transverse myelitis. The development of increased myotatic irritability shows that improvement will not speedily occur, but even rigidity and the state of "spastic paraplegia" does not lessen materially the prospect of some recovery in a case in which the loss of power remains complete for a month or more. Indeed, the spasm often enables the patient to stand with a slighter degree of voluntary power than would suffice if the limbs were supple.

The fact of preceding syphilis must be allowed very little influence on the prognosis in a case of simple acute myelitis, but greatly improves the prognosis if there are indications that the inflammation is secondary to a more chronic process outside the cord.

TREATMENT.-If a case comes under observation at the earliest period, when only slight sensory disturbance and slight weakness of the legs indicate the commencing process, the question arises whether any treatment can avert the further development of the inflammation. If the symptoms are clearly due to exposure to cold, a hot bath, followed by free diaphoresis, should be employed, and followed by counter-irritation and the other measures now described. If considerable paralysis shows that the process of inflammation is fully developed, little can be expected from these measures, and it is better not to subject the patient to treatment that is incompatible with perfect rest. This, in all cases, is of paramount importance. Both functional excitation of the cord and movement of the spinal column should be avoided. The remarks regarding posture made in the account of the treatment of inflammation of the membranes apply also to that of the cord itself; it is most undesirable that the spine should be the lowest part of the body, and it is rather less difficult to keep the patient off the back in myelitis than in meningitis. A plank back-rest in the bed will be found a great assistance in securing comfortable rest on the side. If there is any reason to suspect hæmorrhage, or if there are indications of rapid extension of the inflammation, the prone position should be adopted, and even in myelitis it is well to adopt it at times as a change from the lateral posture.

The removal of blood from the skin of the back over the affected region, by leeches or wet cupping, is an old measure, which finds some theoretical justification in the fact that the blood from the structures behind the spine passes into the same veins as the blood from the spinal cord itself. Hence this measure may conceivably have some influence on the circulation in the cord. If the patient's strength is not such as to render the abstraction of blood desirable, dry cupping may be employed, or the vessels of the skin may be dilated by hot fomentations, or a mustard plaster, or hot water bags. By stimulating the cutaneous nerves, these agents may also influence, in a reflex manner, the vessels of the cord. The application of cold to the spine, as by a spinal ice-bag, has also been recommended. Contrary as these therapeutic agents seem, it is probable that each moderates local

inflammation in the same manner, by causing first contraction and then dilatation of the vessels of the inflamed part, and so lessening the tendency to stasis of the blood, on which some effects of inflammation depend. Unless there is reason to suspect hæmorrhage, the application of warmth is the safer and probably, judging from experience, the more effectual. At the very onset of inflammation mild counterirritation is unquestionably useful, and even a blister may be employed; but when the process has reached a considerable degree, it is very doubtful whether counter-irritation has much influence until the acute stage is over.

In other respects the treatment of acute inflammation of the cord must be guided rather by the nature of the process than by the character of the organ in which it occurs, and the fact that it is an acute local inflammation should be kept in view. A nutritious but unstimulating diet, aperients, and diuretics, are desirable in all cases. If there is constipation a free purgative may be given. Whenever there is evidence of a morbid blood-state, it is important that this should, if possible, be improved, but we have still to learn how most toxæmic states can be neutralised. Nitrous ether may be given as a diuretic with some tincture of digitalis, which tends to render the circulation uniform and to lessen stasis by its influence on the small arteries. The reason for diuresis is that probably no local inflammation occurs that is not associated with a morbid state of the blood which may be to some extent relieved by the action of the kidneys. If any special drug is given, it may be combined with those above named. It is as difficult to ascertain the influence of the drugs which are supposed to exert a special influence on myelitis, as it is in the case of other local inflammations, which have no predetermined degree, and tend to subside when they have reached their height. Ergot was recommended by Brown-Séquard, chiefly on theoretical grounds, and has been extensively employed. In rare cases it has seemed to do good. In cases of hæmorrhagic myelitis it may reasonably be given with greater confidence, or ergotin (3 to 5 gr.) may be injected beneath the skin. Belladonna has also been recommended, but the evidence that it influences the morbid process is not strong. Mercury has been largely employed, given by the mouth and by inunction. The influence of mercury on the inflammation of internal organs does not seem so great as upon that of the fibrous tissues and of the structures that invest organs. Certainly in myelitis its effect is less distinct than it is in many cases of meningitis. Iodide of potassium seems to be no more efficacious than mercury. In cases of transverse myelitis occurring in syphilitic subjects the treatment for syphilis seems to have but little influence on the morbid process. is true that such treatment is rarely adopted at the very onset of acute myelitis, but after the disease has developed energetic treatment does not seem to modify its subsequent course. This is true also of the subacute disseminated myelitis that occurs in the subjects of

