440
13.4.2 Assessment of Carbon Corrosion in Nitrogen-purged Cathode 443
13.4.3 Determination of Performance Loss upon Cycling Cathode Catalyst in
Nitrogen 443
13.4.4 Recommendations for ORR Electrocatalyst Evaluation in RRDE in O2
and in an Inert Gas 446
13.4.5 Electrocatalyst Corrosion 447
13.5 Low-PGM Catalyst Degradation 447
13.5.1 Pt Dissolution 449
13.5.2 Carbon Support Corrosion 452
13.5.3 Pt Catalyst MEA Activity Assessment and Durability 454
13.5.4 PGM Electrocatalyst MEA Conditioning in H2 /Air 454
13.5.5 Accelerated Stress Test of PGM Electrocatalyst Durability 456
13.6 Conclusion 457
Acronyms 459
References 460

Part VII Systems 471

14 Modeling of Polymer Electrolyte Membrane Fuel Cells 473

Andrea Baricci, Andrea Casalegno, Dario Maggiolo, Federico Moro,
Matteo Zago, and Massimo Guarnieri
14.1 Introduction 473
14.2 General Equations for PEMFC Models 474
14.2.1 Analytical and Numerical Modeling 474
14.2.2 Reversible Electromotive Force 476
14.2.3 Fuel Cell Voltage 477
14.2.4 Activation Overpotential 478
14.2.5 Ohmic Overpotential – PEM Model 479
14.2.6 Concentration Overpotential 480
14.2.7 Examples of Fuel Cell Modeling 482
 Contents xiii

14.3 Multiphase Water Transport Model for PEMFCs 483

14.4 Fluid Mechanics in PEMFC Porous Media: From 3D Simulations to 1D
Models 488
14.4.1 From Micro- to Macroscopic Models 490
14.4.2 Porous Medium Anisotropy 491
14.4.3 Fluid–Fluid Viscous Drag 492
14.4.4 Surface Tension and Capillary Pressure 492
14.5 Physical-based Modeling for Electrochemical Impedance
Spectroscopy 496
14.5.1 Experimental Measurement and Modeling Approaches 496
14.5.2 Physical-based Modeling 497
14.5.2.1 Current Relaxation 497
14.5.2.2 Laplace Transform 498
14.5.3 Typical Impedance Features of PEMFC 498
14.5.4 Application of EIS Modeling to PEMFC Diagnostic 500
14.5.5 Approximations of 1D Approach 501
14.6 Conclusions and Perspectives 502
Acronyms 503
Symbols 504
References 507

15 Physics-based Modeling of Polymer Electrolyte Membrane

Fuel Cells: From Cell to Automotive Systems 511
Andrea Baricci, Matteo Zago, Simone Buso, Marco Sorrentino, and
Andrea Casalegno
15.1 Polymer Fuel Cell Model for Stack Simulation 511
15.1.1 General Characteristics of a Fuel Cell System for Automotive
Applications 511
15.1.2 Analysis of the Channel Geometry for Stack Performance Modeling 514
15.1.3 Analysis of the Air and Hydrogen Utilization for Stack Performance
Modeling 516
15.1.4 Introduction to Transient Stack Models 518
15.2 Auxiliary Subsystems Modeling 519
15.2.1 Air Management Subsystem 519
15.2.2 Hydrogen Management Subsystem 521
15.2.3 Thermal Management Subsystem 522
15.2.4 PEMFC System Simulation 522
15.3 Electronic Power Converters for Fuel Cell-powered Vehicles 525
15.3.1 Power Converter Architecture 527
15.3.2 Load Adaptability 527
15.3.3 Power Electronic System Components 528
15.3.3.1 Port Interface Converters 530
15.3.3.2 The PEMFC Interface Converter 530
15.3.3.3 The Motor Interface Converter 530
15.3.3.4 The Energy Storage Interface 531
xiv Contents

15.3.3.5
. Supervisory Control 531
15.4 Fuel Cell Powertrains for Mobility Use 532
15.4.1 Transport Application Scenarios 532
15.4.2 Tools for the Codesign of Transport Fuel Cell Systems and Energy
Management Strategies 534
15.4.2.1 Automotive Case Study: Optimal Codesign of an LDV FCHV
Powertrain 535
Acronyms 540
Symbols 541
References 541

Index 545
 xv

Preface

In electrochemical energy converters such as low-temperature membrane fuel cells,

the slow kinetics of oxygen reduction (ORR) represents one of the main reasons
for a high overpotential in a fuel cell, e.g. polymer electrolyte membrane (PEM)
type. Despite this inherent phenomenon, in these systems, fuel cells constitute (i)
a cornerstone in the energy technologies of the present twenty-first century for
transportation and stationary applications and (ii) one of the two pillars, together
with electrolyzers, of the future Green Hydrogen Economy of the world. These
scenarios are comforted by the rapid advances in the development of materials
based on noble and non-noble electrocatalytic materials that encompass a bunch
of applications operating in a wide pH range (acidic and alkaline). In this context,
in order to find a utility, to the knowledge obtained to date, for current and
future researchers in this field of activity, the repository of such an avalanche of
information is thus a central resource to be transmitted with a global perspective.
It is for this reason that the present book aims to consolidate and transmit this
knowledge while providing the necessary forum to complement what is published
daily in specialized journals. Thus, the contributions of experts working in both
academic and industrial research and development will serve as a reference source
for the fundamentals and applications of fuel cells, establishing the state-of-the-art
and disseminating research advances within a scope corresponding to textbooks for
undergraduate and graduate students.
This book, devoted to fuel cell electrocatalysis, will, we hope, further the devel-
opment and application of this exciting technology on the road to the successful
establishment of a clean and sustainable energy economy in the twenty-first
century. For the reader’s convenience, this book, with a total of 15 chapters, is
organized in seven sections, namely Overview, Fundamentals, State of the Art,
Physical–Chemical Characterization, Modeling, Protocols, and Systems.
The first chapter discusses how application requirements and system-level con-
siderations create constraints on fuel cell materials and electrocatalysts, with the
goal of informing more strategic and impactful research and development efforts. In
the second chapter, the discussion is centered on how an atomically designed cata-
lyst surface efficiently produces protons and electrons from hydrogen on the anode
and water from oxygen, protons, and electrons on the cathode. In the third chapter,
insights are provided on how fundamental electrochemistry can be exploited to
guide fuel cell research, whereas the fourth chapter discloses the quantification of
the kinetic descriptors that determine the activity and stability of the anode and
cathode electrocatalysts, providing analytical methods and electrochemical set-ups
xvi Preface

