Treatment.—During the febrile stage the treatment is that for all forms of acute myelitis, including absolute quiet and rest, ice-bags or counter-irritation to the spine, laxatives, and a non-stimulat ing, easily digested diet. To these meas ures should be added, if there is much fever, antipyretics, such as phenacetin or other coal-tar derivatives. It is cus tomary to use ergot in 7,-drachm doses or less, with or without bromide of potas sium, and no harm is likely to follow its employment. The salicylate of soda has been employed with some advantage in epidemics of the disease, and its use seems rational. Usually this stage is treated symptomatically, for the reason that a diagnosis is rarely made so early. For the permanent residual paralysis our most reliable therapeutic resources con sist of electricity, massage, and exercise of the parts through the assistance of various mechanical appliances to be ap- I propriately devised by the orthopedist. Both currents should be employed. In using galvanism one electrode, a large flat pad, should be placed over the spine at the level affected, the other on the limb paralyzed. Not more than 3 to 5 milliamperes should be used at first. As the child becomes accustomed to it, the current-strength may be gradually in creased. The seance should last twenty minutes daily, and should be followed by an application of the faradic current to the limb itself. The current here should be strong enough to produce gentle con tractions. If there is no response to fara dism except with painfully strong cur rents, the interrupted galvanic current may be used in the same way. As much as possible of the affected muscle should be included in the circuit.
Massage should be given, preferably by one qualified for the work, though, if an expert be not available, simple rub bing is of at least some service in stimu lating the circulation and local nutri tion. Strychnine internally is at times of apparent value. The amount should vary with the age, of course, but much larger doses than are ordinarily pre scribed are indicated. Such large doses may be quite safely reached by a gradual increase. Splints, braces, and other ap pliances serve a useful purpose in pre venting crippling contractions and un sightly deformities. A flaccid leg may be supported by a brace so as to become useful in walking, which in itself is a valuable therapeutic aid. Velocipedes, tricycles, and other similar machines are often of much service.
We should not turn away cases of infantile paralysis telling them that massage and electricity is all that can be done for them and recommending them to wear braces and shoes for the treatment of their deformities. In every case a special study of the muscles in volved must be made, and living tendons transplanted to replace the paralyzed Ones if possible. The operation should not be done until it is definitely settled which groups of muscles are affected. Regarding the amount of strength of the muscle to be grafted as compared with the work it will be called upon to do, much may be left to Nature and the gradual strengthening of the muscle to meet the demands made upon it.
Grafting should preferably be done above the annular ligament, as this liga meat will then hold the tendon in its place. A tendon may be carried by blunt dissection for quite a distance sub fascially or subcutaneously. Beck tun neled the interosseous ligament in graft ing a posterior muscle into an anterior one. The best method of joining the tendon is to pull the paralyzed tendon through a perforation in the normal tendon and apply sutures; or to cut the paralyzed tendon long, reflect it, and suture it to itself, remembering to take a stitch at the bottom of the slit in the normal tendon to prevent its slipping. Chromicized catgut, lasting from four to six weeks, may be used. After opera tion the limb should be kept in a plaster cast for at least four weeks, and some appliance to keep the foot in its proper position worn for several months.
Tenotomy of a spastic muscle causes the spasm to disappear. When spastic paralysis involves the muscles of the pelvis and thigh, tenotomy of the ad ductors and of the internal and external hamstrings may be done. Two personal eases reported. The first was a five year-old male child with spastic para plegia involving all the muscles of both legs. He was unable to stand alone. The tendo Achillis on each side, both t he adductor groups at the perineum, and both left and right, internal and exter nal hamstrings were severed and the right quadriceps extensor tendon length ened. The immediate result was much less spasm of the right leg and attempts at walking improved. The second case was a male, aged 22., suffering from spas tic paralysis as a. result of spinal injury. The adductors, both hamstrings, and the tensor vaginae femoris of the right leg were severed and the quadriceps exten sor lengthened. The improvement in this leg was so great that the other leg was operated upon in the same manner. The patient is now able to walk one hundred and fifty feet. F. S. Coolidge (Phila. Med. Jour., from Annals of Surg., May, 1901).
Amyotrophic Lateral Sclerosis.
Definition.—Amyotrophic lateral scle rosis is a disease characterized essentially by the two symptoms of spastic rigidity and muscular atrophy.
Symptoms. — The clinical history of the disease is quite constant. It gins very insidiously, and its progress is slow at first. ITsually the earliest symp toms are referable to the disease in the anterior horns, and are similar in ter to those which mark the beginning of progressive spinal muscular atrophy: wasting of the thenar and hypothenar muscles, of the interossei or of the mus cles of the arms or legs, almost always symmetrically, with or without tremor, which is rarely fibrillary, however. The degree of wasting may at first be so slight as not to attract attention or it may be readily mistaken at this stage for some form of progressive muscular atrophy.