lasted some years. It is important to distinguish enlargements of this kind from idiopathic chronic engorgement, as such affections, from their tendency to congestion, do not admit of so strong baths as fibrous tumours. No less important is it to distinguish submucous fibriods and such interstitial tumours, which grow towards the internal walls of the uterus from polypus, when still inclosed in the uterine cavity. But there are cases in which the diagnosis cannot be accurately determined, even with the aid of the uterine sound applied by the most skilful hand. A polypus cannot be absorbed by any means, and when the baths are taken, it involves only a loss of time; and, moreover, we must expect that the baths will produce a bad effect on the constitution, when no object exists on which they may act. And actually some cases of polypus have been mistaken for mucous fibroids, and sent here. In one of these cases, after 20 baths had been taken, the polypus passed through the os uteri. I need not say that the baths were immediately suspended. In another case the same circumstances occurred, but not until after the patient had returned home, having gone through a whole course of the waters.

That fibrous tumours can be absorbed, when not entirely of a cartilaginous structure, is a fact. They are found so frequently in the body and fundus of the uterus, that every physician has ample opportunity for making his own observations. All the cases we met with here, even when the tumour was small, had already existed for years, and many remedies had been resorted to in vain. The extent of the cure here was in proportion to the size, hardness, and duration of the tumour. Tumours of a cartilaginous structure were never dissolved by the waters; only a diminution of the enlargement of the uterus took place. On some tumours of the size of a walnut, whose substance was not solid, the baths acted so powerfully that they could not be felt at the end of the course. In others the diminution was not perceptible until the completion of the course, or even some months afterwards. The absorption commenced sometimes in the fibroid, when it was not of a too solid structure, sometimes in the hypertrophied tissue of the uterus. I cannot account for the differIn two cases of tumours of a cartilaginous structure, with hypertrophy of the uterus, the development of the disease was not even arrested at the end of the course; but some months afterwards it began to cease growing, and when a course of waters was resumed the following year, a slight diminution of the swelling of the uterus could be observed. In both patients the disease remained afterwards stationary (it is now 4 and 6 years since the second course was taken), and the patients enjoy good health. When the growth of the tumour ceased, diminution of the same did not immediately begin. When a perceptible diminution of a tumour was produced by the baths, and no increase had taken place after an interval of six months, the improvement was permanent. In some cases in which the increase of the swelling was only arrested without being diminished, diminution took place years afterwards without any

ence.

treatment, on the patient arriving at the climacterical period of life. All tumours of the fundus uteri, which could be felt by the touch, and which were diminished in size by the use of the waters, began towards the end of the course to swell, and became perceptibly softer. These symptoms could always be considered as indications of the commencement of absorption. In some patients, in whose cases a submucous fibroid was presumed, a discharge of a serous fluid, combined with many flakes, appeared during the course. Two of these cases, both young women, who had, on several occasions, miscarried, became pregnant shortly after their return home, and were regularly delivered. Another young lady, who was also presumed to have a submucous fibroid, was, after having taken 20 baths, suddenly affected with uterine colic, followed by a copious discharge of a thick saneous matter, mixed with many small and large flakes. On the following day the discharge became more serous, and continued in small quantities for some weeks. I heard no more of her case after she left Creuznach.