as supports. Moreover, in Chapter 5, the author discusses some means for protecting
catalytic sites in order to maintain high performance in the light of recent data
from the literature. Chapter 6, furthermore, puts into relevance the state-of-the-art
of platinum group metal (PGM)-free ORR catalysts. Herein, the authors provide
an overview of important parameters that influence the catalysis of ORR with
well-defined ORR catalysts. In Chapter 7, recent development in electrocatalysts
for the hydrogen oxidation reaction (HOR) is put on the floor, emphasizing the
state-of-the-art PGM- and non-PGM-based electrocatalysts for the HOR in alkaline
conditions. An important ingredient in the proton exchange membrane fuel cell
(PEMFC) system is the polymeric electrolyte. In this context, Chapter 8 describes the
features that a membrane must exhibit to be implemented in a fuel cell. This chapter
ends with a comprehensive overview of the mechanisms of ion conduction proposed
for fuel cell membranes, followed by a brief summary outlining the perspectives
of the research in this field. The characteristics of ORR electrocatalyst support
(carbon-based and oxide-based) have been analyzed in Chapter 9. Of importance, in
all interface research, is the in operando technique, and/or probing under real fuel
cell operating conditions is offered in Chapter 10 with the use of X-ray absorption
spectroscopy (XAS). Theoretical modeling and computation to unravel the local
reaction environment are given in Chapter 11. This chapter addresses this complex
issue by introducing some basic concepts of electrochemical interfaces, especially
the surface charging relation. The authors highlight the electrocatalytic interfaces
pertaining to the role of chemisorption-induced surface dipoles that could cause
nonmonotonicity in the surface charging behavior. The electrocatalytic materials
research protocols for investigating fuel cell reactions are deployed in Chapters 12
and 13. In sum, the correct evaluation of fuel cell reactions, selection of reference
electrodes, durability tests of PGM-free materials, and fuel cell testing procedures
are put forward in the light of the most advanced literature data research. The
last section of the book presents Chapters 14 and 15. These chapters analyze the
fundamentals of fuel cell simulation by means of a mono-dimensional analytical
model considering multiphase water transport affecting the electrical conductivity
properties of the cell membrane, whereas Chapter 15 analyzes the optimization of
the operative conditions and the prediction of the system durability that back the
design of the PEMFC stack and components of the balance of the plant.
The editors appreciate the contributing authors of this book, who maintained high
scientific standards.
N. Alonso-Vante acknowledges financial support from the European Union
(ERDF) and “Région Nouvelle Aquitaine.”
V. Di Noto thanks the financial support of EIT Raw Materials, project Alpe, and
Graphene Flagship, Core 3, of the European Union.

Nicolas Alonso-Vante
University of Poitiers, IC2MP-UMR CNRS 7285
Poitiers, France

Vito Di Noto
University of Padova, Department of Industrial Engineering
Padova, Italy
 1

Part I

Overview of Systems
Another random document with
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necessary to cover it with some well-warmed and non-conducting
material and to have the room well warmed. If bed-sores are already
formed, they are to be treated according to ordinary surgical
principles. Antiseptic means should be in the foreground in the case
of the malignant bed-sore. It is to be remembered that the latter is a
gangrenous process, and, in so far as the formation of a line of
demarcation between the necrotic and the conserved tissue is
concerned, the ordinary expectant rules of surgery govern the case:
the water-bath appears to yield the best results. Ordinary bed-sores
yield readily to mechanical protection and stimulating ointments or
the balsam of Peru. Iodoform is recommended, but it produces
granulations of an indolent character as compared with those
obtained through the use of resinous ointments.

The warm bath is probably the most useful measure in acute

myelitis. In cases due to exposure I do not believe it can be applied
too soon. Its temperature should, in the beginning at least, not be
higher than about 88° F., and the duration about seven minutes. The
continued administration will depend on the immediate effect on the
patient, and the sittings can be ultimately prolonged to half an hour
or even longer. It should be administered once daily, and, when the
patient is not disturbed by the manipulation connected with its use,
even oftener. Cold baths are recommended by the Germans, but it
seems rather in the passive period of the disease than during its
active phase.

The management of the bladder trouble is one of the most critical

points in the treatment of most cases. The results of retention of
urine are more frequently the cause of a fatal issue than any other
single complication. Where there is complete retention continuous
catheterization is to be employed, as recommended by Strümpell.106
In other cases the bladder should be emptied thrice in the twenty-
four hours. The catheter is to be thoroughly disinfected, and if the
slightest sign of cystitis is noted the bladder should be washed out
with astringent and disinfectant solutions. The continuous irrigation
with a solution of corrosive sublimate, 1:2000, appears to give the
best results.
 106 A. Nelaton's catheter is introduced into the bladder, and kept in place by strips of
adhesive plaster fixed to the inner aspect of the thighs. A perforated condom fixed to
the catheter, and then fastened to the inguinal region, is in my opinion a better
measure, especially in patients who have some motor power left. The catheter is
connected with a rubber tube, which should run on a decline in order to effect
complete drainage.

