of the same character as those of chronic meningitis, but the specia symmetry and peculiar distribution of the atrophic palsy, the prominence of limb-teuderness, and the absence of cord symptoms, preclude such similarity as can cause actual confusion between the two diseases.

PROGNOSIS. The differences between the forms of chronic meningitis, and between the degrees of the same forms, are so vast as to render the prognosis of the disease a matter of individual consideration in every case, to be estimated independently, from the pathological characters. The severe degrees of the affection are attended with danger to life, and even the slighter forms may entail serious consequences, since many effects of the disease, especially the damage to the spinal cord itself, tend to increase by the myelitic tendency which is set up. The neuralgic pains, which result from the damage to the nerve-roots, are extremely obstinate. But in many cases the symptoms ultimately pass away-the irritation ceases and the compressed structures slowly regain their function. The prognosis is most favorable in the cases which result from injury and from syphilis. But in all cases, even those of syphilitic origin, in which there is reason to infer considerable formation of new tissue, the prognosis must be cautious, since the cicatricial contraction of this tissue may perpetuate the damage to cord and nerves which its pressure has produced. The prognosis is better, in other cases, in proportion to the general health of the patient, to the moderate degree of the mischief, and to the extent to which its causes are under control.

TREATMENT.-Rest is essential; in severe cases it should be absolute, and in every case movements which increase pain should be avoided. The pain is the expression of irritation, which tends to maintain the morbid process. Measures, previously ineffective, will often be followed by improvement if rest is added. Posture is also of great importance. The prone couch, impracticable in acute meningitis, can often be employed in chronic cases with advantage, to lessen mechanical congestion of the spine. Warm baths and diaphoretic baths have been recommended as useful, especially in subacute cases. Next in importance to rest and posture is counterirritation. Repeated sinapisms or stimulating liniments may be used if mild counter-irritation only is required, but in most cases greater good will result from more energetic means, blisters, the thermic hammer, or the actual cautery. The last is especially recommended by Joffroy for the hypertrophic pachy meningitis. It is probable that posture favours the beneficial influence of counter-irritation in a very important degree.

Sedatives are usually needed to relieve the pain-morphia, chloral, Indian hemp, injections of morphia or cocaine, or sedative liniments of chloroform, belladonna, &c. In employing sedatives it must be remembered that they will usually be needed, in chronic cases, for many months, and after a time, by the artificial need they create, they 19

VOL. I.

may apparently keep up the pain. It is therefore well, if possible, to alternate two or more sedatives, to make cocaine take the place of morphia as much as possible, and to lessen the dose from time to time, tentatively, and without the knowledge of the patient.

Iodide of potassium and mercury are the agents that have most influence over the morbid process itself. Both are effective in syphilitic cases, but in other forms of the disease mercury has far more influence than iodide; it may be rubbed in over the spine, as recommended in the acute form. The ointment and oleate may be rendered counter-irritant, if necessary, by the addition of cantharides ointment. In many cases, tonics, as iron, quinine, and cod-liver oil, are needed. The muscular wasting which results from damage to the nerve-roots requires treatment by galvanism, rubbing, and by passive movement, to prevent contractures. If hæmorrhagic pachymeningitis is suspected, ergotine may be used in addition to the measures suited for the ordinary form. Treatment appears, however, to exert little influence upon it.

Other measures are the same as have been described for the acute form.

HÆMORRHAGE INTO THE SPINAL MEMBRANES; HEMATORACHIS.

Spinal hemorrhage may be outside the dura mater, between it and the bones (extra-meningeal), or within the dura mater (intrameningeal). In the latter situation the extravasation may be subdural, between the dura mater and arachnoid, or it may be subarachnoid, between this and the pia mater. Hæmorrhage outside the dura mater is more common than within it.

