existence can be recognised, the malady is generally advanced, and its observed rate of progress is the only ground on which a forecast can be based. When the central functions of the cord are considerably impaired, and the symptoms are steadily increasing, it is rare for life to be prolonged for more than one or two years, and the subacute onset of considerable paralysis may herald a course that leads to death in a few months. On the other hand, a stationary condition may last for many years. Treatment can do nothing for the morbid state, nor is it likely that the progress of spinal surgery can afford the means of relief. The severity of some of the individual symptoms may, however, be lessened by appropriate measures; especially trophic changes may be diminished by care and early treatment, bedsores may be prevented, cystitis guarded against, and if any acute paralysis occurs, the possibility of some recovery may suggest the maintenance of the irritability of the muscles by electricity, which cannot be expected to influence the slower atrophy. Pain may need the customary sedatives; but early pain, especially with the hyperesthesia that depends on the intensification of the nerve-impulses at the irritated part, may be much lessened by the diminution of these by cocaine, used as in tabes. Sudden pain in the spine may indicate commencing hæmorrhage, and should lead to the adoption of the posture and other measures appropriate to that grave affection.

ANALGIC PANARITIUM; MORVAN'S DISEASE.

By the term Morvan's Disease is generally known an affection that was called Panaritium Analgicum, or "Painless Whitlows," by the physician of Brittany, Morvan, who, in 1883, first described it.* Observations on it are still few,† but, judging from two fatal cases,‡ it appears to consist in a combination of a condition of syringo-myelia, or of the associated gliomatosis, with a peripheral neuritis in the extremities. The symptoms make the constancy of the neuritis probable; we must wait to learn how far the morbid state of the cord is constant, and whether the changes in the nerves take origin in developmental conditions. It is quite possible that they may share the condition of arrested development, entailing a liability to later morbid changes, especially in view of the analogous conditions observed in the case mentioned on p. 469.§ At the same time, it is possible that the 'Gaz. Hebd.,' 1883, Nos. 35-44.

The chief writings are those of Louazel, 'La Maladie de Morvan,' Paris, 1890; Joffroy and Achard, ‘Arch. de Med. Exp.,' 1890; Charcot, Prog. Méd.,' 1890, Nos. 11 and 12; Häckel, Münch. med. Wochenschr.,' 1889.

Gombault, quoted by Charcot; Joffroy and Achard, Arch. de Méd. exp.,' 1891. § In a case recorded by Jolly (Charité Ann.,' xvi, 1891) there was also a congenital anomaly of the fingers, a web of skin between the third and fourth fingers of each hand.

symptoms of this affection may be due to local neuritis of various nature, and we must be cautious in inferring from then that the pathological state is the same in origin in all cases. In some instances the malady has been apparently set up by an injury. The affection has been met with in both sexes, but more frequently in males, and has generally commenced during the first half of adult life, between twenty and forty. When local injury has preceded the symptoms it has sometimes been at a considerable interval (Häckel), and it has been unilateral when the latter have been bilateral, so that its relation to them is uncertain.

The characteristic symptoms are in the upper extremities; only in rare cases do the feet suffer at a late period. Neuralgic pains may occur first, but the definite symptoms consist of weakness and muscular wasting in the hands and forearms, loss of all forms of sensation, and especially a peculiar trophic change-whitlows on the fingers, with recurring deep ulcerations in various parts of the digits; those near the extremity of the fingers may only heal with the loss of some of the terminal phalanges. The loss of sensibility involves all forms, and usually precedes the occurrence of the whitlows, so that these are painless-a peculiarity which constitutes the most salient feature of the disease, and suggested, in the first instance, its special character. Occasionally the trophic disturbance precedes the anæsthesia, and the whitlows and ulcers are then painful. The latter are deep, and often resemble the perforating ulcers of tabes; cracks in the skin accompany them, and the nails shrivel and split. Vasomotor derangements, lividity and pallor, often precede and accompany the disturbance of nutrition. The progress of the affection is very slow, and extends over many years; one hand is usually affected some time before the other. The electrical irritability of the nerves of the part has been found normal in the early stage, and slowly vanishing as the malady progressed. Although the trophic changes are limited, as a rule, to the hands, and the muscular wasting does not extend above the forearms, the loss of sensation is occasionally more extensive, involving the whole arms, parts of the trunk, and even the face. An affection of the shoulder-joint has been observed. The feet are occasionally, though rarely, the seat of anesthetic ulceration; the legs have also been found weak, with excessive knee-jerk and foot clonus (Häckel).

In the autopsy that was made by Gombault neuritis was found in both arms, and also a diffuse overgrowth of connective tissue in posterior part of the grey matter of the cord and the posterior This growth involved also the coats of the vessels, which places so thickened as to obliterate their cavity. Neuritis en invariably found in the extremities of the fingers when Cropped off.

s of the malady are so peculiar that, if they are known, • Morvan, 'Gaz. Heb.,' 1887, No. 34.

the nature of a case cannot well be mistaken.