If there be a syphilitic taint present—and more particularly is this true

of cases where no other cause can be assigned—large doses of
iodide of potassium107 should be administered, and mercurial
ointment energetically applied, even to the point of salivation.
107 Here, if anywhere, the so-called heroic doses are applicable.

I am unable to say anything with regard to the local use of electricity

in the active period of the disease. Ascending currents are
recommended by Erb, weak currents of about five minutes' duration
being employed over the part supposed to be affected. In order to
secure sufficiently deep deflection of the current large electrodes are
applied. The use of galvanism and faradism on the affected
periphery, the former being preferred where atrophic, the latter
where anæsthetic conditions preponderate, is to be instituted early
and continued through the duration of the disease. The rules stated
in the section devoted to electro-therapeutics are to be followed. In
cases where the bladder or rectum are paralytic, these organs
should have galvanism applied to them by means of electrodes
shaped like catheters or sounds.

After the acute phase of myelitis is passed, the secondary period is

to be managed according to the principles laid down in the section
on the Treatment of the Sclerotic Processes.
 THE CHRONIC INFLAMMATORY AND
DEGENERATIVE AFFECTIONS OF THE SPINAL
CORD.

BY E. C. SPITZKA, M.D.

The intimate dovetailing of parenchymatous and connective

substance in the spinal cord renders the determination of the precise
origin of a morbid process often difficult if not impossible. Whatever
the mode of origin, the typical termination of inflammatory and
degenerative spinal disorders is sclerosis—a condition in which the
essential nervous elements suffer diminution or destruction, while
the connective substance is either absolutely or relatively in
preponderance. The clinical result is nearly the same in all cases,
and with few exceptions depends less upon the histological
character than on the topographical distribution of the lesion. It is for
this reason that we shall follow rather the topographical than the
morbid histological principle in classification.

The chronic disorders of the spinal cord here considered have as a

common character the slow and progressive displacement of the
normal conducting nerve-tubes by a grayish, reddish, or otherwise
discolored tissue, which is firmer in texture than normal nerve-
substance. Minute examination shows that it is above all the myelin
of the nerve-tubes that is wasted or destroyed, while the axis-
cylinders may share in this dissolution, or, as in one form of
sclerosis, they may persist and even continue in their conducting
function. This increased consistency is found to be due to the
increase of connective-tissue trabeculæ and of the neuroglia. In
some cases this increase is active and absolute, like the increase in
certain phases of hepatic cirrhosis; in others it is rather relative and
passive, being merely a condensation of the connective framework
after the intervening elements have wasted away, just as the texture
of a compressed sponge is more compact than that of an expanded
one.

Crudely, the affections of the cord characterized by this change may

be divided into two great groups—the regular and the irregular. The
former are characterized by their limitation to special nerve-tracts.
Thus, in primary lateral sclerosis we find a special tract in the
posterior part of the lateral columns occupied by the lesion. A
number of spinal diseases with well-defined symptoms are due to
active morbid processes which similarly follow the normal distribution
of the great nerve-tracts of the cord, with the same, almost
mathematical, regularity with which the medullary white develops in
the fœtal and infantile cord. In another class of cases we find that the
same tracts are involved in like manner—not in the way of primary
disease, but through the interruption of the physiological continuity of
the nerve-tract by some other disease, to which the sclerosis is
therefore secondary. These are the so-called secondary
degenerations.

The irregular affections of the cord comprise cases in which the

sclerotic foci are either disseminated through the cerebro-spinal axis
in numerous foci, or diffusely involve a greater or lesser length and
thickness of the medullary cylinder, or, finally, extend in the
transverse plane completely or nearly so across the section area of
the cord at a definite level.

As the symptoms of the regular affections of the cord are by far the
most readily recognizable, and a preliminary knowledge of them will
facilitate the better understanding of the irregular forms, we shall
consider the former first. They may be subdivided into two groups.
The largest, longest known, and best studied consists of acquired,
the other, containing less numerous cases and varieties, and
rendered familiar to the profession only within the last decade,
comprises the spinal disorders due to defective development of the
cerebro-spinal and spinal-fibro systems.

Tabes Dorsalis.

SYNONYMS.—Locomotor ataxia and ataxy, Posterior spinal sclerosis;

Graue degeneration der Hinterstränge (Leyden), Rückenmarksdarre
(popular), Rückenmarksschwindsucht; Tabes dorsualis (Romberg);
Ataxie locomotrice progressive (Duchenne).

HISTORY.—Undoubtedly, this disease must have been observed by

the ancient masters of medicine, but their descriptions group
together so many symptoms of other organic as well as functional
diseases of the cord that it is impossible to obtain a clear idea as to
what special form they had in view when they spoke of tabes
dorsualis. This term was adopted by the German writers of the last
and the earlier part of this century as designating all wasting
affections of the cord; and it was not till Romberg in 1853 and
Duchenne in 1858 differentiated the characteristic clinical signs, and
Cruveilhier and Todd (1847) determined the distribution of the lesion
in the posterior columns, that the medical profession began to
recognize the distinctness of this the most common form of organic
spinal ailment.