It

syphilis, and might be expected to be more amenable. I have known this form, concurring with syphilitic disease of the cerebral arteries, to develop and run its course to a fatal termination in spite of continuous antisyphilitic treatment, to which the arteritis yielded.

In the general management of a case of myelitis, two points are of extreme importance. One is to avoid, by extreme cleanliness and care, the exciting causes of bedsores. The skin should be most carefully watched, and any indication of deleterious pressure met by a change of position or an alteration of the mode of supporting the part. Cotton wool is very useful for this purpose. If there is a marked tendency to trophic changes the patient should be placed on a waterbed. When there is incontinence of urine, the difficulty of avoiding irritation of the skin is greatly increased. For males, a bed urinal is sometimes useful, but often it causes irritation and even sloughing of the prepuce, and then does more harm than good. A quantity of boracic or salicylic absorbent cotton wool, changed as often as it becomes saturated, is one of the best means of meeting this difficulty. It must be remembered that the prevention of hedsores is the prevention of one common cause of death. Should offensive sores form, a quantity of picked oakum, placed outside the immediate dressing, is a cheap and most effective means of preserving the air of the room from the fœtor of the sores, and is also a useful substitute for absorbent cotton wool, in the case of the poor, to absorb the urine or receive fæces that are passed unconsciously. Such material is also useful for relieving pressure when a water-bed cannot be obtained. The second point in management is the treatment of retention of urine. If there is either simple retention or overflow incontinence, the bladder must be regularly emptied by the catheter, great care being exercised to prevent the introduction of contaminating germs. The importance of daily examining the abdomen to see that retention has not occurred, cannot be exaggerated. If the bladder is left full and the urine allowed to dribble away, inflammation is sure to be set up, and probably also pyelo-nephritis. If cystitis occurs, antiseptic washes must be used to lessen, as far as possible, the decomposition of the urine. Under this influence the cystitis usually lessens, and one grave danger to life is obviated.

When the disease of the cord has become stationary, the patient may be allowed to move, and a more tonic treatment may be adopted. Iron, quinine, or arsenic may be given. Strychnia must be given only in very small doses if there is any excess of reflex action. Occasional counter-irritation may be employed, repeated frequently if any improvement seems to result. The limbs may be rubbed, and any muscular wasting treated with electricity. It is not desirable to use electricity as a therapeutic agent while the cord disease is in an acutely active stage. There is no evidence that the application of electricity to the spinal column has any influence on the process of recovery of the cord. Its chief value is to maintain, as far as possible, the

nutrition of any muscles of which the nerves have undergone degeneration. In cases of dorsal myelitis, in which the legs are well nourished, and the reflex action is excessive, it is better not to apply any form of electricity. The unavoidable stimulation of the sensory nerves tends to increase the reflex over-action. Careful attention should, in all cases, be paid to the position of the limbs during the stage of helplessness, so as to avoid as far as possible the development of contractions. For the condition of active spasm, which often develops after severe myelitis, not much can be done; such special treatment as can be adopted is described in the chapters on Primary Spastic Paraplegia.