Also, in all affections of this kind the addition of mother-lye to the baths was in proportion to the development of the disease and the constitution of the patient. Further, the baths could, cæteris paribus, be stronger in these than in other affections, and it was surprising how strong the baths could be taken by such patients, even when of a delicate constitution. There were some cases in which it was necessary gradually to strengthen the baths to such a degree, that the bath at last contained, in 400 pints of plain mineral water (the usual quantity in a bath), 23 pounds of muriate of lime, and more than 11 ounces of bromide of sodium; or, in other words, 60 pints of mother-lye in each bath. When the constitution is weakened by accidental complaints, great caution must be exercised in the addition of mother-lye to the bath, and we must endeavour to produce the wished-for result, rather by a prolonged course of the baths, than by giving too much strength to them. But exhaustion, produced by anæmia, in cases of submucous fibroids, does not necessitate weaker baths, any more than other tumours which are not attended with floodings. The hæmorrhage will only be promoted when the additions of mother-lye are injudiciously large, or the temperature of the baths too high. Anæmic patients like hot baths, and cannot therefore be too earnestly cautioned to be careful in this respect. If the temperature be higher than 92 degrees of Fahrenheit, we may expect either hæmorrhage while the patient is in the bath, or the menses will come on sooner and more copiously than at any time. The same caution is necessary with regard to hip-baths. Respecting the use of the douche and other local means, and concerning the principles, determining the duration of the course, and the addition of mother-lye to the bath, I must refer the reader to the remarks I have already made on these points, when speaking of the treatment of the affections of the ovaria.

ARTICLE III.-Diseases of the Spinal Cord and its Membranes. By EVANS REEVES, M.D., Edwards' Street, Portman Square, London.

I. SPINAL MENINGITIS AND ITS COMPLICATIONS.

Pathology of Acute Spinal Meningitis.-The cases observed and collected for the purpose of forming a history of acute spinal meningitis and its complications amount to 39. The arachnoid was affected alone in 7 of the cases; the arachnoid and pia mater, or pia mater alone, in 11; the membranes and the cord in 7; and the membranes of the cord and those of the brain, with or without the substance of the brain or cord being implicated, in 13.

The lesions observed after death in inflammation of the arachnoid,

are

1st, Congestion with effusion of sero-sanguineolent serum. The more intense the congestion, the greater will be the quantity of serum, and the more sanguineous its hue.

2d, Congestion with opacity-thickening-false membranes — pus more or less concrete or sero-purulent fluid.

Where the pia mater is affected,

1st, Congestion, varying in intensity from a pale rose-red to a deep purple, with this, if it has been of some duration and intense, the cellular tissue between it and the arachnoid will contain serum, more or less sanguineolent, gelatinous deposit (most frequent) or pus (rare).

With these changes the membrane itself may be, or not, more or less opaque and adherent to the surface of the cord, from which it cannot be separated without bringing away portions of it.

When the cord is implicated it may present,

1st, Increased vascularity, with or without infiltration of serum. 2d, Increased consistence.

3d, Softening-varying in consistence, from cream-cheese to soft pap; and in hue, from venous red to yellow, or a cream-white. In implication of the membranes of the brain, either of the following states exist :

1st, Congestion of the vessels and membranes, with sero-sanguineolent effusion into the ventricles, or at its base or convexity.

2d, Thickening and opacity of the membranes, with gelatinous or purulent exudation, or the formation of false membranes.

The brain with the above changes may be congested, its substance increased in density, or more or less softened.

In inflammation, both of the arachnoid and of the pia mater of the cord, the cellular tissue between the dura mater and the walls of the spine, is frequently found infiltrated with serum, sometimes blood, and the vessels ramifying in it highly congested.

Pathology of Chronic Spinal Meningitis.-Few opportunities occur of observing the changes, which chronic inflammation induces from its rarely proving fatal, unless disease of the cord (particularly the cervical portion), the brain or its membranes, lungs, kidneys, or sloughing of the sacrum occurs.

In the arachnoid the changes observed are opacity of a greater or lesser extent, adhesions between the visceral fold and the one lining the dura mater, either direct or by cellular bands.

"Cellular bands," observes Dr Copland (Dict. of Pract. Med., art. Spinal Cord), "have, after they have existed sometime, a tendency, from the deposit of oil globules, to be converted into fatty tissue, a result marked by an improvement in the power of motion of the paralytic limbs." Sometimes, however, fresh accessions are made to the cellular deposits, particularly when from some cause, such as chronic disease of the vertebra or kidneys, a state of congestion is kept up or excited. When this is the case they may acquire such a magnitude as to press on the cord and induce either atrophy or softening; sometimes, however, particularly in the case of disease of the vertebræ or chronic inflammation of their ligaments, the arachnoid, although it has undergone considerable change, yet the atrophy or softening may arise from the deposit of inflammatory products in the cellular tissue, external to the dura mater, upon or under the ligaments. A state of paralysis, both of motion and sensation, more or less pronounced, of one or both of the lower extremities, may exist, and yet the nerves forming the cauda equina may be only adherent from the interposition of cellular bands.