CAUSES. Meningeal hæmorrhage may occur at all ages. It is met with in newly-born children, but in them is due to rupture of vessels during birth, and the blood often merely descends into the spinal membranes from those of the brain. Spontaneous hæmorrhage is unknown in early childhood, but occurs at all other ages, and is more common in men than in women. Of the immediate causes, injury is the most frequent, fractures of the spinal column, blows or falls on the back which do not fracture the vertebræ, and even falls on the feet or buttocks. It is occasionally found after death from severe convul. sions, epilepsy, puerperal eclampsia (in which an altered state of the blood may assist), chorea, strychnine poisoning, and tetanus. some instances no symptoms were observed during life which could be referred to the hæmorrhage, and it is probable that the extravasation occurred only during the last moments of life. Hence it seems likely that muscular spasm, resulting from a meningeal hæmorrhage,

may sometimes have been looked on as primary and independentthe cause of the hæmorrhage when it was really the effect thereof. This seems certain in many cases of tetanoid spasm in newly-born children-in most cases, indeed, in which such spasm occurs almost immediately after birth and is associated with meningeal hæmorrhage. Such cases should be separated from those to which the term tetanus neonatorum is applied. They are further considered in the account of hæmorrhage into the cerebral membranes in vol. ii. Severe and prolonged muscular exertion has been, in a few cases, the apparent cause of spontaneous hæmorrhage. It also occurs in some diseases in which there is a hæmorrhagic tendency, such as purpuric states, and the hæmorrhagic forms of some acute specific diseases, smallpox, yellow fever, &c., and very rarely in typhoid fever, apart from any hæmorrhage elsewhere. In most of these cases its occurrence has not been suspected until the post-mortem examination revealed it, and it probably occurs generally during the last moments of life. A rare cause is the bursting of an aortic aneurism into the spinal canal, after erosion of the bodies of the vertebræ, the blood being effused outside the dura mater. Hæmorrhage within the dura mater bas also resulted from the rupture of an aneurism of a vertebral artery. Blood may descend into the spinal membranes from the cranium, in cases in which a cerebral extravasation, especially about the pons, escapes into the meninges; this may occur in adults as well as in the meningeal hæmorrhage that is produced during birth. Lastly, in cases of intense meningeal inflammation, ecchymoses, and sometimes considerable extravasations, have been found on both sides of the dura mater or in the pia mater.

PATHOLOGICAL ANATOMY.-Extra-dural hemorrhage comes from the plexus of large veins which lie between the dura mater and the bone. It is usually not of large extent, and the blood collects chiefly on the posterior aspect, where, in the recumbent posture, gravitation favours accumulation, and the space between the membrane and the bone is greater than in front. But sometimes the extravasation is very extensive, covering a large part of the dura mater, and in such cases it may extend through the intervertebral foramina, along the nerves. Hæmorrhage is more common in the cervical region than elsewhere, but may occur in any part. The blood is usually coagulated, wholly or partially. The dura mater is blood-stained, sometimes even through to the inner surface. The spinal cord may be compressed, but the amount of blood is not often sufficient for this.

It is easy to fall into grave error regarding the presence of meningeal hæmorrhage; when a body has been lying on the back, the veins outside the dura mater become distended with blood, and this escapes when their walls are divided in opening the spinal canal. Care must be taken to avoid the error, on the one hand, of regarding the blood thus escaping as an ante-mortem extravasation, and, on the other, of overlooking a hemorrhage which actually exists. In all cases of

acute spinal disease, in which a post-mortem examination is to be made, the body should at first lie face downwards.

Intra-meningeal hemorrhage.-An extravasation into the sac of the dura mater (subdural hæmorrhage) may be small in quantity, or may fill the whole cavity. When small it may pass from one part to another. In subarachnoid hemorrhage, the blood comes usually from the vessels of the pia mater; it may surround the cord for an inch or two, or may fill the whole subarachnoid cavity. Such extensive effusions are rare, except when the blood descends into the arachnoid from the cerebral membranes. Blood effused into the spinal arachnoid has been known to ascend as high as the pons, and even to break through the valve of Vieussens and get into the cerebral ventricles.* Simultaneous cerebral and spinal hæmorrhages have been known to occur from a common and powerful cause, as, for instance, in a case of puerperal eclampsia (Charrier).