At this time, when tabes dorsalis became recognized as a clinical

entity depending on sclerotic degeneration of the posterior segment
of the cord, the inco-ordination or ataxia manifested in the peculiar
gait of the patient was regarded as the most characteristic, essential,
and constant symptom of the disease. It was regarded as an axiom
in physiology that the posterior segment of the cord was subservient
to centripetal and sensory conduction, and nothing appeared to
follow more naturally than the conclusion that the patient exhibited
inco-ordination because, his sensory conduction being interrupted or
destroyed, he had lost the necessary gauge for judging of the
required extent and force of a given movement. Since then both
spinal physiology and pathology have undergone a profound
revolution. So far are we to-day from regarding anterior and motor or
posterior and sensory as convertible terms that we locate the most
important centrifugal tract of the cord behind the plane which divides
it into anterior and posterior halves, while the most recently
differentiated centripetal tract is represented by Gowers as lying in
front of it. It has been determined, through Türck, Bouchard, and
Flechsig and his pupils, that the posterior white columns of the cord
contain several systems of fibres, whose functions—where
determinable—are of an exceedingly complex nature. The elaborate
investigations of Charcot, Schultze, and Strümpell, made during the
past decade, have shown that the distribution of the diseased field in
the posterior segment is not uniform, but is most intense in special
areas. These were found to be affected with a remarkable constancy
and regularity. Almost coeval with this discovery came the
recognition of symptoms found in the earliest phases of the disorder
by Westphal, which, attributable as they were found to be to the
involvement of the special reflex mechanisms of the cord, enable us
to demonstrate the existence and extent of the disease at periods
which previously were not within the ken of the clinician. The
reproach which Leyden was justified in making, that most tabic
patients pass through the pre-ataxic phase of their disorder under
the diagnosis of rheumatism or some similar affection, can now no
longer be made. Our ability to recognize the advent of this disease
has reached such a degree of refinement that the question arises
whether we are always justified in alarming a patient who has a
prospect of remaining free from invalidating complications for many
years with the announcement of a disease which, above all other
spinal affections, is looked upon with dread as equally hopeless,
insidious, and distressing.

CLINICAL HISTORY.—The development of tabes dorsalis is typically

slow and its precise commencement usually not determinable. In
some cases this or that one of the characteristic symptoms of the
disease preponderates from the beginning, and continues
throughout the illness as a prominent feature; in others distinct
stages can be recognized, each marked by one or several symptoms
which were absent or slight in the other stages. In some cases the
progress of the affection is marked by episodes which are absent or
rare in other cases. As a rule, however, it may be stated that tabes is
a progressive affection, marked by pronounced temporary changes
for better or worse, which are often developed with astonishing
rapidity, and subside as quickly, terminating fatally unless its
progress be arrested by treatment or interrupted by some other fatal
affection. The latter is by far the more frequent termination in the
well-to-do class of sufferers.

For purposes of convenience we may consider the symptoms of the

earlier period of the illness as pre-ataxic, and those of the later as
the ataxic. It is to be remembered, however, that in the strictest
sense of the term there is usually some disturbance of co-ordination
even in the early period, while the symptoms of the pre-ataxic period
continue over the ataxic period, and may even become aggravated
with it. Often the patient does not himself suspect a spinal, or indeed
any nervous, disorder, and consults the physician either on account
of rheumatic pains, double sciatic neuralgia, bladder disturbance,
diminished sexual power, amaurosis, diplopia, or even gastric
symptoms, which on closer examination are revealed to be
evidences of tabes. The determination of the initial symptoms is
retrospective as a rule.

Of the subjective signs, one of the commonest, if indeed it be ever

entirely absent, is a tired feeling, particularly noted in the knees and
ankles. This sensation is compared to ordinary muscle-tire, but is
provoked by slight exertion, and not as easily remedied by rest.
Often a numb feeling is associated with it, although no objective
diminution of cutaneous sensation be determinable. This combined
feeling of tire and numbness, described as a going-to-sleep feeling in
the ankle, has indeed been claimed by one observer1 to be
pathognomonic of early tabes. Next in frequency, and almost as
universal, are peculiar pains: these are manifold in character and
distribution, but so distinctive as to alone suggest the existence of
the disease from the manner in which the patient describes them.
One variety, the lightning-like, is compared to a sudden twinge of
great intensity shooting through the limb. The sciatic and anterior
crural branches are the lines usually followed by this pain, but there
are cases where perineal and abdominal regions are affected. Often
the pain is so severe that the patient cries out or the limb is violently
contracted under its influence. It differs from rheumatic pain in the
fact that it is distinctly paroxysmal and that the intermissions are
complete; that it is not greatly aggravated by motion nor relieved by
rest, while the rheumatic pain is; that tabic pain is usually relieved,
and rheumatic pain aggravated, by pressure, while hyperæsthesia is
present with the former, and either absent or barely indicated with
the latter. The lightning-like pains are sometimes combined with
another form, which is even more distinctive in character. This form
does not affect the distribution of special nerves, but is found limited
to a small area which the patient is able to localize definitely: it may
not exceed a centimeter or two in diameter, and within this area the
pain is excruciating. It is either of a burning character or compared to
the firm pressure of a vise or heavy weight, or to the tearing, boring,
and jumping of a violent toothache.
1 Canfield, Lancet, 1885, vol. ii. p. 110.