ABSCESS OF THE SPINAL CORD.

Simple inflammation of the spinal cord scarcely ever goes on to the formation of pus, although leucocytes may accumulate at certain points of the grey matter so densely as to constitute microscopic collections of pus, and in very rare cases of this kind such minute abscesses have been sufficiently large to be visible to the naked eye. Pus only forms in the substance of the cord in considerable quantity in cases of purulent meningitis. In most instances the purulent meningitis has been of septic origin, rarely traumatic. In the former case, suppuration within the brain may coincide with that in the spinal cord, and in the latter it may be very extensive and occur at more than one spot. The symptoms are those of an acute irritative myelitis, but they are often lost in those of the purulent meningitis which precedes the disease of the cord itself. Their special feature is their association with a cause of septic suppuration, as well as with a high temperature and other symptoms of a septic blood-state.

A good example of the disease is a case recorded by Nothnagel. A patient suffering from cough and most offensive expectoration was suddenly seized with severe pains on both sides of the abdomen, attended by a sense of constriction and quickly followed by paralysis of the bladder and of the legs, with loss of sensation and of reflex action. An abscess of the cord was diagnosed. After death there was extensive purulent spinal meningitis, and the dorsal and lumbar cord contained an extensive collection of gangrenous offensive pus, which seemed to occupy the central part of the cord, from the cervical enlargement downwards. Some abscesses were found also in the white substance of the brain. In another case described by Ullmann* two extensive foci of suppuration existed in the cord, one cervical, the other lumbar; the former had caused extensive destruction of tissue, and the pus had escaped into the subdural space. The affection was supposed to be secondary to gonorrhoea.

Zeitschr. f. kl. Med.,' xvi, 1859.

EMBOLISM OF THE SPINAL Cord.

The occurrence of embolism in the spinal cord has not yet been proved, but a few cases have been met with which suggest the possibility that the process has been the exciting cause of an acute myelitis. In a young man with mitral regurgitation, considerable weakness of the right leg came on suddenly-in a moment-with transient spasm. The onset indicated a sudden lesion in the cord, which might well have been the embolic obstruction of a small vessel. In a case recorded by Weiss, a boy aged sixteen, with chronic mitral disease, was suddenly seized with complete paraplegia, followed by bedsores, &c. He died four months after the onset, and the lumbar enlargement was found completely softened, with old coagula in the arteries. There was embolism of the kidneys and spleen, and the cortex of each cerebral hemisphere presented small foci of softening. Such cases justify a suspicion that embolism may be the cause of a sudden lesion of the cord in a patient in whom a source of embolism exists, and the process has occurred in other organs.

CHRONIC MYELITIS.

The spinal cord may be the seat of chronic inflammation, which develops slowly, as such, in the course of a few or many months; and the condition may also occur as the sequel to acute myelitis, which instead of subsiding, may persist, manifesting from time to time signs of activity. It is often difficult to say whether such a condition should be regarded as an acute myelitis that has not subsided or a chronic inflammation beginning acutely. In many instances, indeed, it is probable that the disease is most accurately regarded as a combined form in which the causes of both are operative, and a subsiding acute inflammation is arrested and maintained by the influences that would be capable of inducing a primary chronic myelitis. Such progressive tendency is especially conspicuous in the disseminated form, in which the foci of inflammation may remain and fresh ones may develop from time to time in a chronic or subacute

manner.

The lesions of chronic myelitis resemble those of acute myelitis in seat and distribution, and intermediate cases connect them by analogous subacute forms. They differ from acute inflammation both in the longer time occupied in their development, and in the absence of the considerable vascular disturbance which forms part of the acute process. Such chronic myelitis may be focal, disseminated, or diffuse. In the former case it may involve the whole thickness of the cord at a certain level, chronic transverse myelitis, or only part of it, sometimes one half, occasionally for a considerable vertical extent. The chronic