In meningeal hæmorrhage, cerebral as well as spinal, the spinal fluid is often blood-stained, and thus spinal hæmorrhage may be thought to be more considerable than it really is. The spinal cord is often discoloured and compressed, and is especially damaged when the hæmorrhage is beneath the arachnoid. In extensive extra-meningeal hæmorrhage, the subarachnoid fluid may be driven away from the compressed part, and may distend the arachnoid beyond the area of compression, the limit of which is thus marked. In cases which have lasted more than a few days there are usually signs of meningitis, set up by the irritation of the blood.

SYMPTOMS.-As already stated, slight meningeal hemorrhage is sometimes found post mortem in death from convulsive diseases when no symptoms of it were observed during life, and in these cases it is probable that the extravasation occurs during the lethal convulsions. In the cases in which hæmorrhage causes symptoms, these are, for the most part, those of meningeal irritation, and thus bear some resemblance to the symptoms of meningitis. They differ in the suddenness and violence of their onset, to which exceptions are extremely rare. These symptoms are nearly the same whether the hæmorrhage is outside or inside the dura mater.

The first indication of the lesion is usually sudden and violent pain in the back, corresponding in position to the seat of the hæmorrhage, but generally felt along a considerable extent of the back, and often severe in the loins. This pain in the back is usually accompanied by pain along the course of the nerves passing through the membrane near the extravasation, darting or burning pains, often of great intensity; they are paroxysmal in character, and between the pains there may be various abnormal sensations, tingling, &c., referred to the same parts, and accompanied by hyperæsthesia. Muscular spasm usually coincides with the pain, and involves partly the vertebral muscles, As in an apparently conclusive case reported by Leprestre, Arch. Gén. de Méd.,' xxii, p. 331.

causing rigidity of the spine or actual opisthotonos, partly the muscles supplied by the nerves in which the pain is felt, partly the muscles supplied from the cord below the seat of the hemorrhage. The convulsive movements are sometimes general. Intense pain in the back and general convulsion have been known to be the only symptoms. Occasionally there is persistent contraction of muscles, and there is usually spasmodic retention of urine. These symptoms of irritation are no doubt due in part to the irritation of the membranes (causing the vertebral pain and reflex spasm), and partly to the irritation of the nerve-roots, motor and sensory. Paralytic symptoms quickly followweakness and lessened sensitiveness in the limbs below the lesion. some cases there is, at last, complete loss of motion and sensation in the lower limbs, but such absolute paralysis is not common. Loss of power at the onset of the symptoms usually indicates either simultaneous hæmorrhage into the cord or the effusion of a very large amount of blood. It occurs, for instance, when an aneurism bursts into the spinal canal.

In

The symptoms necessarily differ in situation according to the seat of the disease. When hæmorrhage is in the cervical region (a frequent seat), the pains are felt in the neck and arms, and the rigidity may cause absolute immobility of the neck, while dysphagia, interference with respiration, and dilatation of the pupils may be added to the other paralytic symptoms. When it is in the dorsal region, intense pain encircles the chest or abdomen. If in the lumbar region, the pain is felt in the legs, and there are early paraplegic symptoms, with loss of reflex action in the legs, and the paralytic incontinence of urine and fæces described on p. 225.

As a rule, in spinal hæmorrhage, the cerebral functions are unaffected; the unfortunate patient is conscious of all his sufferings from first to last. Occasionally, however, consciousness is lost for a short time, apparently from shock, and delirium or coma may come on, either as an indirect effect of the spinal lesion on the brain, or in consequence of a sudden increase in the intra-cranial pressure, due to the displacement upwards of the cerebro-spinal fluid. But in most cases in which cerebral symptoms coexist with those of spinal hæmorrhage, the former have been due to simultaneous intra-cranial disease; this is the case when the blood found in the spinal canal comes from within the skull, as in most cases of meningeal hæmorrhage in newly-born children (see vol. ii). In very rare cases the symptoms of spinal hæmorrhage have come on insidiously, without pain, as in a case in which extensive hæmorrhage outside the dura mater in the cervical and upper dorsal region, in a girl of fourteen, caused only very gradual weakness in the arms, and difficulty of breathing, from which she died at the end of a fortnight.* Such a case illustrates the almost universal law that there is hardly any "characteristic" symptom of a disease that is not sometimes absent, and that the

R. Jackson, Lancet,' 1869, p. 5.