While some patients escape these pains almost entirely,2 others are
tormented with them at intervals for years, their intensity usually
diminishing when the ataxic period is reached. There is little question
among those who have watched patients in this condition that their
pains are probably the most agonizing which the human frame is
ever compelled to endure. That some of the greatest sufferers
survive their martyrdom appears almost miraculous to themselves.
Thus, in one case the patient, who had experienced initial symptoms
for a year, woke up at night with a fulminating pain in the heels which
recurred with the intensity of a hot spear-thrust and the rapidity of a
flash every seven minutes; then it jumped to other spots, none of
which seemed larger than a pin's head, till the patient, driven to the
verge of despair and utterly beside himself with agony, was in one
continued convulsion of pain, and repeatedly—against his conviction
—felt for the heated needles that were piercing him. In another case
the patient, with the pathetic picturesqueness of invalid misery,
compared his fulminating pains to strokes of lightning, “but not,” he
added, “as they used to appear, like lightning out of a clear sky, but
with the background of a general electrical storm flashing and
playing through the limbs.”
2 I have at present under observation two intelligent patients (one of whom had been
hypochondriacally observant of himself for years) who experienced not a single pain,
as far as they could remember, and who have developed none while under
observation. Seguin mentioned a case at a meeting of the Neurological Society with a
record of but a single paroxysm of the fulgurating variety. Bramwell (Brit. Med. Journ.,
Jan. 2, 1886) relates another in which the pains were entirely absent.

Either while the pains are first noticed or somewhat later other signs
of disturbed sensation are noted. Certain parts of the extremities feel
numb or are the site of perverted feelings. The soles of the feet, the
extremities of the toes, the region about the knee-pan, and the
peroneal distribution, and, more rarely, the perineum and gluteal
region, are the localities usually affected.3 In a considerable
percentage of cases the numbness and tingling are noted in the little
finger and the ulnar side of the ring finger; that is, in the digital
distribution of the ulnar nerve. The early appearance of this symptom
indicates an early involvement of the cord at a high level. Some
parallelism is usually observable between the distribution of the
lightning-like pains when present and the anæsthesia and
paræsthesia if they follow them. With these signs there is almost
invariably found a form of illusive sensation known as the belt
sensation. The patient feels as if a tight band were drawn around his
body or as if a pressure were exerted on it at a definite point. This
sensation is found in various situations, according as the level of the
diseased part of the cord be a low or high one. Thus, when the lower
limbs are exclusively affected or nearly so the belt will be in the
hypogastric or umbilical region; if the upper limbs be much involved,
in the thoracic region; and if occipital pain, anæsthesia of the
trigeminus, and laryngeal crises are present, it may even be in the
neck. Correspondingly, it is found in the history of one and the same
patient: if there be a marked ascent—that is, a successive
involvement of higher levels in the cord—the belt will move up with
the progressing disease. This occurrence, however, is less
frequently witnessed than described. In the majority of cases of
tabes disturbances of the bladder function occur very early in the
disease. Hammond indeed claims that in the shape of incontinence it
may be the only prodromal symptom for a long period.4
3 In the exceptional cases where the initial sensory disturbance is marked in the
perineal and scrotal region I have found that the antecedent fulminating pains had
been attributed to the penis, rectum, and anal region; and in one case the subjective
sense of a large body being forcibly pressed through the rectum was a marked early
sign.

4 New England Medical Monthly, 1883.

I have under observation a patient who has been compelled to use

the catheter daily for years, who has gradual disappearance of the
knee-jerk and reflex iridoplegia, but who has presented no other
evidence of tabes during the year and a half he has been watched.
Among the exact signs of tabes, reflex iridoplegia and abolition of the
knee-jerk are probably the earliest to appear. It may be assumed
with safety that in ninety-nine out of a hundred cases both the
inability of the pupil to respond to light and the absence of the knee-
jerk will be found long before ataxia is developed. Cases are
recorded where no other positive signs were found, and no other
signs of the disease developed for a number of years,5 and others
where disappearance of the knee-jerk was the very first indication.
5 Westphal, also Tuczek, Archiv für Psychiatrie, xiii. p. 144.

The opinion of observers as to the frequency of double vision as an

early symptom of tabes is far from being unanimous. The majority of
writers speak of it as rare, but it is probable that this usually transient
symptom is forgotten by the patient, or because of its apparent
triviality escapes notice. The patient while looking at an object sees a
double image of the latter. This may last for a few seconds, minutes,
or hours, and rarely for a day or week.6 A distinct history of this
symptom was given by 58 out of 81 patients in whom I recorded the
oculo-motor signs. By far the most important of the exact prodromal
signs of tabes are two symptoms—one involving a special faculty of
co-ordination, the other the reflex movements of the pupil. One or
both of these must be present to justify the diagnosis of incipient
tabes.7 The disturbance of co-ordination consists in an inability of the
patient to stand steadily when his eyes are closed. The majority of
healthy persons when tested in this way may show a little swaying in
the beginning, but eventually they stand as steadily as they do with
open eyes, and there is no subjective feeling of uncertainty as to
falling. But the tabic patient exhibits oscillations, and makes efforts to
overcome them which, instead of neutralizing, usually aggravate
them and betray the great disturbance of his equilibrium. It is not as
if he swayed merely because he is uncertain of his upright position,
but as if some perverted force were active in throwing him out of it. It
is found to be a pronounced feature even in cases where the patient
with open eyes is able to walk nearly as well as normal persons, and
experiences no trouble in performing intricate evolutions, such as
dancing, walking a line, or even walking in the dark—faculties which
the patient is destined to lose as his disease progresses.8
6 It has been asserted that the severer and more persistent diplopias are found with
tabes dependent on syphilis.

7 Not even the absence of the knee-jerk ranks as high as these two signs. Aside from
the fact that this is a negative symptom, it is not even a constant feature in advanced
tabes.

8 It does not seem as if the disturbance of static equilibrium were due merely to the
removal of the guide afforded by the eyes, for it is noted not alone in patients who are
able to carry out the average amount of locomotion in the dark, but also in those who
have complete amaurosis. Leyden (loc. cit., p. 334) and Westphal (Archiv für
Psychiatrie, xv. p. 733) describe such cases. The act of shutting the eyes alone,
whether through a psychical or some occult automatic influence, seems to be the
main factor.