Anesthetic leprosy

presents the closest resemblance, but in this the peculiar ulcerations are absent, and pigmentary alterations occur in the skin; while in Raynaud's disease there is not the peculiar loss of sensibility, nor an equal tendency to whitlows, and vaso-motor disturbance is a more conspicuous feature. In the peculiar malady known as "sclerodactyla" (a form of scleroderma that affects the fingers and face), there is no loss of sensibility or tendency to destruction of the finger ends. Simple syringomyelia is distinguished by the common absence of the whitlows, by the subordination, in time and degree, of the trophic changes to the other symptoms, and by the common preservation of tactile sensibility. But the distinction is probably not an absolute one. In Morvan's disease there is peripheral neuritis as well as syringo-myelia, and to this is due its special features, and especially the early and intense trophic disturbance.*

SPINA BIFIDA.

Spina Bifida, or split spine, depends on a defect in the closure of the vertebral arches, which usually leads to the protrusion of the membranes as a sac, forming an external tumour, into which the lower part of the spinal cord often extends, normal or variously altered in conformation, sometimes even reduced to a neural lining of part of the wall. Rarely, there is no external prominence-a form known as "spina bifida occulta." The condition is most common in the lumbar region of the spine; sometimes is present at more than one place, very rarely in the whole length of the vertebral column. It is met with in about one child out of every thousand born (Chaussier). The disease is one of chiefly surgical interest, and therefore only an outline of the more important facts is here given. The spinal cord, whether normal or not, generally reaches lower than usual in the vertebral canal, as it does at the early period of development, when the morbid state is produced,-becoming adherent at its lower extremity and remaining so. In many cases the central canal of the cord is enlarged above, and the lower part of the cord may also be similarly distended.

The precise condition presents many variations, which can be, in part at least, understood by what is known of the process of development, a subject that has been very ably discussed by Bland Sutton. The essential element in spina bifida, the defect in the vertebral arches,

The absence of any fundamental difference between this malady and syringomyelia has been pointed out by Bernhardt (Verh. Vereins inu. Med., Berlin, January 19th, 1891) and Jolly (loc. cit.). But the additional element of neuritis must not be ignored.

† The best accounts of spina bifida are in the “Report of the Committee of the Clinical Society" (Transactions,' 1885), and Bland Sutton's "Lectures on Evolution in Pathology" (Lancet,' February 25th, 1888). Spina bifida occulta is described by the same writer in the Lancet,' February 25th, 1887.

depends on a deficiency in that ingrowth of the mesoblast from each side which should enclose the embryonal spinal cord, and form bone, after the superficial epiblastic layers have united to form the epidermis. A similar ingrowth of mesoblast forms the corium, muscle, &c. This apparently takes place in excess in spina bifida occulta, and leads to a curious condition, usually present-an excessive growth of hair over and about the affected part, which is generally the lumbo-sacral region. On the other hand, in many cases in which there is a tumour, this superficial mesoblastic ingrowth seems to be deficient, as well as that for the vertebral arches, so that, at the upper part of the tumour, there is an area in which there is no proper skin, but a peculiar shiny membrane destitute of hair. It is probably this superficial mesoblastic deficiency that permits the protrusion, and formation of an external tumour.

In spina bifida occulta the defect in the arches can be felt on palpation, either in the lumbar or sacral region, and the spinal cord extends lower than normal, as in the ordinary form. The latter, in which there is an external tumour, presents three chief varieties, according as the sac contains only the spinal membranes (meningocele), the spinal cord as well as the membranes (meningo-myelocele), or the latter distended by enlargement of the central cavity (syringomyelocele). These are the chief classes; they do not, indeed, exhaust the rarer forms, but to take full cognizance of these would entail a very complex list of varieties.*

Of the several forms, that without an external tumour has been least frequently met with, although it is probable that a knowledge of the significance of the growth of hair in the lumbar region would lead to the detection of this state in many cases in which it is now undiscovered. Putting this form aside, simple meningocele and

* Several other varieties are enumerated by Bland Sutton (loc. cit.).

FIG. 179.-Spina bifida: sections of a spinal cord, from a case the symptoms and history of which I was unable to ascertain. In A, cervical region, the only abnor mality is a large cruciform central canal and an unusually thick grey commissure. This continues through the dorsal region, at the lowest part of which there is a great change. In B, the canal is larger, and the necks of the posterior horns (and posterior vesicular columns) are united by much commissural tissue; in this, many vertical fibres could be seen, and others runuing from before backwards in the middle line. In C, an extension of the canal backwards has taken place, and it is bounded by a sinuous membrane; the outer part of the grey substance is atrophied. In D, the cavity has extended into each posterior horn almost up to the surface of the cord, in part by a breaking down of tissue, because the membrane limiting the enlarged canal remains undestroyed. In E, still at the junction of the dorsal and lumbar regions, the cavity has receded from the left horn. In F, the division of the cord has taken place, not in the direction of the cavity in the horn (which is filled up), but in the middle line, at or close to the median septum. In G, a wider separation of the posterior columns has taken place, and a cavity has formed on the right side, which extends into the horn, and almost cuts off the posterior column. In H, the cord is spread out and formed part of the wall of the sac. The posterior nerve-roots (pr) mark the position at which the posterior horn comes to the surface. The grey matter is in many parts atrophied and translucent, and, in H, contains many large vessels. The septal lobulation on the surface of the cord is greater than normal.