Sometimes cartilaginous or bony deposits are formed. They may, however, arise from the general tendency which serous membranes have to ossify, and they are nearly invariably accompanied by a similar state of the arteries, and similar deposits in the serous membranes of other parts of the body. These deposits are, particularly when cartilaginous, small, varying in size from a millet seed to a silver penny piece, their number also varies.

In a case recorded by Dr Bright, 50 or 60 existed, and Velpeau found a large number floating on the surface of the arachnoid,resembling minute pieces of white soap. In this case a tumour of an encephaloid character existed on the anterior part of the cord. Esquirol, in the case of a female, who became, when 35 years of age, epileptic, and died 5 years later, asphyxiated during an access, found the whole of the external aspect of the arachnoid covered with bony plates, one or two lines in diameter. They have been occasionally observed in tetanus. Brayne, Swan, and Horner have each recorded a case. These are nearly the only instances, out of 300 recorded cases of this disease which I have examined. They cannot, therefore, be considered either as a result or a cause of

tetanus.

1 Sur l'Épilepsie, Bul. de la Facult. Tome v.

Olivier considered that they were common in those who had suffered from pains considered as rheumatismal. I have several times had an opportunity of observing them, particularly after the 40th year, and co-existing with deposits in the arteries. In one that of a bed ridden man of 73, the deposit was bony and of the size of a shilling, and situated opposite the 12th dorsal vertebra, it was accompanied by a similar state of the pericardium, dura mater of the skull, and arteries generally.

Barbier (Traité Element de Mat. Med., Tome 3, p. 479) found an osseous plate, 3 lines broad and 2 inches long. Softening of the cord existed in this case.

Morgagni (De Sed. et Caus. Morb. Epis. 25, Art. 9), found in an old man the cartilaginous plates accompanied by ossification of the pleura.

Soëmmering, in his translation of Baillie's Morbid Anatomy, published at Berlin in 1794, at page 248, note 524, states that he has several times found cartilaginous bodies in the arachnoid of the

cord.

Lobstein (Compte Rendu, à la Fac. de Med. de Strasbourg, 1820-50), found the arachnoid containing cartilaginous plates. Sabathier, he remarks, had also observed them.

Chaussard (Sur l'Organisation des Vieillards, Paris, 1822), observed them as ivory-like plates, nearly quadrilateral in form.

Dr Fletcher (Prov. Med. Jour., vol. 14) found some ossific plates in a man who was paraplegic. The left corpus striatum contained an old clot of blood.

Rokitansky also observed them accompanied by opacity of the arachnoid. In this case softening of the cord existed.

Changes in the pia mater are still less frequently observed, particularly without chronic disease of the cord. In these cases it may be found opaque, or with false membranes more or less organized on its surface. In a man who had suffered from spasmodic contractions of the muscles of the neck, which drew the head towards the right shoulder, the pia mater opposite the third and fourth cervical vertebra, seemed contracted and deeply injected, but the cord appeared quite healthy.1

Termination and Duration.-Of the 8 cases where the arachnoid was alone inflamed, the termination was successful in 7 of the number. The case which proved fatal was that of a child a few days old, affected with spina bifida, which had ulcerated, first serous and then purulent fluid escaping from the spinal cavity.

The duration of the successful cases seems to have depended greatly on the activity of the treatment adopted and the period when it was had recourse to, as well as on the severity of the symptoms.

1 Polleti, Annali Univ. di Med. xxxvi, 112.

NEW SERIES -NO. VI. JUNE 1855.

3 R