In most cases of early tabes it is found that the pupil does not
respond to light; it may be contracted or dilated, but it does not
become wider in the dark nor narrower under the influence of light.
At the same time, it does contract under the influence of the
accommodative as well as the converging efforts controlled by the
third pair, and in these respects acts like the normal pupil. It is
paralyzed only in one sense—namely, in regard to the reflex to light;
just as the muscles which extend the leg upon the thigh may be as
powerful as in health, but fail to contract in response to the reflex
stimulus applied when the ligamentum patellæ is struck. For this
reason it is termed reflex iridoplegia.9 It is, when once established,
the most permanent and unvarying evidence of the disease, and is
of great differential diagnostic value, because it is found in
comparatively few other conditions.
9 It is also known as the Argyll-Robertson pupil. Most of the important symptoms of
tabes are known by the names of their discoverers and interpreters. Thus, the
swaying with the eyes closed is the Romberg or Brach-Romberg symptom; the
absence of the knee-phenomenon, Westphal's or the Westphal-Erb symptom; and the
arthropathies are collectively spoken of as Charcot's joint disease.

In a number of cases ptosis of one or both eyelids is noted at an

early stage of the disease. It is usually temporary, and coincides as
to time with the diplopia, if present.

Patients presenting some or all of the subjective and objective

manifestations of tabes mentioned may continue in a condition of
otherwise comparative health, enabling them to attend to their
vocation for from one to twenty years, and it is not improbable that
the pre-ataxic period may extend over nearly a lifetime. In a less
fortunate minority of cases some of the most distressing evidences
usually marking the last stages of the disease are found developed
at the onset. Thus, cases are known where optic nerve-atrophy
preceded the true tabic period by ten or more years; others in which
trophic disturbances, manifested in spontaneous fractures of bones10
or violent gastric crises, or even mental disturbance, inaugurated
tabes dorsalis, instead of closing or accompanying the last chapter
of its history, which is the rule.
10 Berger, Deutsche medizinische Wochenschrift, 1885, 1 and 2.
The disturbance of co-ordination above spoken of as manifested in
the inability of the patient to stand well with his eyes closed is the
first step in the development of the characteristic ataxia which marks
the full-blown affection. The patient finds that he tires more and more
on slight exertion—not because his muscles are weak, but because
he has to make more voluntary effort than a person in health. He
finds that he stumbles easily—is unable to ascend and descend at
the curbstone or to walk over an irregular surface with ease. Going
down stairs is peculiarly irksome. “I would rather,” aptly said one
patient, “troubled as I am in walking, go a mile in the street than walk
up three flights of stairs; but I would rather go up six flights of stairs
than walk down one.” Soon the patient notices that walking in the
dark becomes more a feat of relative skill than the easy, almost
automatic, act it was in health. His vocation, if it was one involving
the use of the feet, becomes irksome, difficult, and finally impossible,
and in a number of cases the upper extremities are also involved.11
Delicate motions, such as those required in needlework, in writing,
and by watchmakers, musicians, opticians, and lapidaries, are
clumsily performed; even coarser movements, such as buttoning the
clothes and carrying a glass filled with water to the mouth, are
performed in an uncertain and clumsy manner. Meanwhile, the
disturbance of motion in the lower limbs progresses. Difficult as it
formerly was for the patient to stand on one foot or with both feet
together while the eyes were closed, he is now unable to do either
with the eyes open. He straddles in his walk, or, in order to overcome
the element of uncertainty involved in moving the knee-joint, keeps
this joint fixed and walks with short, stiff steps. If ordered to halt
suddenly while thus walking, the patient sways violently, and makes
movements with his hands or arms to recover his balance, in some
cases staggering and even falling down. He shows a similar
unsteadiness when told to rise suddenly from a chair or to mount
one, and it becomes impossible for him to walk backward. Later on,
it will be found that his feet interfere in walking. He has lost the
power of gauging the extent and power of his motions to such a
degree that he may actually trip himself up. To neutralize in some
way this element of uncertainty of his steps, the patient is compelled
to exaggerate all his ambulatory movements, and there results that
peculiar gait which was the first symptom directing attention to the
disease to which it is due. The feet are thrown outward, and violently
strike the ground; the heel touches the latter first, and the patient
appears as if he were punishing the ground and stamping along
instead of walking. The reason for his adopting these tactics are
twofold. In the first place, he has a subjective sense of walking in a
yielding substance, as if on a feather bed, air-bladders, cushions, or
innumerable layers of carpet, and he therefore makes efforts to
touch firm bottom. In the second place, his motor inco-ordination, in
so far as it is not the result of anæsthesias, is greatest in those
segments of his limbs which are farthest removed from the trunk,
and which, enjoying the greatest freedom of combined motion, are
also most readily disturbed. His uncertainty is therefore greater in the
toes than in the ankle, greater in the ankle than in the knee, and
greater in the knee than in the thigh: he prefers to touch the ground
with the heel to touching it with the toes, and to move his limb in the
hip than in the knee-joint. As the patient advances in life even this
limited and clumsy form of locomotion becomes impossible: he takes
to his bed, and it is found that he loses all sense of the position of his
lower and occasionally of his upper limbs. He is unable to tell which
limb overlies the other when his leg is crossed—unable to bring one
limb in parallel position with another without the aid of his eyes. If
told to touch one knee or ankle with the toes of the other side, his
limb oscillates around uncertainly, and makes repeated unskilful
dashes at the wrong point, and ultimately all but the very coarsest
muscular co-ordination appears to be lost, even when the
supplementary aid of the eyes is invoked.
11 Cases in which the upper extremities are intensely involved in the beginning are
uncommon, and those in which they are more intensely involved than the lower, or
exclusively involved, may be regarded as pathological curiosities.

Together with this gradual impairment and abolition of co-ordination,

which has given the name of locomotor ataxia to the disease, but not
always in that strict parallelism with it on which Leyden12 based his
theory of inco-ordination, the sensory functions proper become
perverted and impaired. Usually the determinable anæsthesias are
preceded by subjectively perverted sensations, such as the
numbness already referred to, or even by hyperæsthesia. Usually, all
categories of cutaneous sensation, whether special or pathic, are
impaired in advanced tabes; the points of the æsthesiometer are not
readily differentiated; the patient is unable to correctly designate the
locality which is touched or pinched; the pain-sense is occasionally
so much blunted that a needle may be run through the calf of the leg
without producing pain, and in some cases without being
appreciated in any form. Even if the pain-sense be preserved, it will
be found that its appreciation by the patient is delayed as to time.
Not infrequently bizarre misinterpretations are made of the
impressions acting on the skin. One of these, the feeling as if the
patient were standing on carpet, cushions, or furs, whereas he may
be standing on stone flagging, has already been mentioned as a
factor in the disturbed locomotion of the patient. In the later period,
numerous perversions of this kind are noted: to one of these, already
mentioned by Leyden, Obersteiner has called renewed attention. It
consists in a confusion of sides; the patient when pricked or touched
on one foot or leg correctly indicates the spot touched, but attributes
it to the wrong side.13
12 Klinik der Rückenmarkskrankheiten, Band ii.

13 Allochiria is the term applied by Obersteiner. Hammond has offered an explanation,

which, as it is based on the assumption of altogether hypothetical nerve-tracts, and
not in any sense accords with positively established facts, is more properly a subject
for consideration in a theoretical treatise.

While it may be affirmed, as a general proposition, that the tendency

of the tabic process is to abolish sensation below the level of the
disease, there are noteworthy exceptions, not only in individual
cases, but with regard to certain kinds of sensation; nor do the
different kinds of sensation always suffer together. Thus, the pain-
sense may be blunted and the contact-sense preserved, or, more
commonly, the latter blunted and the former exaggerated, so that the
unfortunate patient, in addition to being debarred of the useful
varieties of sensation, those of pressure and space, has the painful
ones exaggerated, as a hyperalgesia. According to Donath,14 the
temperature-sense is usually blunted in tabes, and a greater degree
of heat or cold can be borne without discomfort than in health; but in
about two-sevenths of the cases studied there was increased
sensitiveness to heat, and in one-seventh to cold. One of the
commonest manifestations is delayed conduction. This interesting
phenomenon has been especially observed in that phase of the
disease where tactile perception is beginning to be blunted. If the
patient be pricked with a pin, he feels the contact of the latter at the
proper moment as a tactile perception, and then after a distinct
interval, varying from one to four seconds, his limb is suddenly
drawn up and his face contorted under the influence of an
exaggerated pain. This fact furnishes one of the chief grounds for the
assumption that there are distinct channels for the transmission of
pain and tactile perception in the cord, and that they may be involved
separately or with different intensity in the disease under
consideration. In some advanced cases it is found that not only the
transmission of pain-appreciation is delayed, but that there are after-
sensations recurring at nearly regular intervals of several seconds,
and accurately imitating the first pain-impression.
14 Archiv für Psychiatrie, xv. p. 707.

To what extent the muscular sense is affected in tabes at various

stages of the disorder is somewhat in doubt. Strümpell15 by
implication, and other writers directly, attribute the inco-ordination
observed on closing the eyes to the loss of the muscular sense. As
this symptom is also observed in patients who when they lie on their
backs are able to execute intricate movements notwithstanding the
exclusion of the visual sense, and as their uncertainty in an early
stage is not always with regard to the position of their limbs nor the
innervation of individual or grouped muscles, it seems inadmissible
to refer the Romberg symptom16 to the loss of muscular sense alone.
15 Lehrbuch der Speciellen Pathologie und Therapie, p. 193, vol. ii.

16 It should be designated as static ataxia, in distinction from locomotor or motor

ataxia, which is manifested in unskilled movements.
The important part played by eye symptoms in the early stages of
tabes has been already referred to. Reflex iridoplegia is one of these
early and persisting features; it is sometimes complicated with
mydriasis, and occasionally with paralysis of accommodation of one
eye. In the majority of my cases there was spinal myosis, often of
maximum intensity; in a large number there was in addition
irregularity of the outline of the pupil; and where there was mydriasis
I found it to be quite symmetrical, in this respect differing from the
experience of Müller17 and Schmeichler.18
17 Centralblatt für die Gesammte Therapie.

18 Loc. cit.

Atrophy of the optic nerve is a common and sometimes, as stated,

the initial symptom of tabes. It is rarely found in its incipient phase in
advanced stages. The patient who escapes involvement of the optic
nerve in the pre-ataxic stage is very apt to escape it altogether. It is
more frequently found either to precede the pre-ataxic period by
months and even years, or to develop during this period, leading to
complete atrophy in the ataxic period, and sometimes before. Erb
calculates that 12 per cent. of tabic patients have optic-nerve
atrophy; he probably includes only such cases in which the atrophy
was marked or led to amblyopia. Including the lesser degrees of
atrophy, it is found in a larger number of patients. Schmeichler
claims as high as 40 per cent.19 If we regard those cases in which
there is noted progressing limitation of the color-field of the retina as
beginning optic-nerve atrophy, the majority of tabic patients may be
said to have some grade of this disorder. The ophthalmoscopic
changes are quite distinctive: at first there is noted a discoloration of
the papilla and apparent diminution of the number of arterial vessels;
the veins then become dilated; and finally the papilla becomes
atrophied, the vessels usually undergoing a narrowing after their
previous dilatation. In the first stages of this process visual power is
not gravely impaired, but as soon as shrinkage has set in visual
power sinks rapidly to a minimum, decreasing till only quantitative
light-perception remains. This limited function usually remains
throughout, but in a few cases complete amaurosis ensues. As the
field of vision becomes diminished, the concentric extinction of
quantitative perception is preceded by concentric extinction of color-
perception, the color-field for green being the first to suffer; red
follows, and blue remains last.
19 Archives of Ophthalmology and Otology, 1883.

In a large number of cases the only symptoms attributable to a

disturbance of the cerebral functions are those connected with the
motor relations of the eyeball and pupil, and the function and
appearance of the optic nerve. The special senses other than those
of sight and touch are rarely affected. Sometimes there is obstinate
tinnitus, exceptionaly followed by deafness, attributed to atrophy of
the auditory nerve. The development of symptoms resembling those
named after Ménière is not referable with certainty to a disturbance
of the same nerve.

The sexual functions become involved in all cases of tabes sooner or

later. In the majority of cases there is a slow, gradual extinction of
virile power; in a large minority this extinction is preceded by irritative
phenomena on the part of the genital apparatus. Some patients
display increased sexual desire and corresponding performing
powers, but mostly they suffer from erections of long duration which
may be painful, and loss of the normal sensations attending the
sexual orgasm. There is no constant relationship between the
intensity of the general affection and the diminution of sexual power.
It is retained to a limited degree by patients who are barely able to
walk, and it may be entirely destroyed in those who have but entered
the initial period.

The bladder disturbance,20 which in some forms is usually found

among the initial symptoms, is always a marked feature in the ataxic
period. Usually, there is a frequent desire for micturition, with more or
less after-dribbling; sometimes there is retention, alternating with
involuntary discharge; complete incontinence may close the scene
through the channel of an ensuing cystitis and pyelitis. With the
incontinence of urine there is usually found obstinate constipation,
which may be varied by occasional spells of incontinence of feces.
The crises of tabes often complicate these visceral symptoms.
20 Contrary to what might be anticipated from the topographical nearness of the
vesical and genital centres in the cord, the disturbances of bladder function and virile
power do not go hand in hand.

The reflex disturbances are among the most continuous evidences

of the disease. Of two of these, the disappearance of the patellar jerk
or knee-phenomenon and the inability of the pupil to react to light,
we have already spoken when discussing the initial period.
Practically, it may be claimed that both are always found in typical
tabes. It has been claimed that the patellar jerk may be exaggerated,
or even that its disappearance is preceded by exaggeration. As this
disappearance usually occurs extremely early in the pre-ataxic
period, it is difficult to follow the deductions of those who claim to
have watched an alleged earlier phase of exaggeration. It is more
than probable that cases of combined sclerosis, in which the lateral
columns were affected together with or earlier than the anterior, have
been mistaken for typical tabes. Here, it is true, the jerk is first
exaggerated through the disease of the lateral column, and later
abolished as the lesion in the posterior reflex arch progresses and
becomes absolute.

Other tendinous reflexes21 suffer with the knee-jerk in the peripheries

corresponding to and below the involved level of the cord. The
cutaneous reflexes are usually abolished, but may be retained in
advanced stages of the disease. The same is true of the cremaster
reflex.
21 Whether the tendon phenomena are true reflexes or not is a question still agitating
physiologists. Opinion inclines in favor of their reflex nature, and, pathologically
considered, it is difficult to regard them in any other light.

Opinion is divided as to the electrical reactions in tabes dorsalis.

That qualitative changes never occur in uncomplicated cases all
authorities are agreed, but while Strümpell and other modern writers
claim there is no change of any kind, a number of careful
investigators have found an increased irritability in the initial period,
particularly marked in the peroneal group of muscles (Erb). In my
own experience this is frequently the case, where lightning-like pains
are the only subjectively distressing symptoms complained of.

While the symptoms thus far considered as marking the origin and
progress of tabes dorsalis are more or less constant, and although
some of them show remarkable remissions and exacerbations, yet
may in their entity be regarded as a continuous condition slowly and
surely increasing in severity, there are others which constitute
episodes of the disease, appearing only to disappear after a brief
duration varying from a few hours to a few days: they have been
termed the crises of tabes dorsalis. These crises consist in
disturbances of the functions of one or several viscera, and are
undoubtedly due to an error in innervation provoked by the
progressing affection of the spinal marrow and oblongata. The most
frequent and important are the gastric crises. In the midst of
apparent somatic health, without any assignable cause, the patient is
seized with a terrible distress in the epigastric region, accompanied
by pain which may rival in severity the fulgurating pains of another
phase of the disease, and by uncontrollable vomiting. Usually, these
symptoms are accompanied by disturbances of some other of the
organs under the influence of the pneumogastric and sympathetic
nerves. The heart is agitated by violent palpitations, a cold sweat
breaks out, and a vertigo may accompany it, which, but for the fact
that it is not relieved by the vomiting and from its other associations,
might mislead the physician into regarding it as a reflex symptom. In
other cases the symptoms of disturbed cardiac innervation or those
of respiration are in the foreground, constituting respectively the
cardiac and bronchial crises. Laryngeal crises are marked by a
tickling and strangling sensation in the throat, and in their severer
form, which is associated with spasm of the glottis, a crowing cough
is added.22 Enteric crises, which sometimes coexist with gastric
crises, at others follow them, and occasionally occur independently,
consist in sudden diarrhœal movements, with or without pain, and
may continue for several days. Renal or nephritic crises are
described23 as resembling an attack of renal colic. The sudden